Alejandro Bertolotti

Usefulness of PCR Strategies For Early Diagnosis of Chagas' Disease Reactivation and Treatment Follow-Up in Heart Transplantation

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

Presence of vulnerable coronary plaques in middle-aged individuals who suffered a brain death

AIMS Vulnerable plaques in coronary arteries are frequently found in individuals who died suddenly or due to an acute coronary syndrome. The prevalence and characteristics of these plaques in the middle-aged apparently healthy population are unknown. METHODS AND RESULTS From a total of 652 hearts from transplant donors collected between 1996 and 2007, we selected those from apparently healthy individuals older than 40 years old who died of head trauma or stroke and had no evidence of prior vascular diseases. The coronary arteries were examined by serial sectioning at 3 mm intervals, and all areas of cross-sectional luminal narrowing were processed for histological, immunohistochemical, and morphometric studies. The atherosclerotic plaques were classified according to the American Heart Association Report. A total of 160 hearts were examined. Mean age was 50.3 +/- 5.8 years. Sixty-eight hearts had no advanced coronary atherosclerotic lesions (Type I, II, and III of the American Heart classification). In the remaining 92 hearts, we found 179 plaques considered high-risk lesions (American Heart Association Type IV, V, and VI). These plaques were more frequently found in males (P < 0.001) and in those with a higher heart weight (P < 0.001). The median (25th and 75th percentiles) vascular narrowing value using a planimetric analysis was 32% (21-53). No significant association with the cause of death was found (P = 0.09). CONCLUSION High-risk coronary artery plaques not associated with significant vascular lumen reduction exist in 57% of patients who suffered a brain death with a mean of 1.11 lesions prone to rupture per individual.

Valve operations through a minimally invasive approach

BACKGROUND We analyzed in-hospital results of 87 patients undergoing minimally invasive valvular operations (right parasternal incision through third and fourth cartilages). METHODS Age was 21 to 84 years (mean, 56.2 +/- 16); 45 patients (51.7%) were female. Five (5.7%) had a previous valvular operation and 8 (9.2%) had severe left ventricular dysfunction. Valve diseases were as follows: aortic in 35 patients (40.2%), mitral in 44 (50.5%), double in 5 (5.7%), tricuspid regurgitation in 2 (2.2%), and mitral periprosthetic leak in 1 (1.1%). RESULTS Nineteen mitral repairs (21.9%), 22 replacements (25.3%), 1 leak closure (1.1%), 1 tricuspid repair (1.1%), and 1 replacement (1.1%) were performed. Thirty-one patients (35.7%) underwent aortic replacement, 2 (2.3%) aortic decalcification, 1 (1.1%) subaortic membrane resection, 4 (4.6%) a double-valve procedure, and 5 (5.7%) a single-valve operation combined with myocardial revascularization. In-hospital mortality was 5.7% (5 patients). Univariate analysis was significant for previous operation, New York Heart Association class IV and severe ventricular dysfunction. Multivariate analysis was significant for previous operation and severe ventricular dysfunction. Atrial fibrillation (12.6%) was the most frequent complication. Postoperative stay was 6.5 +/- 6 days. CONCLUSIONS The minimally invasive approach is a useful technique in valvular surgery. Patients with a previous valvular operation, severe ventricular dysfunction, and New York Heart Association class IV dyspnea have higher in-hospital mortality.

Left anterior descending coronary artery bypass grafting through minimal thoracotomy

BACKGROUND In recent years, minimally invasive direct coronary artery bypass grafting has emerged as a valid tool for revascularization in a select group of patients with severe lesions of the left anterior descending coronary artery. Here we report the clinical results using two devices designed by us to facilitate the harvesting of the left internal mammary artery up to its origin and to occlude and stabilize the left anterior descending coronary artery while placing the anastomosis. METHODS From January 1996 to January 1998, 122 patients underwent minimally invasive direct coronary artery bypass grafting in the Department of Cardiac Surgery, Favaloro Foundation. One hundred twelve patients received a single left internal mammary artery-left anterior descending coronary artery bypass graft, and in 10 patients, an additional bypass graft was performed. RESULTS Most patients were discharged on day 2 or 3 after the procedure. Three patients (2.5%) had a perioperative myocardial infarction. The overall hospital mortality rate was 3.3% (4 patients). CONCLUSIONS The combination of team experience, more careful dissection of the left internal mammary artery up to its origin, and use of the stabilizer-occluder and interrupted suture technique for the anastomosis has markedly improved our results.

The International Society for Heart and Lung Transplantation Registries in the Era of Big Data With Global Reach.

REVIEWERS Nancy M. Albert, MSN, Chesterland, OH Selim M. Arcasoy, MD, New York, NY Abbas Ardehali, MD, Los Angeles, CA Robert M. Aris, MD, Chapel Hill, NC Carla C. Baan, MD, Rotterdam, The Netherlands Wayne D. Babcock, MD, Modesto, CA Peter Bergin, MBBS, FRAC, Melbourne, Australia Sangeeta M. Bhorade, MD, Chicago IL Roberta C. Bogaev, MD, San Antonio, TX Dominic C. Borie, MD, PhD, Stanford, CA Robert J. Boucek, Jr., MD, St. Petersburg, FL Robert C. Bourge, MD, Birmingham, AL Caron L. Burch, RN, MSN, FNP, Manhattan Beach, CA Michael Burch, MD, London, United Kingdom Margaret Burke, MB, MRCPath, Harefield, Middlesex, United Kingdom Clifford Chin, MD, Palo Alto, CA Jason D. Christie, MD, Philadelphia, PA David K.C. Cooper, MD, PhD, FRCS, Pittsburgh, PA Paul A. Corris, MD, Newcastle Upon Tyne, United Kingdom Maria G. Crespo-Leiro, MD, La Coruna, Spain Hiroshi Date, MD, Okayama, Japan G. William Dec, MD, Boston, MA Sabine M. DeGeest, RN, PhD, NFESC, Basel, Switzerland Marc DePerrot, MD, Le Plessis-Robinson, France Mary Amanda Dew, PhD, Pittsburgh, PA Debi H. Dumas-Hicks, RN, BS, CCTC, Metairie, LA Niloo M. Edwards, MD, Madison, WI Jim J. Egan, MD, Dublin, Ireland Gregory A. Ewald, MD, St. Louis, MO Albert Faro, MD, Gainesville, FL David S. Feldman, MD, Columbus, OH Roberto Fiocchi, MD, PhD, Bergamo, Italy Stefan Fischer, MD, Hannover, Germany Michael C. Fishbein, MD, Los Angeles, CA Eli Gabbay, FRACP, Perth, Australia Edward R. Garrity, Jr., MD, Maywood, IL James F. George, PhD, Birmingham, AL Allan R. Glanville, MD, FRACP, Sydney, Australia Martin J. Goddard, MD, Cambridge, United Kingdom F. Kate Gould, MB, BS, Newcastle Upon Tyne, United Kingdom Kathleen L. Grady, RN, PhD, Chicago, IL Eduardo G. Gronda, MD, Milan, Italy Elizabeth Hammond, MD, Salt Lake City, UT Paul J. Hauptman, MD, St. Louis, MO Marshall I. Hertz, MD, Minneapolis, MN Roland Hetzer, MD, PhD, Berlin, Germany Stephan W. Hirt, MD, Kiel, Germany Daphne T. Hsu, MD, New York, NY Shahid Husain, MD, Pittsburgh, PA Mariell Jessup, MD, Philadelphia, PA Frances L. Johnson, MD, Baltimore, MD Walter Klepetko, MD, Vienna, Austria Masashi Komeda, MD, PhD, Kyoto, Japan Robert M. Kotloff, MD, Elkins Park, PA Tom Kotsimbos, MD, Melbourne, Australia Christiane Kugler, MSN, RN, Hannover, Germany Guenther Laufer, MD, Innsbruck, Austria Robert D. Levy, MD, FRCP, Vancouver, Canada Robert B. Love, MD, Madison, WI Charles C. Marboe, MD, New York, NY Bruce McManus, MD, PhD, Vancouver, BC, Canada Bruno M. Meiser, MD, Munich, Germany Eric N. Mendeloff, MD, Dallas, TX Bryan F. Meyers, MD, St. Louis, MO Nader Moazami, MD, St. Louis, MO Michael S. Mulligan, MD, Seattle, WA Srinivas Murali, MD, Pittsburgh, PA Yoshifumi Naka, MD, PhD, New York, NY Linda Ohler, RN, MSN, FAAN, Arlington, VA Charlie G. Orosz, PhD, Columbus, OH Francis D. Pagani, MD, PhD, Ann Arbor, MI Scott M. Palmer, MD, Durham, NC Francesco Parisi, MD, Rome, Italy Soon J. Park, MD, San Francisco, CA Si M. Pham, MD, Miami, FL Richard N. Pierson, III, MD, Baltimore, MD Branislav Radovancevic, MD, Houston, TX Vivek Rao, MD, PhD, Toronto,ON, Canada Hermann L. Reichenspurner, PhD, Hamburg, Germany Nancy L. Reinsmoen, PhD, dip ABHI, Durham, NC Richard J.Rodeheffer, MD, Rochester, MN Heather J. Ross, MD, Toronto, ON, Canada Robert E. Shaddy, MD, Salt Lake City, UT Lianne G. Singer, MD, FRCPC, Toronto, ON, Canada Joshua Sonett, MD, New York, NY Randall C. Starling, MD, Cleveland, OH Hans Ulrich Stempfle, MD, Munich, Germany Marc Stern, MD, Suresnes, France Thoralf M. Sundt, MD, Rochester, MN Stuart C. Sweet, MD, PhD, St. Louis, MO George Tellides, MD, New Haven, CT Elbert P. Trulock, MD, St. Louis, MO Steven S.L. Tsui, MD, Cambridge, United Kingdom Patricia A. Uber, PharmD, New Orleans, LA Adrian B. Van Bakel, MD, PhD, Charleston, SC Dirk Van Raemdonck, MD, PhD, Leuven, Belgium Andres Varela, MD, Madrid, Spain Federico Venuta, MD, Rome, Italy Geert M. Verleden, MD, PhD, Leuven, Belgium Erik A.M. Verschuuren, MD, Groningen, The Netherlands John Wallwork, MBChB, FRCS, Cambridge, United Kingdom Richard D. Weisel, MD, Toronto, ON, Canada George M. Wieselthaler, MD, Vienna, Austria David S. Wilkes, MD, Indianapolis, IN Gayle L. Winters, MD, Boston, MA Gordon D. Wu, MD, Los Angeles, CA James B. Young, MD, Cleveland, OH Samuel A. Yousem, MD, Pittsburgh, PA Adriana Zeevi, PhD, Pittsburgh, PA Andreas O. Zuckermann, MD, Vienna, Austria DEVELOPMENT COMMITTEE Mandeep R. Mehra, MD, Co-Chair Leslie W. Miller, MD, Co-Chair Alec Patterson, MD Jon Kobashigawa, MD Mark L. Barr, MD

Open lung biopsy for diffuse disease in patients with and without previously transplanted solid organs.

BACKGROUND Studies on whether surgical lung biopsy (SLB) modifies the treatment of patients with diffuse lung disease are conflicting, and information is limited on whether it alters treatment in solid-organ transplant recipients. Our objective was to determine and compare the rate of treatment change after SLB for diffuse lung disease in patients with and without a history of solid-organ transplantation. METHODS Patients undergoing SLB for diffuse lung disease between March 2004 and March 2009 were identified. A retrospective review was performed. RESULTS Sixty patients had SLB. Thirty-four patients (57%) had solid-organ transplantation. Twenty of 60 patients (33%) had a change in treatment as a result of the findings of the SLB. No significant differences in the treatment change rate were found between the transplant and nontransplant groups (10 of 34 versus 10 of 26; p = 0.46). Transplant patients were more likely to be on mechanical ventilation at the time of SLB (12 of 34 versus 3 of 26; p = 0.03). Mechanical ventilatory support at the time of SLB was associated with increased postoperative complications (odds ratio, 6.20; 95% confidence interval [CI], 1.70 to 22.66; p = 0.006) and in-hospital mortality (odds ratio, 9.75; 95% CI, 2.54 to 37.38; p = 0.001). Being on mechanical ventilation (hazard ratio, 3.91; 95% CI, 1.40 to 10.93; p = 0.009), a diagnosis of cancer (hazard ratio, 13.20; 95% CI, 2.87 to 60.78; p = 0.001), and a history of solid-organ transplantation (hazard ratio, 5.52; 95% CI, 1.08 to 28.14; p = 0.04) were independent predictors of survival. CONCLUSIONS Surgical lung biopsy changes treatment in one third of patients, with no significant difference between patients without transplantation and solid-organ transplant recipients. Patients who undergo SLB while on mechanical ventilation have a significantly increased risk of postoperative complications and death.

Surgical Lung Biopsy in Transplant Patients With Diffuse Lung Disease: How Much Worse When the Lung Is the Graft?

BACKGROUND There are no data that compare the clinical presentation and results of surgical lung biopsy (SLB) for diffuse lung disease (DLD) in lung transplant patients, in contrast to individuals with other type of solid organ grafts. Our objective was to compare the clinical picture, radiologic pattern, pathology results, and outcomes of SLB for DLD in these two subsets of patients. METHODS We retrospectively reviewed the clinical records of transplant patients undergoing SLB for DLD at our institution between 2004 and 2011. Patients with lung transplants and those with other transplants were compared. RESULTS During the study period, 1,232 solid organ transplants were done at our institution. Of these, 49 patients (4%) had DLD that needed SLB for diagnosis, and 24 of these patients had a lung transplant. Dyspnea and a radiologic reticular pattern were more frequent in lung transplant patients, 21 of 24 vs 11 of 25 (p = 0.001) and 14 of 24 vs 7 of 25 (p = 0.03), respectively. Although postoperative complications and in-hospital deaths were more common in lung transplant patients, the differences were not statistically significant. Having the SLB performed for diagnosis, as opposed to being conducted for DLD that did not improve on medical treatment, had a protective effect on multivariate analysis (hazard ratio, 0.39; 95% confidence interval, 0.16 to 0.96; p = 0.042). A prior lung transplant was the only independent predictor of survival (hazard ratio, 4.62; 95% confidence interval, 1.53 to 13.92, p = 0.006). CONCLUSIONS It is relatively uncommon for a solid organ transplant patient with DLD to require a SLB. Clinical and radiologic presentation differ in patients with lung transplants compared with other transplants. Postoperative outcomes are not significantly different between the groups. SLB performed early in the course of the disease might be beneficial. Having a lung transplant is a significant negative predictor of survival.