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1.
Transplantation ; 2021 Mar 22.
Artigo em Inglês | MEDLINE | ID: mdl-33756548

RESUMO

BACKGROUND: Heart transplant (HT) recipients may be at higher risk of acquiring SARS-CoV-2 infection and developing critical illness. The aim of this study is to describe characteristics and outcomes of HT recipients infected by SARS-COV-2, from a high-volume transplant center. METHODS: We have described data of all adult HT recipients with confirmed COVID-19 by RT-PCR in nasopharyngeal samples from April 5th,2020 to January 5th, 2021. Outcomes and follow-up were recorded until February 5th, 2021. RESULTS: Forty patients were included. Twenty-four patients (60%) were men; the median age was 53 (40-60) years old; median HT time was 34 months and median follow-up time 162 days. The majority needed hospitalization (83%). Immunosuppressive therapy was reduced/withdrawn in the majority of patients, except from steroids, which were maintained. Seventeen patients (42.5%) were classified as having severe disease according to the ordinal scale developed by the WHO Committee. They tended to have lower absolute lymphocyte count (p<0.001) during follow-up when compared to patients with mild disease. Thirty-day mortality was 12.5%. However, a longer follow-up revealed increased later mortality (27.5%), with median time to death around 35 days. Bacterial nosocomial infections were a leading cause of death. Cardiac allograft rejection (10%) and ventricular dysfunction (12.5%) were also not negligible. CONCLUSIONS: Major findings of this study corroborate other cohorts' results, but it also reports significant rate of later events, suggesting that a strict mid-term surveillance is advisable to HT recipients with COVID-19.

2.
Trop Med Infect Dis ; 6(1)2021 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-33579042

RESUMO

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 has infected over 90 million people worldwide, therefore it is considered a pandemic. SARS-CoV-2 infection can lead to severe pneumonia, acute respiratory distress syndrome (ARDS), septic shock, and/or organ failure. Individuals receiving a heart transplantation (HT) may be at higher risk of adverse outcomes attributable to COVID-19 due to immunosuppressives, as well as concomitant infections that may also influence the prognoses. Herein, we describe the first report of two cases of HT recipients with concomitant infections by SARS-CoV-2, Trypanosoma cruzi, and cytomegalovirus (CMV) dissemination, from the first day of hospitalization due to COVID-19 in the intensive care unit (ICU) until the death of the patients.

3.
Transpl Infect Dis ; : e13567, 2021 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-33448054

RESUMO

BACKGROUND: Chagas disease reactivation (CDR) after heart transplantation is characterized by relapse of the infectious disease with proliferation and dissemination of Trypanosoma cruzi parasites. Serial blood PCR testing is consensually recommended for CDR monitoring, but there is uncertainty about the incremental value in performing the molecular tests in endomyocardial biopsies (EMB). METHODS: We compared qualitative and quantitative results of PCR for T cruzi DNA in 62 pairs of blood and EMB collected with a maximum time interval of 7 days, from 34 heart-transplanted, chagasic patients. RESULTS: Blood PCR resulted positive in 39/62 (62.9%) samples, with PL ranging from 0.14 to 1610.73 (median: 3.31). PCR resulted positive in 8/60 (13.3%) EMB, with PL ranging from 2.82 to 1670.55 (median: 65.63). All blood samples which tested negative presented a paired EMB which also tested negative. However, 31/39 (79.5%) blood samples which tested positive presented a paired EMB which tested negative. There was poor agreement between blood and EMB PCR (kappa = 0.153). CDR affecting the myocardium (myo-CDR) was diagnosed in three occasions. PCR resulted positive in both blood and EMB at the time of myo-CDR, with PL ranging from 0.61 to 1610.73 in blood and 13.8 to 1670.55 in EMB. CONCLUSIONS: Negative PCR for T cruzi in blood rules out myo-CDR, with no value of testing EMB. Positive PCR in blood with high PL is diagnostic for myo-CDR. If PCR in blood results positive with low PL, testing EMB is useful: negative PCR turns unlikely, and positive PCR reinforces greatly the possibility of myo-CDR.

4.
Arq Bras Cardiol ; 115(5): 945-948, 2020 Nov.
Artigo em Português, Inglês | MEDLINE | ID: mdl-33295462

RESUMO

Recent evidence suggests cardiac amyloidosis (CA) is a mostly underdiagnosed condition, particularly in the transthyretin-mediated form, and is a frequent cause of heart failure with preserved ejection fraction (HFpEF) in the elderly. New paradigms about CA also involve the development of disease-modifying specific therapies. This article summarizes these new concepts.

5.
BMC Cardiovasc Disord ; 20(1): 469, 2020 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-33129270

RESUMO

BACKGROUND: Candida prosthetic endocarditis is associated with high mortality rates and valve replacement surgery, together with antifungal treatment, play a major role in eradicating the fungal infection. Valve reoperations in these scenarios may be relatively common due to the high infection relapse rates and, in some cases, heart transplantation may be an imposing therapy for infection resolution and for the heart failure related to the myocardial reoperation injury. Among the many postoperative complications related to heart transplantation, chylopericardium is a rare but challenging example. CASE PRESENTATION: We report the case of a 55-year-old man who was admitted to our hospital with a 1-month history of progressive dyspnea and fatigue. His past medical history included four open-heart surgeries for aortic and mitral valve replacement due to recurrent Candida parapsilosis infective endocarditis. Transthoracic echocardiogram showed a markedly reduced left ventricular systolic function and normofunctioning bioprosthetic valves. An inotropic dependency condition led to heart transplantation surgery. In the early postoperative period, a persistent chylous fluid started to drain from the pericardial tube, compatible with the diagnosis of chylopericardium. The lack of clinical response to total parenteral nutrition and intravenous infusion of octreotide imposed the need of interventional radiology with diagnostic lymphography through cisterna chyli puncture and thoracic duct catheterization, confirming the presence of a lymphatic fistula. A successful treatment outcome was achieved with percutaneous thoracic duct embolization using coils and n-butyl-cyanoacrilate glue, possibiliting hospital discharge. CONCLUSIONS: Fungal endocarditis requires combined treatment (surgical and antimicrobial) for eradication. Valve replacement, while necessary, may lead to severe ventricular deterioration and heart transplantation may be the only viable therapeutic solution. Among the several postoperative complications of heart transplantation, chylopericardium is an uncommon and defiant example. Advances in interventional radiology like the percutaneous embolization allow a less invasive and highly efficient approach for this complication.

6.
Arq. bras. cardiol ; 115(5): 945-948, nov. 2020. tab, graf
Artigo em Português | LILACS, Sec. Est. Saúde SP | ID: biblio-1142261

RESUMO

Resumo Evidências recentes sugerem que a amiloidose cardíaca é uma doença amplamente subdiagnosticada, particularmente na sua forma ligada à transtirretina, podendo ser uma causa comum de insuficiência cardíaca com fração de ejeção preservada (ICFEP) no idoso. Os novos paradigmas sobre a doença incluem o desenvolvimento de novas terapias específicas que modificam a história natural da doença. Este artigo traz uma síntese destes novos conceitos.


Abstract Recent evidence suggests cardiac amyloidosis (CA) is a mostly underdiagnosed condition, particularly in the transthyretin-mediated form, and is a frequent cause of heart failure with preserved ejection fraction (HFpEF) in the elderly. New paradigms about CA also involve the development of disease-modifying specific therapies. This article summarizes these new concepts.


Assuntos
Humanos , Idoso , Insuficiência Cardíaca/etiologia , Amiloidose , Volume Sistólico , Pré-Albumina
7.
ESC Heart Fail ; 7(4): 1744-1752, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32383349

RESUMO

AIMS: Exhaled breath acetone (EBA) has been described as a new biomarker of heart failure (HF) diagnosis. EBA concentration increases according to severity of HF and is associated with poor prognosis, especially in acute decompensated HF. However, there are no data on chronic HF patients. The aim is to evaluate the role of EBA for predicting cardiac and overall mortality in chronic HF patients. METHODS AND RESULTS: In GENIUS-HF cohort, chronic patients were enrolled between August 2012 and December 2014. All patients had left ventricular ejection fraction ≤ 50%, and the diagnosis was established according to Framingham criteria. After consent, patients were submitted to clinical evaluation and exhaled breath collection. EBA identification and quantitative determination were done by spectrophotometry. The clinical characteristics associated with acetone were identified. All participants were followed for 18 months to assess cardiac and overall mortality. Around 700 participants were enrolled in the current analysis. Patients were 55.4 ± 12.2 years old, 67.6% male patients, and 81% New York Heart Association I/II with left ventricular ejection fraction of 32 ± 8.6%. EBA median concentration was 0.6 (0.3-1.2) ug/L. Acetone levels increased with the number of symptoms of HF and were associated with right HF signs/symptoms and liver biochemical changes. EBA at highest quartile (EBA > 1.2ug/L) was associated with a significantly worse prognosis (log rank test, P < 0.001). Cox proportional multivariable regression model revealed that EBA > 1.20ug/L was an independent predictor of cardiac (P = 0.011) and overall (P = 0.010) mortality in our population. CONCLUSIONS: This study shows that EBA levels reflect clinical HF features, especially right HF signs/symptoms. EBA is an independent predictor of cardiac and overall mortality in chronic HF patients.

10.
Am J Transplant ; 20(5): 1451-1453, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31834977

RESUMO

Epipericardial fat necrosis is an uncommon clinical condition of unknown etiology. It typically presents as acute pleuritic chest pain and should be differentiated from acute pulmonary embolism and acute coronary syndrome. This condition is diagnosed by characteristic chest computed tomography findings of an ovoid mediastinal fatty lesion with intrinsic and surrounding soft-tissue stranding. Treatment of epipericardial fat necrosis includes the administration of anti-inflammatory agents, and symptoms usually resolve within a few days after treatment initiation. This disease entity has rarely been reported since it was first described in 1957. Most current knowledge of epipericardial fat necrosis is based on case reports that describe this condition in previously healthy individuals. We present the case of a 39-year-old woman with a history of heart transplant, who presented with chest pain secondary to epipericardial fat necrosis. Serial computed tomography revealed lesion resolution after appropriate treatment.

11.
Transpl Infect Dis ; 22(1): e13209, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31698532

RESUMO

BACKGROUND: Reactivation of Chagas disease after heart transplantation is characterized by proliferation and dissemination of Trypanosoma cruzi parasites to several organs. Reactivation affecting the allograft can simulate acute cellular rejection, from which it should be distinguished through the analysis of endomyocardial biopsies (EMB). METHODS: We evaluated retrospectively 100 EMB collected in the first year of follow-up from 13 heart-transplanted, chagasic patients who presented reactivation and were successfully treated. Additionally, 37 EMB from 8 patients who did not present reactivation constituted the control group. We reviewed histopathology and performed a real-time PCR-based assay in order to evaluate the T cruzi parasitic load of each EMB. RESULTS: The parasitic load of the EMB at the time of reactivation ranged from 22.80 to 190 000/106 cells (median: 1555). In 6 patients, none of the EMB obtained prior to reactivation amplified T cruzi DNA. On the other hand, 10 EMB from 7 patients, obtained 9-105 days before reactivation (median: 26 days), showed parasitic load ranging from 8.25 to 625/106 cells (median: 167.55). In all patients, the parasitic load increased at the time of reactivation, usually sharply. After initiation of treatment, all patients showed negative PCR or a dramatic reduction of the parasitic load in the following EMB. None of the EMB from the control group amplified T cruzi DNA. CONCLUSIONS: Sequential measurement of T cruzi parasitic load in EMB is useful for monitoring Chagas disease reactivation after heart transplantation. Its increase suggests imminent reactivation and its decrease after treatment indicates favorable evolution for cure of the episode of reactivation.


Assuntos
Cardiomiopatia Chagásica/diagnóstico , DNA de Protozoário/isolamento & purificação , Endocárdio/parasitologia , Transplante de Coração/efeitos adversos , Carga Parasitária , Adulto , Idoso , Biópsia , Cardiomiopatia Chagásica/patologia , Diagnóstico Precoce , Endocárdio/patologia , Feminino , Rejeição de Enxerto/parasitologia , Rejeição de Enxerto/prevenção & controle , Técnicas Histológicas , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trypanosoma cruzi
12.
Transplantation ; 104(4): 873-880, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31403557

RESUMO

BACKGROUND: Data on the prevention of fractures after heart transplant (HTx) are controversial in the literature. Understanding the effects of HTx on bone may guide appropriate treatments in this high-risk population. METHODS: Seventy adult HTx patients were followed for 12 months. Clinical and laboratory parameters, bone mineral density, microarchitecture, and vertebral fractures were assessed at baseline (after intensive care unit discharge) and at 6 and 12 months. Patients received recommendations regarding calcium intake and vitamin D supplementation after HTx. RESULTS: At baseline, 27% of patients had osteoporosis, associated with the length of hospitalization before HTx (P = 0.001). Bone mineral density decreased in the first 6 months, with partial recovery later. Bone microarchitecture deteriorated, mainly in the trabecular bone in the first 6 months and cortical bone in the subsequent 6 months. At baseline, 92.9% of patients had vitamin D levels <30 ng/mL and 20.0% <10 ng/mL. Patients also had calcium at the lower limit of normal, high alkaline phosphatase, and high bone resorption biomarker. These abnormalities were suggestive of impaired bone mineralization and normalized at 6 months with correction of vitamin D deficiency. The majority of vertebral fractures were identified at baseline (23% of patients). After multivariate analyses, only a lower fat mass persisted as a risk factor for vertebral fractures (odds ratio, 1.23; 95% confidence interval, 1.04-1.47; P = 0.012). CONCLUSIONS: High frequencies of densitometric osteoporosis, vitamin D deficiency, bone markers abnormalities, and vertebral fractures were observed shortly after HTx. Calcium and vitamin D supplementation should be the first step in correcting bone mineralization impairment before specific osteoporosis treatment.


Assuntos
Densidade Óssea , Remodelação Óssea , Transplante de Coração/efeitos adversos , Osteoporose/etiologia , Fraturas por Osteoporose/etiologia , Fraturas da Coluna Vertebral/etiologia , Adulto , Biomarcadores/sangue , Densidade Óssea/efeitos dos fármacos , Remodelação Óssea/efeitos dos fármacos , Cálcio/uso terapêutico , Suplementos Nutricionais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Osteoporose/diagnóstico , Osteoporose/fisiopatologia , Osteoporose/prevenção & controle , Fraturas por Osteoporose/diagnóstico , Fraturas por Osteoporose/fisiopatologia , Fraturas por Osteoporose/prevenção & controle , Estudos Prospectivos , Fatores de Risco , Fraturas da Coluna Vertebral/diagnóstico , Fraturas da Coluna Vertebral/fisiopatologia , Fraturas da Coluna Vertebral/prevenção & controle , Fatores de Tempo , Resultado do Tratamento , Vitamina D/uso terapêutico
13.
Rev. Soc. Cardiol. Estado de Säo Paulo ; 29(3 Supl): 287-290, jul.-set. 2019.
Artigo em Português | LILACS | ID: biblio-1023063

RESUMO

Existem poucos sistemas de avaliação de mortalidade após transplante cardíaco (TC) que se baseiem em fatores relacionados com o doador e que sejam capazes de predizer o prognóstico. Identificar características dos doadores que têm impacto na sobrevida depois do TC pode contribuir para melhorar os resultados e a alocação de órgãos. Aplicamos um sistema de avaliação americano para predizer a mortalidade pós-TC em uma coorte brasileira. Objetivo: Avaliar um escore americano como preditor de mortalidade depois de TC em uma coorte brasileira. Métodos: Análise de uma base de dados de um centro de TC brasileiro de 2013 a 2015. Foram avaliadas quatro características dos doadores: tempo de isquemia, idade do doador, discordância racial doador/receptor e a função renal do doador. A sobrevida foi estimada pelo teste de log-rank em faixas de pontuação pré-determinadas. Resultados: Foram 110 doadores, 89% homens e 62% brancos. A principal causa de morte foi trauma (66,6%). Os doadores tinham em média 29,8 anos, 18,6 de relação Nitrogênio da ureia sanguínea / Creatinina, 175 minutos de tempo de isquemia e 42% de discordância racial com o receptor. Não houve diferença de sobrevida entre as faixas de pontuação. Conclusão: Apesar de preditor de mortalidade após transplante cardíaco em uma população americana, esse escore não foi útil para uma coorte de transplante brasileira. As diferenças, inclusive a alta taxa de miscigenação pode ser uma explicação para esses achados


here are few systems to assess mortality after heart transplantation (CT) that are based on donor-related factors and can predict prognosis. Identifying donor characteristics that impact post-CT survival can contribute to improved outcomes and organ allocation. We applied a US evaluation system to predict mortality after CT in a Brazilian cohort. Objective: To evaluate an American score as a predictor of mortality following CT in a Brazilian cohort. Method: Database analysis of a Brazilian CT center from 2013 to 2015. Four donor characteristics were evaluated: ischemia time, donor age, donor-recipient race mismatch, and donor renal function. Survival was estimated by the log-rank test in predetermined score ranges. Results: There were 110 donors, 89% male and 62% white. The main cause of death was trauma (66.6%). Donors had a mean age of 29.8 years, a mean blood urea nitrogen / creatinine ratio of 18.6, a mean ischemia time of 175 minutes, and race mismatch with the recipient of 42%. There was no difference in survival between the score ranges. Conclusion: Although it was a predictor of mortality after cardiac transplantation in an American population, this score was not useful for a Brazilian transplant cohort. Differences, including the high rate of miscegenation, may explain these findings


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Doadores de Tecidos , Transplante/mortalidade , Transplante de Coração/mortalidade , Prognóstico , Doenças Cardiovasculares , Análise de Sobrevida , Prevalência , Valor Preditivo dos Testes , Estudos de Coortes , Resultado do Tratamento , Insuficiência Cardíaca/terapia
14.
Arq Bras Cardiol ; 111(3): 436-539, 2018 09.
Artigo em Português | MEDLINE | ID: mdl-30379264
17.
In. Soeiro, Alexandre de Matos; Leal, Tatiana de Carvalho Andreucci Torres; Oliveira Junior, Múcio Tavares de; Kalil Filho, Roberto. Manual da condutas da emergência do InCor: cardiopneumologia / IInCor Emergency Conduct Manual: Cardiopneumology. São Paulo, Manole, 2ª revisada e atualizada; 2017. p.491-498.
Monografia em Português | LILACS | ID: biblio-848485
18.
PLoS One ; 11(12): e0168790, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28030609

RESUMO

BACKGROUND: The identification of new biomarkers of heart failure (HF) could help in its treatment. Previously, our group studied 89 patients with HF and showed that exhaled breath acetone (EBA) is a new noninvasive biomarker of HF diagnosis. However, there is no data about the relevance of EBA as a biomarker of prognosis. OBJECTIVES: To evaluate whether EBA could give prognostic information in patients with heart failure with reduced ejection fraction (HFrEF). METHODS: After breath collection and analysis by gas chromatography-mass spectrometry and by spectrophotometry, the 89 patients referred before were followed by one year. Study physicians, blind to the results of cardiac biomarker testing, ascertained vital status of each study participant at 12 months. RESULTS: The composite endpoint death and heart transplantation (HT) were observed in 35 patients (39.3%): 29 patients (32.6%) died and 6 (6.7%) were submitted to HT within 12 months after study enrollment. High levels of EBA (≥3.7µg/L, 50th percentile) were associated with a progressively worse prognosis in 12-month follow-up (log-rank = 11.06, p = 0.001). Concentrations of EBA above 3.7µg/L increased the risk of death or HT in 3.26 times (HR = 3.26, 95%CI = 1.56-6.80, p = 0.002) within 12 months. In a multivariable cox regression model, the independent predictors of all-cause mortality were systolic blood pressure, respiratory rate and EBA levels. CONCLUSIONS: High EBA levels could be associated to poor prognosis in HFrEF patients.


Assuntos
Acetona/metabolismo , Expiração , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/metabolismo , Adulto , Testes Respiratórios , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico
19.
Einstein (Sao Paulo) ; 13(2): 310-8, 2015.
Artigo em Inglês, Português | MEDLINE | ID: mdl-26154552

RESUMO

Heart transplantation is currently the definitive gold standard surgical approach in the treatment of refractory heart failure. However, the shortage of donors limits the achievement of a greater number of heart transplants, in which the use of mechanical circulatory support devices is increasing. With well-established indications and contraindications, as well as diagnosis and treatment of rejection through defined protocols of immunosuppression, the outcomes of heart transplantation are very favorable. Among early complications that can impact survival are primary graft failure, right ventricular dysfunction, rejection, and infections, whereas late complications include cardiac allograft vasculopathy and neoplasms. Despite the difficulties for heart transplantation, in particular, the shortage of donors and high mortality while on the waiting list, in Brazil, there is a great potential for both increasing effective donors and using circulatory assist devices, which can positively impact the number and outcomes of heart transplants.


Assuntos
Rejeição de Enxerto/complicações , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Infecções Oportunistas/complicações , Complicações Pós-Operatórias , Disfunção Primária do Enxerto/complicações , Brasil , Cardiomiopatia Chagásica/complicações , Cardiomiopatia Chagásica/cirurgia , Rejeição de Enxerto/classificação , Rejeição de Enxerto/fisiopatologia , Transplante de Coração/métodos , Transplante de Coração/tendências , Coração Auxiliar , Humanos , Imunossupressão/efeitos adversos , Imunossupressão/métodos , Neoplasias/induzido quimicamente , Neoplasias/complicações , Doadores de Tecidos/provisão & distribução
20.
Einstein (Säo Paulo) ; 13(2): 310-318, Apr-Jun/2015. tab
Artigo em Inglês | LILACS | ID: lil-751427

RESUMO

ABSTRACT Heart transplantation is currently the definitive gold standard surgical approach in the treatment of refractory heart failure. However, the shortage of donors limits the achievement of a greater number of heart transplants, in which the use of mechanical circulatory support devices is increasing. With well-established indications and contraindications, as well as diagnosis and treatment of rejection through defined protocols of immunosuppression, the outcomes of heart transplantation are very favorable. Among early complications that can impact survival are primary graft failure, right ventricular dysfunction, rejection, and infections, whereas late complications include cardiac allograft vasculopathy and neoplasms. Despite the difficulties for heart transplantation, in particular, the shortage of donors and high mortality while on the waiting list, in Brazil, there is a great potential for both increasing effective donors and using circulatory assist devices, which can positively impact the number and outcomes of heart transplants.


RESUMO O transplante cardíaco é atualmente a abordagem cirúrgica definitiva padrão-ouro no tratamento da insuficiência cardíaca refratária. No entanto, a escassez de doadores limita a realização de um número maior de transplantes cardíacos, situação em que vem aumentando a utilização de dispositivos de assistência circulatória mecânica. Com indicações e contraindicações bem estabelecidas, além de diagnóstico e tratamento de rejeição, por meio de protocolos definidos de imunossupressão, os resultados do transplante cardíaco são muito favoráveis. Dentre as complicações precoces que podem impactar a sobrevida, destacamos a disfunção primária do enxerto, a disfunção do ventrículo direito, rejeição e infecções; já as complicações tardias incluem a doença vascular do enxerto e as neoplasias. Apesar das dificuldades para realização do transplante cardíaco, em especial pela escassez de doadores e pela elevada mortalidade em fila de espera, no Brasil, existe um grande potencial, tanto no aumento de doadores efetivos, quanto na utilização de dispositivos de assistência circulatória, o que pode vir a impactar positivamente no número e nos resultados do transplante cardíaco.


Assuntos
Humanos , Complicações Pós-Operatórias , Infecções Oportunistas/complicações , Transplante de Coração , Disfunção Primária do Enxerto/complicações , Rejeição de Enxerto/complicações , Insuficiência Cardíaca/cirurgia , Doadores de Tecidos/provisão & distribução , Brasil , Cardiomiopatia Chagásica/cirurgia , Cardiomiopatia Chagásica/complicações , Coração Auxiliar , Transplante de Coração/métodos , Transplante de Coração/tendências , Imunossupressão/efeitos adversos , Imunossupressão/métodos , Rejeição de Enxerto/classificação , Rejeição de Enxerto/fisiopatologia , Neoplasias/complicações , Neoplasias/induzido quimicamente
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