Ivabradine plus conventional treatment vs conventional treatment alone in reducing the mean heart rate in heart transplant recipients: A randomized clinical trial.

The absence of afferent nerves for heart rate (HR) regulation leaves the transplanted heart under the influence of its internal and hormonal control. The HR of heart transplantation (HTx) recipients varies from to 90-110 bpm, indicating a lack of vagal parasympathetic tone. We hypothesized that the reduction in mean HR using an If-channel antagonist (ivabradine) could be effective and safe in HTx recipients. The primary objective of this open-label randomized clinical trial was to compare the mean HR at 3, 6, 12, 18, 24, 30, and 36 months after randomization between an ivabradine plus conventional treatment group (IG) and conventional treatment alone group (CG). The secondary objectives were reduction in mortality, graft dysfunction, and ventricular mass. All patients were randomized between 1 and 12 months after HTx. Ivabradine started at randomization. Of the 35 patients, 54.28% were in the CG and 45.72% in the IG. There were no significant between-group differences in demographics. Over time, the HR differences between the groups became significant (P < .01). There were no significant between-group differences in mortality, graft dysfunction, and ventricular mass. We conclude that ivabradine could effectively and consistently reduce the HR in HTx recipients.

Donor hypernatremia and smoking addiction contribute to primary graft failure in heart transplantation.

INTRODUCTION: Primary graft failure (PGF) is an important contributor to early mortality, accounting for 41% of deaths within the first 30 days after heart transplantation (HT). Donor hypernatremia has been associated with PGF development. However, controversial data exist regarding the impact of sodium deregulation in patient survival after HT. This study aimed to assess the influence of donor hypernatremia on PGF development and to determine the serum sodium level threshold to assist in decision-making for organ procurement. METHODS: The medical record from 200 HT patients and organ donors were retrospectively assessed and categorized by PGF occurrence. Donor sodium levels were compared and cut-off points obtained by receiver operating characteristic (ROC) curve. A multiple logistic regression model was applied to assess the effects of factors and covariates that influence PGF development. RESULTS: Sodium levels of donors were significantly higher in recipients who developed PGF than those who did not develop PGF (162 vs. 153 mmol/L, P = .001). The sodium cut-off value determined by the ROC curve was 159 mmol/L. The group who received organs from donors with a serum sodium concentration ≥159 mmol/L had a higher incidence of PGF (63.3% vs 32.4%, P < .001). Furthermore, donor sodium levels ≥159 mmol/L increased the likelihood of recipients developing PGF by 3.4 times. It is also observed that the incidence of donor smoking addiction was significantly higher in the PGF group (28.6% vs. 11.5%, P = .004) and donor smoking addiction increased the risk of developing PGF by 2.8 times. CONCLUSION: Smoking addiction and the application of suboptimal organs from donors with hypernatremia contribute to primary graft failure in heart transplantation.

Autologous blood salvage in cardiac surgery: clinical evaluation, efficacy and levels of residual heparin.

OBJECTIVE: Intraoperative blood salvage (cell saver technique) in cardiac surgery is universally used in surgical procedures with a marked risk of blood loss. The primary objectives of this study were to determine the concentration of residual heparin in the final product that is reinfused into the patient in the operating room and to evaluate the efficacy and safety of the cell saver technique. METHOD: Twelve patients undergoing elective cardiac surgery were enrolled in this study. Using the XTRA Autotransfusion System, blood samples were collected from the cardiotomy reservoir, both prior to blood processing (pre-sample) and after it, directly from the bag with processed product (post-sample). Hematocrit and hemoglobin levels, the protein, albumin and residual heparin concentrations, hemolysis index, and the platelet, erythrocyte and leukocyte counts were measured. RESULTS: Hematocrit and hemoglobin levels and red blood cell counts were higher in post-processing samples, with a mean variation of 54.78%, 19.81g/dl and 6.84×106/mm3, respectively (p<0.001). The mean hematocrit of the processed bag was 63.49 g/dl (range: 57.2-67.5). The residual heparin levels were ≤0.1IU/ml in all post-treatment analyses (p=0.003). No related adverse events were observed. CONCLUSION: The reduced residual heparin values (≤0.1IU/ml) in processed blood found in this study are extremely important, as they are consistent with the American Association of Blood Banks guidelines, which establish target values below 0.5IU/ml. The procedure was effective, safe and compliant with legal requirements and the available international literature.

A Coronary Artery Anomaly Presenting as Acute Coronary Syndrome: A Case Report.

BACKGROUND Coronary artery anomalies (CAAs) are rare congenital malformations with different clinical presentations and pathophysiological mechanisms. These anomalies are frequently the cause of sudden death in young patients. Most CAAs are incidental findings owing to the lack of symptoms; however, they may be associated with acute coronary syndrome in rare cases. CASE REPORT We describe the case of a 47-year-old man who presented with a 1-day history of progressive typical chest pain and elevated troponin levels. The patient underwent a coronary angiography, which unveiled the anomalous origin of the left main coronary artery arising from the right coronary artery, with an interarterial course between the ascending aorta and the pulmonary artery, without coronary artery disease. Coronary computed tomography angiography confirmed the CAA and its relationship with the symptoms. An uneventful coronary artery bypass graft was undertaken, and at the 1-year follow-up, the patient was asymptomatic, with a normal stress test. CONCLUSIONS This case depicts the presentation of atypical acute coronary syndrome in a young patient with a rare CAA. In such patients, coronary angiography and coronary computed tomography angiography are essential tools to confirm the diagnosis and to determine treatment. Although controversial, in young individuals presenting CAA with an interarterial course, such as the left main coronary artery arising from the right coronary artery, coronary artery bypass graft may be an important treatment option to avoid sudden death in the future.

Focused Endocardial Septal Ablation: A New Technique to Treat Postmyectomy Recurrent Gradient.

This report describes the case of a 64-year-old woman with a previous diagnosis of obstructive hypertrophic cardiomyopathy who underwent surgical myectomy but who had a persistent midventricular residual gradient. The patient was symptomatic despite medical treatment and chose to undergo percutaneous radiofrequency (RF) ablation focused on the gradient. RF delivery was performed, and the gradient was reduced from the initial 105/68 mm Hg (during Valsalva maneuver/at rest before ablation) to 24/10 mm Hg. This reduction was sustained for the next 12 months. Percutaneous RF ablation may be a reasonable option for second surgical myectomy, and the protocol can be easily reproduced.

Age-related transcriptional modules and TF-miRNA-mRNA interactions in neonatal and infant human thymus.

The human thymus suffers a transient neonatal involution, recovers and then starts a process of decline between the 1st and 2nd years of life. Age-related morphological changes in thymus were extensively investigated, but the genomic mechanisms underlying this process remain largely unknown. Through Weighted Gene Co-expression Network Analysis (WGCNA) and TF-miRNA-mRNA integrative analysis we studied the transcriptome of neonate and infant thymic tissues grouped by age: 0-30 days (A); 31days-6 months (B); 7-12 months (C); 13-18 months (D); 19-31months (E). Age-related transcriptional modules, hubs and high gene significance (HGS) genes were identified, as well as TF-miRNA-hub/HGS co-expression correlations. Three transcriptional modules were correlated with A and/or E groups. Hubs were mostly related to cellular/metabolic processes; few were differentially expressed (DE) or related to T-cell development. Inversely, HGS genes in groups A and E were mostly DE. In A (neonate) one third of the hyper-expressed HGS genes were related to T-cell development, against one-twentieth in E, what may correlate with the early neonatal depletion and recovery of thymic T-cell populations. This genomic mechanism is tightly regulated by TF-miRNA-hub/HGS interactions that differentially govern cellular and molecular processes involved in the functioning of the neonate thymus and in the beginning of thymic decline.

Left Ventricular Reconstruction Surgery in Candidates for Heart Transplantation.

OBJECTIVE: To report our center's experience in the surgical treatment of ventricular reconstruction, an effective and efficient technique that allows patients with end-stage heart failure of ischemic etiology to have clinical improvement and increased survival. METHODS: Observational, clinical-surgical, sequential, retrospective study. Patients with ischemic cardiomyopathy and left ventricular aneurysm were attended at the Heart Failure, Ventricular Dysfunction and Cardiac Transplant outpatient clinic of the Dante Pazzanese Cardiology Institute, from January 2010 to December 2016. Data from 34 patients were collected, including systemic arterial hypertension, ejection fraction, New York Heart Association (NYHA) functional classification (FC), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II value, Society of Thoracic Surgeons (STS) score, ventricular reconstruction technique, and survival. RESULTS: Overall mortality of 14.7%, with hospital admission being 8.82% and late death being 5.88%. Total survival rate at five years of 85.3%. In the preoperative phase, NYHA FC was Class I in five patients, II in 18, III in eight, and IV in three vs. NYHA FC Class I in 17 patients, II in eight, III in six, and IV in three, in the postoperative period. EuroSCORE II mean value was 6.29, P≤0.01; hazard ratio (HR) 1.16 (95% confidence interval [CI] 1.02-1.31). STS mortality/morbidity score mean value was 18.14, P≤0.004; HR 1.19 (95% CI 1.05-1.33). Surgical techniques showed no difference in survival among Dor 81% vs. Jatene 91.7%. CONCLUSION: Surgical treatment of left ventricular reconstruction in candidates for heart transplantation is effective, efficient, and safe, providing adequate survival.

B cell subsets in thymus from infants with Down syndrome

ABSTRACT: B lymphocytes are still poorly characterized in the human thymus, and due to the immunological peculiarities of Down syndrome, a detailed investigation of thymic B lymphocytes and their subsets was performed in <2-year-old infants. This is a period of intense thymic activity, and here we compared thymuses from infants with Down syndrome (DG) and age-matched control group (CG) with heart disease as the only described malformation, no clinical signs of immunodeficiency and normal blood lymphocyte numbers. METHODS: This study, approved by the institutional ethics committee, included 10 thymic samples from DG infants, and 20 from CG infants. Depending on thymus size and the type of surgical approach, babies were submitted to total thymectomy or only the removal of a small thymic fragment (mainly in the DG), always during cardiac surgery in order to correct congenital defects. Flow cytometry was used for immunophenotyping of cell suspension obtained from thymic tissue; and the B lymphocyte topographic localization was investigated by immunohistochemistry, and a quantitative evaluation of B-cells in each region was carried out using methods of digitized images analysis. RESULTS: Flow cytometry revealed that CD20+ cells represent around 1% of total lymphocytes in both groups, with higher naive and lower unswitched memory B lymphocyte frequencies in DG when compared to the CG, while B1 cells were present in much higher frequency in DG than in CG. All the other B-cell subpopulations (transitional, switched memory, plasmablasts and plasmocytes) were statistically equivalent between groups. Immunohistochemistry showed higher frequencies of CD20+ cells in medullary region compared to cortex, without differences between the groups (DG = 16.8% and CG = 17.1% of total cell number), while the cortex region had few B cells in both groups, with significantly lower frequency in DG group, reaching 0.25%, compared with the CG, which showed 0.6%. CONCLUSION: Flow cytometry revealed a different distribution of B-cell subtypes in DG thymus compared to CG and, thus, data obtained from such rare material could be relevant in the characterization and further analysis and understanding of the immunological mechanisms that involve the participation of B lymphocyte subpopulations in the thymus. FAPESP (grant 2014/50489-9).

Minipuberty and Sexual Dimorphism in the Infant Human Thymus.

AIRE expression in thymus is downregulated by estrogen after puberty, what probably renders women more susceptible to autoimmune disorders. Here we investigated the effects of minipuberty on male and female infant human thymic tissue in order to verify if this initial transient increase in sex hormones - along the first six months of life - could affect thymic transcriptional network regulation and AIRE expression. Gene co-expression network analysis for differentially expressed genes and miRNA-target analysis revealed sex differences in thymic tissue during minipuberty, but such differences were not detected in the thymic tissue of infants aged 7-18 months, i.e. the non-puberty group. AIRE expression was essentially the same in both sexes in minipuberty and in non-puberty groups, as assessed by genomic and immunohistochemical assays. However, AIRE-interactors networks showed several differences in all groups regarding gene-gene expression correlation. Therefore, minipuberty and genomic mechanisms interact in shaping thymic sexual dimorphism along the first six months of life.

Use of Doppler Ultrasound for Saphenous Vein Mapping to Obtain Grafts for Coronary Artery Bypass Grafting.

INTRODUCTION: The great saphenous vein is widely used as a graft in coronary artery bypass grafting surgery. Complications due to saphenous vein harvesting can be minimized when using ultrasonography mapping and marking. OBJECTIVE: To analyze by clinical trial the use of vascular ultrasonography to map the saphenous vein in coronary artery bypass grafting to determine viability and dissection site. METHODS: A total of 151 consecutive patients submitted to coronary artery bypass surgery with the use of the great saphenous vein as a graft were selected for this prospective study. They were divided into two groups: Group 1 - 84 patients were submitted to ultrasonographic mapping and marking of the saphenous vein; Group 2 - 67 patients had saphenous vein harvested without any previous study. Both groups were coupled with follow-up on the 1st, 5th and 30th postoperative days. Primary endpoints were need for incision of the contralateral leg and wound complications within 30 days. RESULTS: Both legs had to be incised in 6 (8.95%) patients from Group 2 (P=0.0067). Wound complications occurred in 33 (23.4%) patients within 30 days, 21 (35%) from Group 2 e 12 (14.8%) from Group 1 (OR 3.095, 1.375-6.944, CI 95%, P=0.008). Within 30 days there were 4 (2.8%) deaths, all in Group 2 (P=0.036). CONCLUSION: The use of vascular ultrasonography for mapping of the great saphenous vein in coronary artery bypass surgery has properly identified and evaluated the saphenous vein, significantly reducing wound complications and unnecessary incisions. It would be advisable to use this noninvasive and easy to use method routinely in coronary artery bypass surgery.

Oclusão das comunicações interventriculares musculares congênitas pela técnica híbrida perventricular: indicações, resultados imediatos e tardios / Occlusion of congenital muscle interventricular communications by the perventricular hybrid technique: indications, immediate and late results

OBJETIVOS: Avaliar resultados imediatos e tardios do tratamento perventricular das comunicações interventriculares musculares (CIVm) congênitas em dois centros de referência em cardiopatias congênitas no Brasil. MÉTODOS: Realizado estudo retrospectivo incluindo os pacientes submetidos à oclusão perventricular de CIVm entre 2007 e 2017. Os casos foram divididos em dois grupos de acordo com a indicação do procedimento: tratamento primário (onde a correção da CIVm é o objetivo principal) ou tratamento complementar (onde há associação com outros defeitos). Foram analisados os dados pré-operatórios, intraoperatórios e do pós-operatório imediato e tardio a partir das informações do prontuário médico. RESULTADOS: No período estudado, 21 pacientes foram submetidos a 23 procedimentos para oclusão de CIVm pela técnica híbrida. A mediana de idade foi de 4,6 meses (22 dias-3,2 anos) e a média de peso foi 5,5±1,9 kg. O tratamento primário foi realizado em 9 pacientes com diâmetro de CIV = 9,0(4-17) mm. Dois pacientes tinham bandagem do tronco pulmonar prévia. Neste grupo, o sucesso ocorreu em 8 casos. Em 1 paciente houve deslocamento da prótese com necessidade de correção cirúrgica. Houve 1 óbito tardio por infecção em neonato com comorbidades. O restante do grupo não apresentou nenhum tipo de complicação. Em 12 pacientes foi realizado tratamento complementar, com CIVm=6,9(4,5-16) mm e 4 pacientes com CIVm múltiplas. Oito passaram por procedimentos recentes e 7 por correção cirúrgica concomitante ao procedimento híbrido. Em 11 pacientes a oclusão com prótese foi bem-sucedida e houve 1 óbito associado ao procedimento, não havendo complicações nos demais. Entre todos os pacientes tratados efetivamente pelo método perventricular o tempo médio de seguimento foi de 4,6 anos (8,5 meses-10,6 anos). Nenhum apresentou shunt residual maior que discreto, necessitou de reintervenção não-planejada ou apresentou sintomas cardiovasculares. CONCLUSÃO: O tratamento híbrido para oclusão de CIVm congênitas apresenta altas taxas de sucesso em casos bem selecionados. Pacientes com baixo peso, em condição clínica desfavorável para cirurgia ou com cardiopatias complexas associadas são os principais candidatos para esta técnica. O procedimento mostra baixo índice de lesões residuais, baixa associação com arritmias, insuficiência valvar ou disfunção ventricular com resultados animadores a médio e longo prazo.

Autologous blood salvage in cardiac surgery: clinical evaluation, efficacy and levels of residual heparin

ABSTRACT Objective: Intraoperative blood salvage (cell saver technique) in cardiac surgery is universally used in surgical procedures with a marked risk of blood loss. The primary objectives of this study were to determine the concentration of residual heparin in the final product that is reinfused into the patient in the operating room and to evaluate the efficacy and safety of the cell saver technique. Method: Twelve patients undergoing elective cardiac surgery were enrolled in this study. Using the XTRA Autotransfusion System, blood samples were collected from the cardiotomy reservoir, both prior to blood processing (pre-sample) and after it, directly from the bag with processed product (post-sample). Hematocrit and hemoglobin levels, the protein, albumin and residual heparin concentrations, hemolysis index, and the platelet, erythrocyte and leukocyte counts were measured. Results: Hematocrit and hemoglobin levels and red blood cell counts were higher in post-processing samples, with a mean variation of 54.78%, 19.81 g/dl and 6.84 × 106/mm3, respectively (p < 0.001). The mean hematocrit of the processed bag was 63.49 g/dl (range: 57.2-67.5). The residual heparin levels were ≤0.1 IU/ml in all post-treatment analyses (p = 0.003). No related adverse events were observed. Conclusion: The reduced residual heparin values (≤0.1 IU/ml) in processed blood found in this study are extremely important, as they are consistent with the American Association of Blood Banks guidelines, which establish target values below 0.5 IU/ml. The procedure was effective, safe and compliant with legal requirements and the available international literature.

Long-term Mortality Predictors in Patients with Small Aortic Annulus Undergoing Aortic Valve Replacement with a 19- or 21-mm Bioprosthesis.

Introduction: Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population. Objective: To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis. Methods: In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery. Results: Mean valve index was 0.82±0.08 cm(2)/m(2). Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm(2)/m(2), without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant. Conclusion: A valve index of < 0.75 cm(2)/m(2) did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

Prolongando a sobrevida no paciente transplantado cardíaco / Prolonging survival in heart transplant patients

FUNDAMENTO: A sobrevida média do paciente adulto após transplante cardíaco é de 11 anos. A taxa melhorou expressivamente nas últimas décadas, sendo superior a 85% no primeiro ano. Os principais ganhos ocorrem nos primeiros 6 a 12 meses, contudo a taxa de mortalidade a longo prazo permanece em torno de 3,4% ao ano. O prognóstico é determinado por características do doador, do receptor e do procedimento cirúrgico. A imunossupressão acrescenta risco adicional de infecções oportunistas, diabetes, dislipidemia, hipertensão arterial, neoplasia e insuficiência renal. RELATO DE CASO: MFM, feminina, iniciou acompanhamento no Instituto Dante Pazzanese de Cardiologia (IDPC) em 1988, aos 35 anos, devido a miocardiopatia dilatada de etiologia idiopática com fração de ejeção reduzida. Relatava antecedentes de febre reumática sem cardite, hipertensão arterial sistêmica, miocardite de etiologia indeterminada e uso de marcapasso devido a episódios de taquicardia ventricular. Como se manteve sintomática (CF IV NYHA) apesar do tratamento otimizado para insuficiência cardíaca, foi submetida, aos 43 anos, a transplante cardíaco bicaval e pulmonar. No pós-operatório apresentou rejeição aguda com boa resposta à corticoterapia. Aos 49 anos foi diagnosticada com neoplasia maligna de mama, sendo submetida a mastectomia parcial. Aos 61 anos apresentou angina instável (AI) tratada com intervenção coronariana percutânea (ICP) com stent para artéria descendente anterior (ADA). Após 4 anos houve recorrência do quadro, novamente com ICP para ADA, durante a qual sofreu infarto agudo do miocárdio tipo 4A, sendo necessária ICP com stent para artéria coronária direita. Evoluiu com insuficiência renal crônica por toxicidade aos imunossupressores, com necessidade de hemodiálise e transplante renal. No pósoperatório apresentou nova AI, com diagnóstico de coronariopatia multiarterial, tratada desta vez, com cirurgia de revascularização miocárdica. Após o tratamento das infecções oportunistas, recebeu alta, mantendo boa funcionalidade dos enxertos e assintomática em seguimento clínico ambulatorial. CONCLUSÃO: As complicações pós-transplante são frequentes e podem coexistir como diabetes, dislipidemia, hipertensão arterial e doença renal crônica, e contribuem para o surgimento da doença arterial coronariana, sendo esse diagnóstico retardado devido à desnervação cardíaca. Neoplasias e infecções são frequentes pelo uso contínuo de regimes intensos de imunossupressão. Internações por doença renal descompensada e procedimentos cirúrgicos podem favorecer a rejeição do enxerto. Como foi evidenciado no caso relatado, vigilância, diagnóstico precoce e tratamento adequado dos diferentes tipos de complicação tem contribuído para o aumento da sobrevida desses pacientes em curto e longo prazo.

Estimation of right ventricular mass by two-dimensional echocardiography.

BACKGROUND: This report describes two original echocardiographic approaches to measure right ventricular (RV) mass (RVM). METHODS: In the bullet formula (5/24 pi D1 D2 L), where D1 and D2 are short axes and L the log axis, the RVM is obtained by subtracting the cavity volume from the RV total volume and subsequently multiplying the difference by myocardium density. The second method uses 3 endocardium segments measured at: (1) short axis plane of the aortic valve and left atrium (b1); (2) short axis plane at the midpoint between the tricuspid valve annulus and the apex (b2); and (3) 4-chamber view (h). Those segment lengths are applying in the formula A = [(b1 + b2)/2] x h. The result is multiplied by the wall thickness and by myocardium density. RESULTS: Both formulas were primarily tested in 30 mongrel dogs and have shown good correlation with the true mass ( r = 0.869 with the segments formula and r = 0.819 with the bullet formula). The same method was used in 20 human patients before heart transplant with similar results ( r = 0.810 with the segments formula and r = 0.836 with the bullet formula). CONCLUSIONS: The RVM can be satisfactorily estimated by 2-dimensional echocardiography. The linear regression between the calculated mass (using the smoothest and thinner myocardium thickness) and the actual mass may provide the correction factor for the RVM calculation. Two echocardiographic methods were used to measure right ventricular mass. One of them used a bullet formula variant (5/24 pi D1 D2 L). The second method used 3 endocardium segments measured in 3 2-dimensional echocardiographic planes (short axis of aortic valve and left ventricle, and 4-chamber view), and applied in the formula A = [(b1 + b2)/2] x h. Both formulas have shown good correlation with the true mass in 30 mongrel dogs ( r = 0.869 with the segments formula and r = 0.819 with the bullet formula) and in 20 human patients before heart transplant ( r = 0.810 and r = 0.836, respectively).

Evolução tardia das próteses biológicas e mecânicas em posição aórtica / Late evolution of biological and mechanical prostheses in aortic position

INTRODUÇÃO: Apesar da constante renovação e aprimoramento das próteses valvares cardíacas a decisão sobre substituição por prótese biológica ou mecânica permanece controversa. OBJETIVO: Esse estudo avalia pacientes submetidos à cirurgia para troca valvar aórtica utilizando substituto biológico ou mecânico. MÉTODOS: Estudo observacional, do tipo coorte histórica por análise de prontuário. Foram selecionados 202 pacientes operados entre 2004 e 2008, com seguimento médio de 10 anos. RESULTADOS: A probabilidade de sobrevida livre de óbito por qualquer causa e reoperação foi significativamente maior em pacientes tratados com prótese biológica em comparação com a prótese mecânica (HR = 0,33; 95% intervalo de confiança [IC] 0,13-0,79; p =0,013). Foram observados oito óbitos num período de 10 anos no grupo de pacientes portadores de prótese biológica e cinco no grupo de prótese mecânica. Esses dados correspondem a um percentual ajustado de 6,11% de mortalidade para o grupo de prótese biológica e 7,9% para prótese mecânica (p = 0,68). A análise de reoperação isolada evidenciou uma diferença significativa a favor da prótese mecânica (HR = 0,062; IC = 0,008-0,457; p = 0,006), principalmente para menores de 30 anos, quando analisados por subgrupo. Num período de 10 anos, dezenove pacientes portadores de prótese biológica foram reoperados, correspondendo a um percentual de 21,24% e nenhum paciente do grupo de prótese mecânica. O risco de eventos adversos composto de acidente vascular cerebral, sangramento, endocardite, trombose e regurgitação paraprotética não foi diferente entre os grupos (HR = 1,20; IC 95% = 0,74-1,93; p = 0,44). O risco de sangramento foi significativamente maior em pacientes tratados com prótese mecânica em comparação com a prótese biológica (HR = 3,65; IC 95% = 1,43-9,29; p = 0,0064), porém não houve sangramento fatal. CONCLUSÕES: Não há diferença de mortalidade em 10 anos entre os dois grupos. Há um aumento significativo no risco de reoperação ao se optar por próteses biológicas, principalmente para os menores de 30 anos. Já os pacientes portadores de prótese mecânica têm maior risco de sangramento não fatal. Figura 1 - Curva de Kaplan-Meier para avaliar probabilidade de sobrevida livre de eventos (óbito ou reoperação). Figura 2 - Gráfico de forest plot do efeito dos eventos adversos em relação ao tipo de prótese (mecânica ou biológica).

Age-related transcriptional modules and TF-miRNA-mRNA interactions in neonatal and infant human thymus

The human thymus suffers a transient neonatal involution, recovers and then starts a process of decline between the 1st and 2nd years of life. Age-related morphological changes in thymus were extensively investigated, but the genomic mechanisms underlying this process remain largely unknown. Through Weighted Gene Co-expression Network Analysis (WGCNA) and TF-miRNA-mRNA integrative analysis we studied the transcriptome of neonate and infant thymic tissues grouped by age: 0-30 days (A); 31days-6 months (B); 7-12 months (C); 13-18 months (D); 19-31months (E). Age-related transcriptional modules, hubs and high gene significance (HGS) genes were identified, as well as TF-miRNA-hub/HGS co-expression correlations. Three transcriptional modules were correlated with A and/or E groups. Hubs were mostly related to cellular/metabolic processes; few were differentially expressed (DE) or related to T-cell development. Inversely, HGS genes in groups A and E were mostly DE. In A (neonate) one third of the hyper-expressed HGS genes were related to T-cell development, against one-twentieth in E, what may correlate with the early neonatal depletion and recovery of thymic T-cell populations. This genomic mechanism is tightly regulated by TF-miRNA-hub/HGS interactions that differentially govern cellular and molecular processes involved in the functioning of the neonate thymus and in the beginning of thymic decline.

Abordagem cirúrgica da taquicardia ventricular instável associada a aneurisma de ventrículo esquerdo: resultados da evolução hospitalar / Surgical approach to unstable ventricular tachycardia associated with left ventricular aneurysm: results of hospital evolution

INTRODUÇÃO: O aneurisma do ventrículo esquerdo (VE) é uma complicação do infarto do miocárdio e da doença de Chagas. O CDI é um prótese indicada para prevenção da MS, está indicado quando não há causas removíveis. O aneurisma de VE é uma condição que pode ser tratada cirurgicamente e quando associada a outras abordagens, como a endoaneurismorrafia e a reconstução geométrica do VE, além da ablação com radiofrequência do foco arritmogênico e revascularização miocárdica, pode abolir o circuito da arritmia, melhorar a função ventricular e com isso o prognóstico dos P acometido OBJETIVO: Apresentar a experiência da fase hospitalar da ressecção cirúrgica de aneurisma de VE associado à TV instável. MÉTODOS: Foram analizados, restrospectivamente, os prontuários de 14 P com aneurisma de VE e TVS hemodinamicamente instável (10P com ICo, 4P D. Chagas; média de idade 59±5,2a, variando entre 52 e 70 anos; fração de ejeção média de VE 36±11%). Após a aneurismotomia, procedeu-se a indução da TV com estimulação ventricular programada (EVP) seguida de mapeamento endocárdico. Após a localização da área alvo foi realizada a ablação local com RF utilizando-se o Cardioablate. Nova EVP para reindução da TV era realizada, em caso de não reindução a cirurgia era complementada com a endoaneurismorrafia seguida de reconstrução do VE com retalho de pericárdio. A revascularização miocárdica era a etapa final caso indicada. Após a cirurgia, antes da alta os P eram submetidos a nova EVP. Sendo negativa recebiam alta, com tratamento clínico, em caso positivo submetiam-se ao implante do CDI. RESULTADOS: a TV foi induzida e mapeada com o coração aberto em 8/14 casos permitindo sua localização e ablação. Nos outros casos era realizada ablação de áreas responsáveis pela TVS baseado na morfologia da TV ao ECG. Com essa abordagem em apenas um paciente a TV foi reinduzida após a resseção da área acometida. Em 13 P a TV não mais foi induzida inclusive na alta. Apenas um paciente morreu devido a choque séptico, ainda internado. Um paciente apenas recebeu o CDI. CONCLUSÕES: a) a aneurismectomia de VE com abordagens para arritmia, reconstrução do VE e revascularização miocárdica é conduta eficaz em P com risco de MS; b) a comprovação do sucesso terapêutico quanto à TV pode ser demonstrada ainda na cirurgia e confirmada antes da alta com a EVP; c) a conduta utilizada evitou o implante de CDI na maioria dos casos.

Abordagem cirúrgica da taquicardia ventricular instável associada a aneurisma de ventrículo esquerdo: resultados da evolução hospitalar / Surgical approach to unstable ventricular tachycardia associated with left ventricular aneurysm: results of hospital evolution

INTRODUÇÃO: O aneurisma de VE (ANEUVE) é uma complicação pós IAM e da doença de Chagas. É causa de arritmias, ICC e tromboembolismo. O CDI está indicado para prevenção da morte súbita arrítmica na ausência de causas removíveis. O ANEUVE pode ser ressecado cirurgicamente e, quando, aplica-se outras abordagens (endoaneurismorrafia, reconstrução do VE, revascularização miocárdica e ablação do foco arritmogênico) pode abolir o circuito da arritmia, melhorar a função ventricular e com isso o prognóstico dos pacientes (P). Objetivo: Apresentar a experiência da fase hospitalar da aneurismectomia de VE com TV instável. Métodos: Revisaram-se os prontuários de 14 P com ANEUVE e TVS hemodinamicamente instável (10P com ICo, 4P DCh; média de idade 60±5,6a, variando entre 52 e 70 a; média da FEVE 35±10%). Após a aneurismotomia, procedeu-se a indução da TV com estimulação ventricular programada (EVP) seguida de mapeamento endocárdico. Após a localização da área alvo realizou-se a ablação com cateter com RF (Cardioablate®). Nova EVP era realizada e, em caso de não indução da TV a cirurgia era complementada com a endoaneurismorrafia e reconstrução do VE com retalho de pericárdio. A revascularização miocárdica era a etapa final caso indicada. Antes da alta hospitalar, os P eram submetidos à EVP. Sendo negativa recebiam alta, em tratamento clínico, em caso positivo submetiam-se ao implante do CDI. Resultados: O ANEUVE localizou-se predominantemente na região anterior. A trombose ventricular foi observada em 3/14P (21%). A TV foi induzida e ablacionada com RF em 14/14 casos (100%). Em apenas 1P (7%) a TV foi reinduzida após a aneurismectomia. Houve tendência de melhora da FE no PO em 12/14P (35±9,8 vs. 39±7,7%; p=0,156). Em 13/14P (93%) a TV não mais foi induzida. Um P (7%) morreu por choque séptico, ainda internado. Um P implantou CDI devido a reindução de TV. Os outros P receberam alta estáveis. Conclusões: a) a aneurismectomia com abordagens para TVS é conduta eficaz em P com risco de MS; b) a comprovação do sucesso terapêutico pode ser demonstrada ainda na cirurgia e confirmada antes da alta com a EVP; c) a conduta utilizada evitou o implante de CDI na maioria dos casos.

Risk factors associated with cardiac surgery during pregnancy.

BACKGROUND: This study is aimed at analyzing risk factors for fetal and maternal mortality in cardiac surgery during pregnancy. METHODS: Seventy-four pregnant women underwent cardiac surgery and 58 (78.3%) were followed. The most frequent pathology was valve disease (93.2%). Mitral valve disease was the most prevalent (72.9%), and mitral commissurotomy or replacement was required in 78% of the cases. Most were in functional class III or IV and mean gestational age was 22 weeks. RESULTS: There was functional class improvement after surgery (91% into class I or II), and 70.4% were restored to sinus rhythm. Twenty percent required reoperation. There were five maternal deaths (8.6%) and 11 fetal deaths (18.6%). Several aspects were considered as contributing risk factors for maternal mortality, such as the use of vasoactive drugs and other preoperative medications, age, kind of surgery, reoperation, and functional class. Functional class was the factor that predicted higher risk for maternal death. As to fetal mortality, several factors played a role, such as maternal age more than 35 years, functional class, reoperation, emergency surgery, type of myocardial protection, and anoxic time. CONCLUSIONS: Cardiac surgery during pregnancy is associated with acceptable maternal and fetal mortality rates. These rates may be even lower if the factors mentioned above are maintained under control.