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

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

Revascularização cirúrgica do miocárdio - análise crítica da evolução e estado atual / Surgical mocardial revascularization - critical analysis of its evolution and current state

O desenvolvimento da cinecoronariografia por Sones, no início da década de 1960, abriu caminho para a moderna cirurgia de revascularização do miocárdio. Em 1967, Favarolo realizou as primeiras pontes de veia safena e a técnica se expandiu mundialmente. Apesar de seu começo empolgante, no início da década de 1970, estudos angiográficos mostraram taxas de oclusão dos enxertos venosos, no primeiro ano, entre 10 a 15%. Em 1986, Loop e colaboradores mostraram o aumento da sobrevida dos pacientes em 10 anos, quando utilizava-se a artéria torácica interna esquerda anastomosada na artéria descendente anterior. Lytle, em 1999, indicou que esse benefício era melhorado quando utilizava-se ambas as artérias torácicas internas. Paralelamente, novas técnicas também foram surgindo, como a cirurgia sem o uso da circulação extracorpórea e, também, a partir de 1995, a utilização de mini acesso. Durante todos esses anos, inúmeros estudos foram realizados, dentre eles podemos destacar: o estudo SYNTAX e sua grande contribuição com o desenvolvimento do syntax score ; o estudo Freedom, mostrando que pacientes diabéticos apresentam maior benefício com a cirurgia de revascularização do miocárdio em comparação ao tratamento percutâneo. Em relação às lesões de tronco de coronária esquerda, dois grandes estudos (NOBLE e EXCEL) mostraram que o tratamento percutâneo, em pacientes com syntax score baixo, é uma boa opção terapêutica. Nas síndromes coronarianas agudas sem elevação do segmento ST no eletrocardiograma, a opinião do Heart Team é de extrema importância para decisão de qual tratamento realizar, seja ele clínico, percutâneo ou cirúrgico. Já nas SCA com elevação do segmento ST no eletrocardiograma, o tratamento por cateter, com a colocação de stent, é o preferencial, reservando o tratamento cirúrgico apenas para casos de falha no tratamento percutâneo ou quando há aparecimento de complicações mecânicas

The development of coronary angiography by Sones, in the early 1960s, opened the way for modern myocardial revascularization surgery. In 1967, Favarolo performed the first saphenous vein coronary artery bypass grafting (CABG) surgery, and the technique expanded worldwide. Despite its exciting start, at the beginning of the 1970s, angiographic studies showed vein graft occlusion rates, in the first year, of between 10% and 15%. In 1986, Loop and colleagues showed increased 10-year patient survival when the left anastomosed internal thoracic artery was used in the left anterior descending artery. Lytle, in 1999, indicated that this benefit was improved when both internal thoracic arteries were used. Meanwhile, new techniques were also emerging, such as off-pump CABG and since 1995, the use of minimally invasive surgery. During these years, numerous studies were carried out, including: the SYNTAX Trial, with its major contribution with the development of the syntax score; and the Freedom Trial, which showed that diabetic patients still benefit most from myocardial revascularization surgery compared to percutaneous treatment. In relation to lesions of the left coronary trunk, two large studies (NOBLE and EXCEL) showed that percutaneous treatment in patients with a low syntax score is a good therapeutic option. In acute coronary syndromes without ST segment elevation in the electrocardiogram, the opinion of the Heart Team is extremely important for deciding on the best treatment, be it clinical, percutaneous, or surgical. In ACS with ST segment elevation in the electrocardiogram, catheter treatment with stent placement is the preferred choice, reserving surgical treatment only for cases of percutaneous treatment failure, or where there are mechanical complications.

Dilatação Idiopática do Átrio Direito em Adolescente Assintomático – Relato de Caso / Idiopathic Dilation of the Right Atrium in Asymptomatic Adolescent – Case Report

A dilatação idiopática do átrio direito (AD) é uma condiçãorara, frequentemente assintomática, com tratamentocontroverso, podendo se restringir ao acompanhamentoclínico ou tratamento cirúrgico. Descrevemos aqui um caso deum adolescente com achados ecocardiográficos compatíveiscom essa doença...

Resultados imediatos e seguimento clínico dos pacientes submetidos a implante valvar aórtico transcateter / Immediate results and clinical follow-up of patients undergoing transcatheter aortic-valve implantation

INTRODUÇÃO: Um terço da população idosa portadora de estenose aórtica calcificada sintomática não apresenta condições cirúrgicas em decorrência do elevado risco operatório. O implante valvar aórtico transcateter (IVAT) surgiu como uma alternativa terapêutica para esses pacientes. MÉTODOS: Incluímos, no período de novembro de 2008 a abril de 2012, todos os pacientes submetidos a IVAT em nosso serviço. Relatamos as características clínicas basais, os dados dos procedimentos, os resultados hospitalares e o seguimento clínico dessa população. As definições utilizadas foram baseadas nos critérios do Valve Academic Research Consortium. RESULTADOS: O IVAT foi realizado em 23 pacientes, com 79 ± 6,7 anos de idade, 56% do sexo feminino. O EuroSCORE foi de 20,4 ± 11,1%. A prótese CoreValve® foi utilizada em 19 pacientes (82,6%) e a Edwards SAPIEN TM nos demais. A taxa de sucesso do procedimento foi de 96%. O tempo médio de seguimento clínico foi de 22 ± 12,8 meses, observando-se 6 óbitos (26,1%) nesse período, 3 dos quais ocorreram nos primeiros 30 dias (13%) e outros 2 (21,7%), até o final do primeiro ano. Um paciente apresentou ataque isquêmico transitório na fase hospitalar (4,3%), mas não ocorreram episódios de acidente vascular encefálico ou de infarto do miocárdio no período periprocedimento ou no acompanhamento tardio. O desfecho combinado de segurança aos 30 dias ocorreu em 5 pacientes (21,7%) e o desfecho combinado de eficácia aos 12 meses foi de 78,3%. CONCLUSÕES: Os resultados obtidos neste estudo demonstram o IVAT como procedimento atrativo para o tratamento de pacientes portadores de estenose aórtica calcificada de alto risco cirúrgico.

BACKGROUND: One third of the elderly population with symptomatic calcified aortic stenosis cannot undergo surgery due to their high operative risk. The transcatheter aortic-valve implantation (TAVI) has emerged as an alternative therapy for this group of patients. METHODS: All patients submitted to TAVI from November 2008 to April 2012 were included in our study. We report the baseline clinical characteristics, procedural data, hospital outcomes and clinical follow-up of this population. Definitions were based on the Valve Academic Research Consortium criteria. RESULTS: TAVI was performed in 23 patients, with 79 ± 6.7 years of age, and 56% were female. The EuroSCORE was 20.4 ± 11.1%. The CoreValve® prosthesis was used in 19 patients (82.6%) and the Edwards SAPIEN TM valve was used in the remaining ones. Procedure success rate was 96%. The mean follow-up was 22 ± 12.8 months, with 6 deaths (26.1%) in this period, 3 of which were observed in the first 30 days (13%) and other 2 (21.7%) by the end of the first year. One patient had a transient ischemic attack during hospitalization (4.3%), but there were no episodes of stroke or myocardial infarction in the periprocedural period or in the follow-up. The composite safety endpoint at 30 days was observed in 5 patients (21.7%) and the composite efficacy endpoint at 12 months was 78.3%. CONCLUSIONS: The results of this study demonstrate that TAVI is an attractive procedure for the treatment of patients with calcified aortic stenosis and high operative risk.

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

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

Synergism between keratinocyte growth factor and carboxymethyl chitosan reduces pericardial adhesions.

BACKGROUND: Mesothelial injury is the pivot in the development of adhesions. An increase in the proliferation of mesothelial cells was verified by in vitro studies with the use of keratinocyte growth factor (KGF). This study investigated the influence of KGF associated with thermo-sterilized carboxymethyl chitosan (NOCCts) in the reduction of pericardial adhesions. METHODS: An induction model of pericardial adhesion was carried out in 24 pigs. Animals were randomly allocated to receive topical application of KGF, KGF + NOCCts, NOCCts, or saline (control). At 8 weeks, intrapericardial adhesions were evaluated and a severity score was established. The time spent to dissect the adhesions and the amount of sharp dissection used, were recorded. Histologic sections were stained with sirius red for a morphometric evaluation using a computer-assisted image analysis system. Cytokeratin AE1/AE3 immunostaining were employed to identify mesothelial cells. RESULTS: The severity score expressed in median (minimum to maximum), in relation to the control group (17 [15 to 18]), was lower in the KGF + NOCCts group (7 [6 to 9], p < 0.01) followed by the KGF group (11.5 [9 to 12], 0.01 < p < 0.05) and the NOCCts group (12 [9 to 14], p > 0.05). The dissection time was significantly lower in the KGF + NOCCts group (7.1 + or - 0.6 vs 33.9 + or - 9.2 minutes, p < 0.001). A significantly less sharp dissection was also required in the KGF + NOCCts group. In the adhesion segment, a decreased collagen proportion was found in the KGF + NOCCts group (p < 0.05). Mesothelial cells were present more extensively in groups in which KGF was delivered (p = 0.01). CONCLUSIONS: The use of KGF associated with NOCCts resulted in a synergic action that decreases postoperative pericardial adhesions in a highly significant way.

Surgical myocardial revascularization of patients with ischemic cardiomyopathy and severe left ventricular disfunction.

OBJECTIVE: To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction. METHODS: Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/rest. Survival was determined by Kaplan-Meier analysis. RESULTS: Mean left ventricular ejection fraction was 29+/-4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32+/-5% to 39+/-5%, p <0.001. Gated left ventricular ejection fraction at exercise/rest increased markedly after surgery: from 27+/-8%/23+/-7% to 37+/-5%/31+/-6%, p <0.001. CONCLUSIONS: In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/rest.

Surgical myocardial revascularization of patients with ischemic cardiomyopathy and severe left ventricular disfunction

Objective: To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction. Methods: Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35 percent were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/ rest. Survival was determined by Kaplan-Meier analysis. Results: Mean left ventricular ejection fraction was 29±4 percent (ranged from 9 percent to 35 percent). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7 percent (9 patients). The 4-year survival rate was 89.7 percent. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5 percent. Left ventricular ejection fraction rise from 32±5 percent to 39±5 percent, p <0.001. Gated left ventricular ejection fraction at exercise/ rest increased markedly after surgery: from 27±8 percent/ 23±7 percent to 37±5 percent/ 31±6 percent, p <0.001. Conclusions: In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/ functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/ rest.

Seguimento a longo prazo de pacientes submetidos à revascularização do miocárdio com uso exclusivo de enxertos arteriais / Long-term follow-up of patients undergone coronary artery bypass grafting with exclusive use of arterial grafts

OBJETIVO: Avaliar os resultados a longo prazo da cirurgia de revascularização do miocárdio com o uso exclusivo de enxertos arteriais em pacientes com doença coronariana triarterial. MÉTODOS: Avaliamos 136 pacientes submetidos a cirurgia de revascularização do miocárdio isolada, no período janeiro de 1995 e dezembro de 1997. Utilizaram-se 353 enxertos para revascularizar 449 artérias (média: 3,30 por paciente). Foram utilizadas a artéria torácica interna esquerda (99,2 por cento), artéria torácica interna direita (56,6 por cento), artéria radial (87,5 por cento), artéria gastroepiplóica direita (20,5 por cento) e uma artéria epigástrica inferior. Setenta e seis (55,8 por cento) pacientes receberam enxertos compostos (em "Y") e 66 (48,5 por cento) receberam anastomoses seqüenciais. RESULTADOS: A mortalidade hospitalar foi de 4,4 por cento. No seguimento a longo prazo, (9,5 a 12,8 anos), 82,1 por cento dos pacientes não apresentaram nenhum evento cardíaco. Vinte (17,9 por cento) pacientes necessitaram de reinternação por eventos cardiovasculares; 15 com angina e cinco com infarto agudo do miocárdio, sendo que três apresentaram insuficiência cardíaca associada. Oito (7,1 por cento) pacientes necessitaram de reintervenção por doença coronariana, sendo um reoperado e os demais submetidos a angioplastia com stent. A probabilidade estimada livre de eventos cardíacos foi de 98,2 por cento, 95,4 por cento e 84,2 por cento em 1, 5 e 10 anos, respectivamente. Ocorreram 16 (14,2 por cento) óbitos tardios, sendo quatro deles (3,6 por cento) de causa cardíaca. Sobrevida actuarial em 12,8 anos por todas as causas foi de 85 por cento neste grupo. CONCLUSÃO: Revascularização do miocárdio com o uso exclusivo de enxertos arteriais em pacientes com doença coronariana triarterial é um procedimento seguro, com bons resultados a longo prazo.

OBJECTIVE: To evaluate the long-term results of the coronary artery bypass grafting with exclusive use of arterial grafts for patients with triple vessel disease. METHODS: We evaluated 136 patients who underwent isolated coronary artery bypass grafting between January 1995 and December 1997. 353 grafts were used for revascularization of 449 arteries (mean: 3.30 per patient). Grafts used were left internal thoracic artery (99.2 percent), right internal thoracic artery (56.6 percent), radial artery (87.5 percent), right gastroepiploic artery (20.5 percent) and one inferior epigastric artery. 76 (55.8 percent) patients received composite grafts ("Y" shape) and 66 (48.5 percent) patients received sequential anastomoses. RESULTS: Hospital mortality was 4.4 percent. In the long-term follow-up (9.5 to 12.8 years), 82.1 percent of the patients were free of cardiac events. 20 (17.9 percent) patients had hospital readmission due to cardiac events: 15 presented angina and five presented acute myocardial infarction, and three of them presented associated heart failure. Eigth (7.1 percent) patients needed coronary reintervention: one of them underwent coronary bypass reoperation and the others underwent coronary angioplasty with stent. Estimated probability of cardiac event-free was 98.2 percent, 95.4 percent e 84.2 percent at 1, 5 and 10 years follow-up respectively. There were 16 (14.2 percent) late deaths and four of them (3.6 percent) were cardiac-related. Actuarial 12.8-year-survival of all deaths was 85 percent in this group. CONCLUSION: Coronary artery bypass grafting with exclusive use of arterial grafts is a safe procedure for patients with triple vessel coronary disease with good long-term results.

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

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

[Cell therapy plus transmyocardial laser revascularization: a proposed alternative procedure for refractory angina]. / Terapia celular associada à revascularização transmiocárdica laser como proposta no tratamento da angina refratária.

OBJECTIVE: We tested the hypothesis that TMLR combined with intramyocardial injection of BMC is safe, and may help increase the functional capacity of patient with refractory angina. METHODS: Nine patients (eight men), 65+/-5 years old, with refractory angina for multivessel disease and previous myocardial revascularization procedures (CABG/PCI), not candidates for another procedure due to the extension of the disease were enrolled. TMLR (11+/-3 laser drills) was performed via a limited thoracotomy using a CO2 Heart Laser System. BMC were obtained immediately prior to surgery, and the lymphomonocytic fraction separated by density gradient centrifugation. During surgery, 5 mL containing approximately 1.9+/-0.3 x 10(8) BMC were delivered by multiple injections in the ischemic myocardium. Before (B) and 6 months (6M) after the procedure, patient underwent clinical evaluation and myocardial perfusion assessment by cardiac magnetic resonance imaging (MRI) during pharmacological stress with dypiridamole. RESULTS: No major complications or deaths occurred during the procedure. One patient died after 2 years (non cardiac cause). There was a reduction in the ischemic score as assessed by MRI from 1.64+/-0.10 (B) to 0.88+/-0.09 (6M) (P=0.01). Clinically, there was a reduction in functional class of angina from 3.7+/-0.2 (B) to 1.3+/-0.2 (6M) (P<0.0001). CONCLUSIONS: In this initial experience, the combined strategy of TMLR plus cell therapy appeared to be safe, and may have synergistically acted to reduce myocardial ischemia, with clinically relevant improvement in functional capacity. Provided these data are confirmed in a larger, randomized, controlled trial with longer follow-up, this strategy could be used as a novel therapeutic option for treating pt with refractory angina.

Terapia celular associada à revascularização transmiocárdica laser como proposta no tratamento da angina refratária / Cell therapy plus transmyocardial laser revascularization: a proposed alternative procedure for refractory angina

OBJETIVO: É descrita uma proposição cirúrgica para o tratamento de pacientes com doença arterial coronária (DAC) terminal, não mais passíveis de revascularização miocárdica convencional. Constitui-se na revascularização transmiocárdica com raios laser (RTML), associada ao emprego de células progenitoras hematopoiéticas autólogas (CPH). MÉTODOS: Nove pacientes (oito homens), 65±5 anos, com as características supracitadas foram submetidos ao procedimento combinado. Além da avaliação clínica, o protocolo incluiu o estudo da perfusão miocárdica através da ressonância cardíaca (RMC) sob estresse farmacológico, antes e seis meses após a intervenção cirúrgica. Procedeuse à RMTL através de minitoracotomia esquerda e utilização de laser de CO2, com média de 11±3 tiros por paciente. As CPH foram obtidas por punção medular, seguindo-se sua injeção direta (1,9±0,3x10(8) células/paciente) em múltiplas áreas do miocárdio isquêmico. RESULTADOS: Não ocorreram óbitos ou complicações imediatas decorrentes dos procedimentos. Um paciente faleceu no segundo ano de pós-operatório, de causa não cardíaca (choque séptico). O seguimento clínico pós-operatório desses pacientes revelou redução significativa da classe funcional de angina de 3,7±0,2 para 1,3±0,2 (p<0,0001). Também se verificou redução estatística do índice isquêmico do ventrículo esquerdo (VE) avaliado pela RMC de 1,64±0,10 para 0,88±0,09 (p=0,01). CONCLUSÃO: A associação da terapia celular com a RTML demonstrou-se segura nessa experiência inicial. Caso confirmado esse sinergismo em estudos mais abrangentes, com melhora da angina e redução documentada da isquemia miocárdica, passamos a contar com uma nova possibilidade de tratamento alternativo para esse grave grupo de pacientes.

OBJECTIVE: We tested the hypothesis that TMLR combined with intramyocardial injection of BMC is safe, and may help increase the functional capacity of patient with refractory angina. METHODS: Nine patients (eight men), 65±5 years old, with refractory angina for multivessel disease and previous myocardial revascularization procedures (CABG/PCI), not candidates for another procedure due to the extension of the disease were enrolled. TMLR (11±3 laser drills) was performed via a limited thoracotomy using a CO2 Heart Laser System. BMC were obtained immediately prior to surgery, and the lymphomonocytic fraction separated by density gradient centrifugation. During surgery, 5mL containing approximately 1.9±0.3x10(8) BMC were delivered by multiple injections in the ischemic myocardium. Before (B) and 6 months (6M) after the procedure, patient underwent clinical evaluation and myocardial perfusion assessment by cardiac magnetic resonance imaging (MRI) during pharmacological stress with dypiridamole. RESULTS: No major complications or deaths occurred during the procedure. One patient died after 2 years (non cardiac cause).There was a reduction in the ischemic score as assessed by MRI from 1.64±0.10 (B) to 0.88±0.09 (6M) (P=0.01). Clinically, there was a reduction in functional class of angina from 3.7±0.2 (B) to 1.3±0.2 (6M) (P<0.0001). CONCLUSIONS: In this initial experience, the combined strategy of TMLR plus cell therapy appeared to be safe, and may have synergistically acted to reduce myocardial ischemia, with clinically relevant improvement in functional capacity. Provided these data are confirmed in a larger, randomized, controlled trial with longer follow-up, this strategy could be used as a novel therapeutic option for treating pt with refractory angina.

Long-term follow-up of patients undergone coronary artery bypass grafting with exclusive use of arterial grafts.

OBJECTIVE: To evaluate the long-term results of the coronary artery bypass grafting with exclusive use of arterial grafts for patients with triple vessel disease. METHODS: We evaluated 136 patients who underwent isolated coronary artery bypass grafting between January 1995 and December 1997. 353 grafts were used for revascularization of 449 arteries (mean: 3.30 per patient). Grafts used were left internal thoracic artery (99.2%), right internal thoracic artery (56.6%), radial artery (87.5%), right gastroepiploic artery (20.5%) and one inferior epigastric artery. 76 (55.8%) patients received composite grafts ('Y' shape) and 66 (48.5%) patients received sequential anastomoses. RESULTS: Hospital mortality was 4.4%. In the long-term follow-up (9.5 to 12.8 years), 82.1% of the patients were free of cardiac events. 20 (17.9%) patients had hospital readmission due to cardiac events: 15 presented angina and five presented acute myocardial infarction, and three of them presented associated heart failure. Eighth (7.1%) patients needed coronary reintervention: one of them underwent coronary bypass reoperation and the others underwent coronary angioplasty with stent. Estimated probability of cardiac event-free was 98.2%, 95.4% e 84.2% at 1, 5 and 10 years follow-up respectively. There were 16 (14.2%) late deaths and four of them (3.6%) were cardiac-related. Actuarial 12.8-year-survival of all deaths was 85% in this group. CONCLUSION: Coronary artery bypass grafting with exclusive use of arterial grafts is a safe procedure for patients with triple vessel coronary disease with good long-term results.

Mitral valve replacement with chordae tendineae preservation, traction and fixation in end-stage dilated cardiomyopathy.

OBJECTIVE: This study aimed at evaluating results of mitral valve replacement using a new technique of complete chordae tendineae adjustment for left ventricular remodeling. METHODS: Twenty end-stage idiopathic dilated cardiomyopathy patients with severe functional mitral valve regurgitation underwent mitral valve replacement. Seventeen (85%) were in functional class IV. Both anterior and posterior leaflets of the mitral valve were divided to obtain 4 pillars of chordae tendineae. These were displaced with traction toward the left atrium and anchored between the mitral annulus and a valvular prosthesis. To evaluate the left ventricular remodeling, Doppler echocardiography was performed. For statistical analysis, variance analysis and the Friedman's test were employed. RESULTS: Two (10%) early deaths occurred. Kaplan-Meyer showed survival at one year post-operative was 85%, 2 years it was 44%, at 3 years 44%, at 4 years 44% and at 5 years it was 44%. In the 48- and 54-month follow-ups, the McNemar test showed improvement in the functional class (p<0.001). In the third month of follow-up, variance analysis showed improvement in the ejection fraction (p=0.008) and reductions of the end diastolic diameter (p=0.038), end systolic diameter (p=0.008), end systolic volume (p=0.029) and end diastolic volume (p=0.009). No statistical differences were noted in the systolic volume. Comparing pre-operative and third- and six-month follow-ups, the Friedman test showed no statistical differences for all studied variables. Variance analyses between pre, three-month and final evaluations showed no significant differences. CONCLUSION: This technique of mitral valve replacement improved the left ventricle ejection fraction and decreased the end diastolic and systolic diameters and the end systolic diastolic volumes up to the third month of follow-up. From then on the variables stabilized.

Left ventricular free-wall rupture after acute myocardial infarction imaged by cardiovascular magnetic resonance.

This manuscript describes a rare situation where after acute myocardial infarction a patient underwent cardiovascular magnetic resonance (CMR), which identified a previously undiagnosed rupture of the free wall of the LV, leading to successful surgical management.

Papel da hiperglicemia no infarto agudo do miocárdio / Role of hyperglycemia in acute myocardial infarction

O infarto agudo do miocárdio em diabéticos acarreta maior mortalidade em relação aos não-diabéticos. Recentemente tem se destacado a importância da hiperglicemia aguda como determinante do prognóstico do infarto agudo do miocárdio. Sua presença aumenta a mortalidade, principalmente em pacientes não diabéticos. O bom controle glicêmico nas primeiras 24 horas determina a melhora do prognóstico. Níveis de glicemia acima de 170 mg/dl pioram a evolução de não diabéticos. Variações de glicemia acima de 50 mg/dl e de hemoglobina glicada acima e 2 por cento são deletérias, aumentando a mortalidade em 20 por cento.

Substituição da valva mitral com tração dos músculos papilares em pacientes com miocardiopatia dilatada / Mitral valve replacement with chordae tendineae preservation, traction and fixation in end-stage dilated cardiomyopathy

OBJETIVO: Avaliar a geometria e a função do ventrículo esquerdo (VE) após a troca mitral com tração e fixação dos papilares, em portadores de insuficiência cardíaca terminal com insuficiência mitral secundária. MÉTODO: Dos 20 pacientes avaliados, 70 por cento eram homens, com idade média de 50,2 anos e 55 por cento recebiam inotrópicos. A fração de ejeção (FEVE) foi menor que 30 por cento em todos; 85 por cento estavam em classe funcional (CF) IV. Dezoito receberam próteses de pericárdio bovino e dois, mecânicas. Os períodos considerados foram: 3, 6, 12 e 18 meses. As variáveis consideradas: volume sistólico do VE (VS), a FEVE, os diâmetros sistólico e diastólico finais (DSF e DDF) e os volumes sistólico e diastólico finais (VSF e VDF). No estudo estatístico, empregou-se da análise de variância (AV) e o teste de Friedmann (F). A sobrevida foi aferida pelo método de Kaplan-Meyer. RESULTADOS: Dois (10 por cento) faleceram no período imediato. A sobrevida no primeiro ano foi de 85 por cento, no segundo, 44 por cento, no terceiro, 44 por cento, no quarto, 44 por cento e no quinto, 44 por cento. A comparação entre pré e 3 meses, empregando-se a AV, não revelou alteração significativa para o VS (p=0,086). Houve acréscimo da FEVE (p=0,008) e decréscimo do DDF (p=0,038); do DSF (p=0,008); do VDF (p=0,029) e do VSF (p=0,009). Os momentos pré, 3 e 6 meses, com o teste F, não revelaram alterações. Entre os momentos pré, 3 meses e final, empregando-se a AV, não houve significância. CONCLUSÃO: Há melhora da FEVE, dos VDF, VSF, DDF e DSF; até o terceiro mês. A partir de então, as variáveis permanecem estáveis.

OBJECTIVE: This study aimed at evaluating results of mitral valve replacement using a new technique of complete chordae tendineae adjustment for left ventricular remodeling. METHODS: Twenty end-stage idiopathic dilated cardiomyopathy patients with severe functional mitral valve regurgitation underwent mitral valve replacement. Seventeen (85 percent) were in functional class IV. Both anterior and posterior leaflets of the mitral valve were divided to obtain 4 pillars of chordae tendineae. These were displaced with traction toward the left atrium and anchored between the mitral annulus and a valvular prosthesis. To evaluate the left ventricular remodeling, Doppler echocardiography was performed. For statistical analysis, variance analysis and the Friedman's test were employed. RESULTS: Two (10 percent) early deaths occurred. Kaplan-Meyer showed survival at one year post-operative was 85 percent, 2 years it was 44 percent, at 3 years 44 percent, at 4 years 44 percent and at 5 years it was 44 percent. In the 48- and 54-month follow-ups, the McNemar test showed improvement in the functional class (p<0.001). In the third month of follow-up, variance analysis showed improvement in the ejection fraction (p=0.008) and reductions of the end diastolic diameter (p=0.038), end systolic diameter (p=0.008), end systolic volume (p=0.029) and end diastolic volume (p=0.009). No statistical differences were noted in the systolic volume. Comparing pre-operative and third- and six-month follow-ups, the Friedman test showed no statistical differences for all studied variables. Variance analyses between pre, three-month and final evaluations showed no significant differences. CONCLUSION: This technique of mitral valve replacement improved the left ventricle ejection fraction and decreased the end diastolic and systolic diameters and the end systolic diastolic volumes up to the third month of follow-up. From then on the variables stabilized.