Short- and long-term outcomes of every graft recovered during a multi-organ procurement procedure including the intestine.

BACKGROUND: The development of intestinal transplant (Tx) programs introduces thymoglobulin donor treatment as well as an almost complete warm dissection of the abdominal organs to allocate them to different recipients. Our aim is to assess the reproducibility and feasibility of the surgical technique of multi-organ procurement with the use of thymoglobulin donor pre-treatment and report the short- and long-term outcomes of every graft harvested as part of multi-organ procurement (MTOp), including the intestine. METHODS: Data were collected of all organs harvested from MTOp, including the intestines allocated to our center from March 2006 to July 2011. Data from 92 recipients and 116 organs procured from 29 MTOp were analyzed. Twelve hearts, 2 lungs, and 1 cardio-pulmonary block were transplanted; primary graft dysfunction developed in 4 of the 12 hearts and in the cardio-pulmonary block. RESULTS: The survival rate was 75% and 100% for hearts and lungs, respectively. Nineteen livers, 9 kidney-pancreas, 19 kidneys, and 29 intestines were transplanted. Delayed graft function (DGF) of the pancreas developed in 3 of 9 kidney-pancreas, and the other 3 exhibited DGF of the kidney; 4 of 19 Tx kidneys had DGF. The survival was 84%, 78%, 95%, and 65.5% for livers, kidney-pancreas, kidneys, and intestines, respectively. CONCLUSIONS: Organs procured during MTOp including the intestine can be safely used, increasing organ availability and transplant applicability without compromising allocation, quality, and long-term results of the non-intestinal-procured organs.

Trypanosoma cruzi discrete typing units in Chagas disease patients from endemic and non-endemic regions of Argentina.

Genetic diversity of Trypanosoma cruzi may play a role in pathogenesis of Chagas disease forms. Natural populations are classified into 6 Discrete Typing Units (DTUs) Tc I-VI with taxonomical status. This study aimed to identify T. cruzi DTUs in bloodstream and tissue samples of Argentinean patients with Chagas disease. PCR-based strategies allowed DTU identification in 256 clinical samples from 239 Argentinean patients. Tc V prevailed in blood from both asymptomatic and symptomatic cases and Tc I was more frequent in bloodstream, cardiac tissues and chagoma samples from immunosuppressed patients. Tc II and VI were identified in a minority of cases, while Tc III and Tc IV were not detected in the studied population. Interestingly, Tc I and Tc II/VI sequences were amplified from the same skin biopsy slice from a kidney transplant patient suffering Chagas disease reactivation. Further data also revealed the occurrence of mixed DTU populations in the human chronic infection. In conclusion, our findings provide evidence of the complexity of the dynamics of T. cruzi diversity in the natural history of human Chagas disease and allege the pathogenic role of DTUs I, II, V and VI in the studied population.

Status and development of allied health personnel in cardiothoracic surgery in Latin America.

INTRODUCTION: The role of allied health personnel (not physician) in cardiothoracic surgery has evolved substantially since the beginnings of this discipline in the 70´s, especially in developed countries. METHODS: To explore the status of allied health personnel in cardiothoracic surgery in Latin America, a research was geared to know the general context of human resources in public health and specifically in cardiothoracic surgery. Official data from the World Health Organization and the Pan American Health Organization were acquired. An on-line survey was sent to Latin-American cardiothoracic surgeons through either scientific societies or personal e-mail, to get direct information on human resources management of the surgical services. RESULTS: There is lack of information on the medical literature regarding the allied health personnel activities in the region. Sixty one Latin American cardiothoracic centers answered the survey. The survey revealed that the profile of the allied health personnel is outlined by nurses, perfusion and anesthesiology technicians; whose routine activities are restricted to minor controls. CONCLUSIONS: At the moment, the lack of information and official data generates difficulties in analyzing the development status of allied health personnel in cardiothoracic surgery departments in the region of Latin America. In the light of the results and growing interest of developed countries in incorporating the allied health personnel to improve the work capacity and the quality of care in cardiothoracic surgery centers, it would be sensible to develop policies oriented to train and organize this activity in Latin America.

Results of heart transplantation: 16 years' experience in a center in Argentina.

UNLABELLED: Heart transplantation (HTx) is the treatment of choice for advanced heart failure refractory to other treatments. OBJECTIVE: To report the outcomes of patients undergoing orthotopic HTx in a center with 16 years' experience. METHODS: We retrospectively examined the outcomes from three hundred nine HTx recipients between February 1993 and March 2009. The mean recipient age was 46 +/- 16 years, and 80% were male. Ischemic cardiomyopathy was present in 37%; 43% (n = 133) were elective procedures and 57% (n = 176) were urgent/emergency procedures. The mean donor age was 26 years; their main cause of death was head/brain trauma. Survival was studied using Kaplan-Meier curves. RESULTS: The global survival rates at 1, 5, 10, and 15 years were 80%, 74%, 71%, and 65%, respectively. Excluding losses during the first year after transplantation (conditional survival), the survival rate at 5 and 10 years reached 92% and 88.5%, respectively. The median follow-up was 7.7 years. The etiology and the urgent/emergency nature of the procedures did not show significant differences regarding the mortality rate (P = .8). The main causes of death were sepsis (28%) and primary nonfunction (18%). In-hospital mortality reached 16%. No significant differences were observed between the urgent/emergency versus the elective transplant procedures (P = .06). During the follow-up, the incidence of severe acute cellular rejection episodes was <3% after 5 years. The global incidence of antibody-mediated rejection reached 4.5%. Eleven subjects (3.5%) were diagnosed with post-transplantation lymphoproliferative disorder. During long-term follow-up, the incidences of kidney failure, diabetes mellitus, hypertension, and dyslipemia were 21%, 24%, 69%, and 70%, respectively. One percent required chronic dialysis. CONCLUSION: In our center, post-HTx survival rates at 1, 5, 10, and 15 years were 80%, 74%, 71%, and 65%, respectively, which were similar to those reported by the International Society of Heart and Lung Transplantation (ISHLT).

Beneficio de la rosuvastatina en el tratamiento de la hipertensión arterial y el remodelamiento ventricular / Beneficial effects of rosuvastatin in patients with arterial hypertension and ventricular remodeling

This paper describes the beneficial effects of rosuvastatin in patients with arterial hypertension in ventricular remodeling. As a conclusion, our data supports new evidence to encourage the use of statins for the treatment of cronic arterial hypertension and venticular remodeling

Usefulness of PCR strategies for early diagnosis of Chagas' disease reactivation and treatment follow-up in heart transplantation.

Heart transplantation (HTx) is a useful therapy for end-stage Chagas cardiomyopathy; however, Chagas reactivation remains a mayor complication. Parasitological methods offer poor diagnostic sensitivity, and use of more sensitive tools such as the Polymerase chain reaction (PCR) is usually necessary. In the present study, reactivation incidence and PCR usefulness for early reactivation diagnosis, as well as for treatment response evaluation during follow-up, were analyzed using Strout parasite detection test, in 10 of 222 consecutive HTx patients suffering Chagas cardiomyopathy. PCR strategies targeted to minicircle sequences (kDNA, detection limit 1 parasite/ 10 mL blood) and miniexon genes (SL-DNA, 200 parasite/10 mL) were performed to compare parasite burdens between samples. No patients received prophylactic antiprotozoal therapy (benznidazole). Five patients (50%) exhibited clinical reactivation within a mean period of 71.6 days; positive Strout results were observed in most cases presenting clinical manifestations. kDNA-PCR was positive 38-85 days before reactivation, whereas SLDNA-PCR became positive only 7-21 days later, revealing post-HTx parasitic load enhancement present prior to clinical reactivation development. Reactivations were successfully treated with benznidazole and generated negative PCR results. Results observed in this study indicate the value of PCR testing for an early diagnosis of Chagas reactivation as well as for monitoring treatment efficacy.

Effect of preservation solution on graft viability in single-lung transplantation from heart-beating donors in pigs.

BACKGROUND: Low-potassium-dextran preservation solution Perfadex (PER) may provide better outcome of transplanted lungs than high-potassium Euro-Collins (EC) solution. However, there are no comparative studies of the recipient inflammatory response to the graft. PURPOSE: The purpose of this study was to compare EC versus PER as preservation solutions with respect to the functional performance and inflammatory response in single-lung transplantation from heart-beating donors in pigs. MATERIALS AND METHODS: The donor left lung flushed with the corresponding cold preservation solution was stored at 3 degrees C for 3 hours. We assessed hemodynamic values and pulmonary function in the recipient over a 2-hour reperfusion period calculated as percent of basal values, and expressed as mean of the reperfusion period. Interleukin-8 (IL-8) concentration in the donor was estimated in bronchoalveolar lavage fluid 2 hours after recipient reperfusion. Biopsies of the donor right lung and the transplanted lung were obtained to measure myeloperoxidase (MPO) activity. IL-8 and MPO values were expressed as percent of the donor value. We evaluated the wet/dry pulmonary weight ratio (W/D), polymorphonuclear neutrophil count (PMN), and a score of histological damage in the transplanted graft. RESULTS: Pulmonary function evaluated by % static: 66.6 +/- 6.8 (EC), 82.3 +/- 10.2 (PER), and dynamic: 74.0 +/- 7.3 (EC), 89.3 +/- 7.7 (PER) compliances, as well as % IL-8: 562.5 +/- 168.6 (EC), 232.3 +/- 148.7 (PER), % MPO: 485.9 +/- 194.9 (EC), 140.8 +/- 21.1 (PER), W/D: 9.9 +/- 3.1 (EC), 6.8 +/- 1.4 (PER), PMN 13.5 +/- 6.8 (EC), 5.5 +/- 3.3 (PER) and the histological damage score: 3.0 +/- 1.5 (EC), 0.7 +/- 0.4 (PER) showed significant differences between the EC and the PER (P < .01). CONCLUSIONS: PER affords good lung preservation with early graft function and modest evidences of inflammation, lung injury, and edema compared with the EC perfused lung.

Lung transplant at the Favaloro Foundation: a 13-year experience.

BACKGROUND: The outcomes of lung transplantation (LT) are well known in developed countries, but not in Latin America. Our objective was to report the LT experience at a single center in Argentina. METHODS: From June 1994 to February 2003, the 54 LT that were performed included 36 single-lung transplants SLT (45.5%) and 18 double-lung transplants (DSLT) (22.7%). Indications for SLT (n = 36) were emphysema (n = 23) and pulmonary fibrosis (n = 13); for DSLT (n = 18), bronchiectasis (n = 8), cystic fibrosis (n = 8), pulmonary emphysema (n = 1), and bronchiolitis obliterans syndrome caused by graft-versus-host disease after bone-marrow transplantation (n = 1). A univariate analysis, chi-square test with Yates' correction was used for qualitative variables; Wilcoxon-Mann-Whitney test, for quantitative and ordinal variables. Survivals were estimated by the Kaplan-Meier method. RESULTS: In-hospital mortality (HM) was 21.1%. Among SLT, early death was due to sepsis in six patients and by ischemia-reperfusion injury (IRI) and acute rejection in other two. In DSLT, two patients died due to IRI and one, sepsis. The overall estimated survival rates at 1, 2, and 4 years were 70.1% +/- 6.5%, 54.3% +/- 7.2%, and 44.3% +/- 7.9%, respectively. The median overall survival was 26.5 (10 to 34) months. When HM was excluded, survival at 4 years was 51.3% +/- 8.7%. The estimated survival at 3 years was 43.3% +/- 9.3% for SLT and 58.7% +/- 13% for DSLT (P = 6). Survival differences according to the baseline diagnosis were not significant (P =.6). Median follow-up time (percentiles 25 to 75) was 16 (2 to 27) months. CONCLUSIONS: Our LT program shows similar results to those reported by the International Society for Heart and Lung Transplantation for developed countries.

Orthotopic heart transplantation in elderly patients: a 10-year experience at a single center.

INTRODUCTION: A consensus has not yet been reached regarding the indications for orthotopic heart transplantation (OHT) in elderly patients or the age limit contraindicating the procedure. The objective of this study was to assess OHT outcomes to determine whether elderly patients benefit from the procedure. METHODS: From February 1993 to February 2003, 178 OHTs were performed on recipients of mean age 47.4 +/- 15 years (range, 4 to 74) including 80.3% men. The population was divided into two groups: group A included patients >/= 60 years, and group B those younger than that age. Survival was analyzed for the overall population and for both age groups during a 10-year follow-up period. RESULTS: Group A included 36 patients (20.8%) and group B 142 patients (79.2%). Mean age was 63.7 +/- 2.9 years (60 to 74) in A, and 43 +/- 13.9 years (4 to 59) in B. In-hospital mortality was significantly higher among group A (n = 11, 31.4%) compared to B (n = 17, 12.1%, P =.008). Survival at 1, 5, and 10 years was 61.5% +/- 8%, 58.1% +/- 8.3%, and 49.8% +/- 10.5% group A; and 84.2% +/- 3%, 73.7% +/- 4.1%, and 69.9% +/- 4.7 for group B. Elderly patients showed a lower survival rate (49.8%) compared with the younger group (69.9%) at 10-year follow-up (P =.007). Conditional survival at 9 years failed to show significant differences (A 72.2% vs B 79.6%, P =.4). CONCLUSION: In our population, elderly recipients showed a higher in-hospital mortality. However, when the first post-OHT year was excluded, we found similar survival rates for both age groups.

Trasplante pulmonar en la enfermedad respiratoria avanzada. Características poblacionales y evolución de los pacientes en evaluación y espera pre-trasplante / Lung transplantation for end-staged lung disease. Population characteristics and evolution of patients for evaluation and in transplant waiting list

El número de pacientes que se incluyen en programas de transplante pulmonar es creciente y su sobrevida en lista de espera depende de la posibilidad de acceder a un TxP así como de la progresión de la enfermedad de base. El objetivo de este trabajo es analizar la evolución y sobrevida de los pacientes con enfermedad respiratoria avanzada (ERA) evaluados para trasplante uni y bipulmonar

Trasplante pulmonar en la enfermedad respiratoria avanzada. Características poblacionales y evolución de los pacientes en evaluación y espera pre-trasplante / Lung transplantation for end-staged lung disease. Population characteristics and evolution of patients for evaluation and in transplant waiting list

El número de pacientes que se incluyen en programas de transplante pulmonar es creciente y su sobrevida en lista de espera depende de la posibilidad de acceder a un TxP así como de la progresión de la enfermedad de base. El objetivo de este trabajo es analizar la evolución y sobrevida de los pacientes con enfermedad respiratoria avanzada (ERA) evaluados para trasplante uni y bipulmonar

Cardiac myocyte nuclear size and ploidy status decrease after mechanical support.

Two patients with end-stage dilated cardiomyopathy of ischemic and idiopathic origin were treated with a left ventricular assist device (LVAD) as a bridge for heart transplantation. Myocardial tissue was collected during LVAD insertion and from the left ventricular apex of the explanted hearts. The myocyte diameter, nuclear area and DNA content of myocyte nuclei were measured by static cytomorphometry in tissue sections and in isolated myocytes with a digital analysis system. The presence of apoptotic nuclei was investigated by the TdT mediated X-dUTP nick end labeling technique (TUNEL). The prolonged use of a LVAD was associated with a reduction in myocyte diameter, indicating that the LVAD may induce a reversion of myocyte hypertrophy, a process described as "reverse remodeling." In addition, unloading of the heart induced a reduction in the size and DNA content of myocyte nuclei. These results suggest that the cardiomyocyte nuclei are in a dynamic state and, as it occurs with cell hypertrophy, nuclear hypertrophy and polyploidization may be a reversible phenomenon.

[Coronary surgery in elderly patients. In-hospital and long-term results]. / Cirugía coronaria en pacientes ancianos. Resultados hospitalarios y a largo plazo.

BACKGROUND: Taking into account the steady increase in the number of elderly patients requiring coronary artery bypass grafting, we sought to analyze the in-hospital and long-term evolution of a group of elderly patients (>/= 75 years) who underwent coronary artery bypass grafting, and to identify clinical predictors of mortality and long-term symptoms. METHODS: Between April 1996 and February 2000, 207 patients older than 75 years of age who had undergone coronary bypass grafting were prospectively and consecutively analyze. Mean age was 78.4 +/- 2.7. RESULTS: An average of 2.6 grafts/patients was constructed. Left mammary artery was used in 93% of patients. The in-hospital incidence of heart failure, atrial fibrillation, preoperative infarction and stroke was 38%, 29%, 4.8% and 2.8% respectively. The in-hospital mortality rate was 5.8%. Mean follow-up was 18 months (25th an 75th percentiles 9-29). Late mortality rate was 4.1% in eight patients. Excluding the in-hospital deaths, the estimated probability of survival (Kaplan-Meier) at 3 years was 94% and the survival freedom from symptoms was 86%. A multivariate analysis showed that only age was predictor of in-hospital mortality (OR 1.16, p = 0.009). Only peripheral vascular disease was found as a predictor of symptoms during the long-term follow-up (p = 0.001). CONCLUSIONS: In this series of senile patients who underwent coronary surgery, those of an older age (> 80 years) showed a higher risk of in-hospital mortality. The presence of peripheral vascular disease is useful in the prognosis assessment of the group.

Early diagnosis of recurrence of Trypanosoma cruzi infection by polymerase chain reaction after heart transplantation of a chronic Chagas' heart disease patient.

Heart transplantation is contraindicated as an effective treatment for end-stage Chagas' heart disease because of post-operative recurrence of Trypanosoma cruzi infection and reactivation of disease after immunosupression. In a follow-up study of a heart transplanted patient with Chagas' disease, we prospectively evaluated the usefulness of the polymerase chain reaction (PCR) for early diagnosis of reactivation. We monitored post-operative recurrence of Trypanosoma cruzi infection with microscopic observation of the parasite in peripheral blood (Strout's method), endomyocardial biopsies (EMBs), skin lesions, and 2 PCR assays, based on the amplification of specific T cruzi kinetoplastid and nuclear DNA sequences. During follow-up, parasite DNA was amplified in blood samples and EMB sections 41 days before we observed patent parasitemia and cutaneous manifestations of reactivation, proving that PCR is much more sensitive than direct microscopic observation for early diagnosis of disease reactivation in heart-transplanted Chagas' disease patients.

Myocardial revascularization with radial and mammary arteries: initial and mid-term results.

BACKGROUND: The radial artery is being used with increasing frequency instead of the saphenous vein in coronary artery bypass grafts. We analyzed the in-hospital and midterm results in patients undergoing coronary artery bypass surgery in whom a combination of arterial grafts was used, including radial artery and one or both internal mammary arteries. METHODS: Between 1995 and 1998, 1,023 patients underwent coronary artery bypass surgery using arterial conduits. The left internal mammary artery and the right internal mammary artery were employed in combination with the radial artery. RESULTS: An average of 3.2 grafts per patient were done. The left internal mammary artery and radial artery were used in 100% of patients, the right internal mammary artery in 21.7%, and a venous graft in 31%. The operative mortality rate was 2.5%. On repeat angiography performed in 62 patients before their discharge, the arterial conduits were patent in 98.4%. Mean follow-up was 25.0 +/- 9.6 months (1 to 48 months). The probability of survival was 92.8%. CONCLUSIONS: Revascularization using mammary and radial artery grafts is safe. Complications are not higher than those observed with saphenous vein grafting. It was possible to use arterial conduits in all the patients, even in those with impaired left ventricular function.

[Coronary revascularization surgery with arterial conduits. The technic, results and 4-year follow-up in 1023 consecutive patients]. / Cirugía de revascularización coronaria con conductos arteriales. Técnica, resultados y seguimiento a cuatro años en 1,023 pacientes consecutivos.

OBJECTIVE: The main objective of the present study was to analyze the in-hospital and mid term results obtained in 1,023 consecutive patients undergoing coronary artery bypass surgery (CABG) in whom a combination of arterial grafts was used: radial arteries (RA) and one or both internal mammary arteries (IMA). METHODS: From May 1995 to May 1998, 1,023 consecutive patients underwent CABG alone, using arterial conduits (AC) (one or two IMA and RA) for myocardial revascularization. The left internal mammary artery (LIMA) was employed as an "in situ" graft, and the right internal mammary artery (RIMA) as a free graft or "in situ" both in combination with the RA. The latter was connected to the LIMA through a T or Y anastomosis, or emerged directly from the ascending portion of the aorta. RESULTS: An average of 3.2 bypasses per patient were performed. The LIMA was used in 100% of the patients. The RIMA was used in 21.7% and the RA in 100% of the cases. Operative mortality was 2.5% (26 patients) and 32 (3.1%) suffered perioperative acute myocardial infarction. The first 62 patients were angiographically re-studied before discharge, and a 98.4% patency of the AC used was found. Mean follow up time was 25.0 +/- 9.6 months (range, 1 to 48 months). CONCLUSIONS: a) myocardial revascularization procedures using a combination of mammary and RA grafts are safe; b) in-hospital and mid term morbidity and mortality are not higher than those observed with saphenous vein grafts; c) it is possible to achieve complete myocardial revascularization with only AC, even in patients with impaired left ventricular function, and d) AC can be used in elderly patients.