Alessandro Wasum Mariani

Histologic and functional evaluation of lungs reconditioned by ex vivo lung perfusion

BACKGROUND Only about 15% of donor lungs are considered suitable for transplantation (LTx). Ex vivo lung perfusion (EVLP) has been developed as a method to reassess and repair damaged lungs. We report our experience with EVLP in non-acceptable donor lungs and evaluate its ability to recondition these lungs. METHODS We studied lungs from 16 brain-dead donors rejected for LTx. After harvesting, the lungs were stored at 4°C for 10 hours and subjected to normothermic EVLP with Steen Solution (Vitrolife, Göteborg, Sweden) for 60 minutes. For functional evaluation, the following variables were assessed: partial pressure of arterial oxygen (Pao(2)), pulmonary vascular resistance (PVR), and lung compliance (LC). For histologic assessment, lung biopsy was done before harvest and after EVLP. Tissue samples were examined under light microscopy. To detect and quantify apoptosis, terminal deoxynucleotide transferase-mediated deoxy uridine triphosphate nick-end labeling assay was used. RESULTS Thirteen lung donors were refused for having impaired lung function. The mean Pao(2) obtained in the organ donor at the referring hospital was 193.7 mm Hg and rose to 489 mm Hg after EVLP. During EVLP, the mean PVR was 652.5 dynes/sec/cm(5) and the mean LC was 48 ml/cm H(2)O. There was no significant difference between the mean Lung Injury Score before harvest and after EVLP. There was a trend toward a reduction in the median number of apoptotic cells after EVLP. CONCLUSIONS EVLP improved lung function (oxygenation capacity) of organs considered unsuitable for transplantation. Lung tissue structure did not deteriorate even after 1 hour of normothermic perfusion.

Medical teaching beyond graduation: undergraduate study groups

Continuing with our series of discussion papers on extension activities and their importance for present-day medical training, we will now cover undergraduate study groups within medicine. Although there are different formats for such entities, we can define them as nonprofit student organizations that create opportunities for in structional, scientific, cultural and social activities for their members, always covering a certain field within health care, with the aims of achieving learning and development. They are administered by the students themselves, but with guidance from teaching staff. 1

Perfusão pulmonar ex vivo: experiência nacional inicial

In the last 20 years, lung transplantation has become the standard treatment for patients with end-stage lung disease. However, less than 20% of the donor lungs available for transplant are actually usable. This disparity between the growing number of recipients and the small number of donors has resulted in increased mortality among lung transplant candidates on waiting lists. Strategies such as the utilization of organs from marginal donors have proven ineffective in increasing the number of transplants. In 2000, a new method for reconditioning human lungs that had been previously rejected for transplantation was developed in Sweden. We describe our initial experience with ex vivo lung perfusion.

Telemedicine: a technological revolution

Instituto do Coracao (InCor), Hospital das Clinicas (HC), Faculdade de Medicina da Universidade de Sao Paulo (FMUSP) Telemedicina ou telessaude representam termos que englobam o uso da tecnologia de comunicacao para fins de atencao a saude, seja na disseminacao do conhecimento, seja no atendimento ao paciente, na consultoria remota por um especialista etc. Com aproximadamente 40 anos de evolucao esse segmento da medicina, ja nao tao novo assim, ainda e recebido com desconfianca por muitos profissionais. Todavia, seu crescimento e inequivoco e sustentado. Iniciativas e programas baseados em telemedicina sao cada vez mais presentes na pratica moderna da medicina. Os Estados Unidos representam nao somente o berco da telemedicina, mas tambem o pais onde sua pratica esta firmemente consolidada. Alguns exemplos de sua aplicacao na medicina norte-americana incluem: monitorizacao remota de sinais vitais; transmissao de imagens para interpretacao e confeccao de laudos de exames radiologicos, anatomopatologicos, cardiologicos, entre outros; consultas de pacientes via teleconferencia; educacao medica continuada, portais de informacao voltados ao paciente; aplicativos para dispositivos sem fio com informacoes medicas de consulta rapida; assessoria a distância por medico especialista ao medico generalista em contato com o paciente; coleta de dados para pesquisa clinica; entre muitas outras. A American Telemedicine Association e uma associacao sem fins lucrativos, fundada em 1993, que visa o desenvolvimento e a organizacao da telemedicina em territorio norte-americano, e aponta os seguintes beneficios:1 1. A facilidade de acesso: o uso da telemedicina permite que informacoes medicas de alto valor possam chegar e sair, mesmo de areas remotas, sem a necessidade de deslocamento do paciente ou da equipe profissional; 2. Reducao de custos: alem da reducao da necessidade de deslocamento e da reducao do tempo do internacao intra-hospitalar, a maior eficiencia atingida no tratamento ocasiona melhor emprego dos recursos com menor desperdicio; 3. Maior comodidade ao paciente: a reducao da necessidade de deslocamento e a pronta reacao da equipe medica ao aparecimento de alguma alteracao geram maior satisfacao ao paciente e seus familiares. Uma boa perspectiva do crescimento dessa area pode ser observada pela busca dos termos telemedicine e telehealth na base de dados PubMed, que retorna com 14.748 itens, sendo o primeiro datado de 1974. Nota-se que o numero de publicacoes anuais com o tema permaneceu baixo ate a decada de 90, quando essa taxa disparou de poucos para centenas de trabalhos. Essa tendencia de aumento permaneceu nos anos 2000, atingindo pico em 2011, totalizando 1.224 publicacoes indexadas. Varios estudos comprovam os bons resultados do emprego da telemedicina em suas diversas vertentes. Weaver e Murdock, em 2012, demonstraram o valor da telemedicina para a triagem primaria de retinopatia associada a prematuridade. Em um trabalho avaliando um total de 582 exames, todos realizados de forma remota numa populacao de 137 neonatos prematuros, os autores encontraram diagnostico de retinopatia em 13 infantes.2 Um sistema de telemedicina ligada a telefone movel para monitorar arritmias cardiacas foi utilizado por Kirtava e cols. sendo publicado em 2012. Os autores estudaram 35 pacientes com arritmias e 7 voluntarios saudaveis por meio de um dispositivo de telecardiologia, que se mostrou eficiente por diagnosticar alteracoes do ritmo cardiaco, nao so em 3 pacientes, mas tambem surpreendendo com o diagnostico de arritmia em 1 dos voluntarios saudaveis. Esse estudo serviu para demonstrar a viabilidade e a eficiencia da telemedicina na monitorizacao e diagnostico precoce de arritmias em pacientes ambulatoriais.3 Dentre diversos trabalhos estudando a eficacia do emprego da tele-educacao em medicina, Pereira e cols. publicaram recentemente uma experiencia nacional bem sucedida. Os autores estudaram o programa de teleconferencias do Hospital das Clinicas da Universidade Estadual de Campinas com outras instituicoes, nacionais e estrangeiras, no periodo entre setembro de 2009 e agosto de 2010. A avaliacao demonstrou que a telemedicina foi ferramenta valiosa para a educacao, pois promoveu o intercâmbio de conhecimentos, a troca de experiencias, discussoes e desenvolvimento de pesquisas na area.4 A proposito, no Brasil a telemedicina desenvolveu-se fortemente vinculada a educacao medica a distância, sendo utilizada por muitos autores como um sinonimo para tele-educacao em medicina. Diversas universidades brasileiras ja possuem grupos dedicados a telemedicina vinculados a informatica em saude. Estas iniciativas sao fundamentais para o desenvolvimento

Comparison of lung preservation solutions in human lungs using an ex vivo lung perfusion experimental model

OBJECTIVE: Experimental studies on lung preservation have always been performed using animal models. We present ex vivo lung perfusion as a new model for the study of lung preservation. Using human lungs instead of animal models may bring the results of experimental studies closer to what could be expected in clinical practice. METHOD: Brain-dead donors whose lungs had been declined by transplantation teams were used. The cases were randomized into two groups. In Group 1, Perfadex® was used for pulmonary preservation, and in Group 2, LPDnac, a solution manufactured in Brazil, was used. An ex vivo lung perfusion system was used, and the lungs were ventilated and perfused after 10 hours of cold ischemia. The extent of ischemic-reperfusion injury was measured using functional and histological parameters. RESULTS: After reperfusion, the mean oxygenation capacity was 405.3 mmHg in Group 1 and 406.0 mmHg in Group 2 (p = 0.98). The mean pulmonary vascular resistance values were 697.6 and 378.3 dyn·s·cm-5, respectively (p = 0.035). The mean pulmonary compliance was 46.8 cm H2O in Group 1 and 49.3 ml/cm H2O in Group 2 (p = 0.816). The mean wet/dry weight ratios were 2.06 and 2.02, respectively (p = 0.87). The mean Lung Injury Scores for the biopsy performed after reperfusion were 4.37 and 4.37 in Groups 1 and 2, respectively (p = 1.0), and the apoptotic cell counts were 118.75/mm2 and 137.50/mm2, respectively (p = 0.71). CONCLUSION: The locally produced preservation solution proved to be as good as Perfadex®. The clinical use of LPDnac may reduce costs in our centers. Therefore, it is important to develop new models to study lung preservation.

Lung Resection Improves the Quality of Life of Patients With Symptomatic Bronchiectasis

BACKGROUND Bronchiectasis is a significant cause of morbidity. Surgical resection is a treatment option, but its main outcomes regarding quality of life (QOL) and physiologic consequences have not been addressed previously, to our knowledge. We aimed to evaluate the effect of surgical procedures on QOL, exercise capacity, and lung function in patients with bronchiectasis in whom medical treatment was unsuccessful. METHODS Patients with noncystic fibrosis in whom medical treatment was unsuccessful and who were candidates for lung resection were enrolled in a prospective study. The main measurements before lung resection and 9 months afterward were QOL according to the Short Form 36 Health Survey and World Health Organization Quality of Life Questionnaires, lung function test results, and the results of maximal cardiopulmonary exercise testing on a cycle ergometer. RESULTS Of 61 patients who were evaluated, 53 (50.9% male, age 41.3 ± 12.9 years) underwent surgical resection (83% lobectomies), and 44 completed the 9-month follow-up. At baseline, they had low QOL scores, mild obstruction, and diminished exercise capacity. After resection, 2 patients died and adverse events occurred in 24.5%. QOL scores improved remarkably at the 9-month measurements, achieving values considered normal for the general population in most dimensions. Functionally, resection caused mild reduction of lung volume; nevertheless, exercise capacity was not decreased. In fact, 52% of the patients improved their exercise performance. Multiple linear regression analysis showed that low QOL before resection was an important predictor of QOL improvement after resection (p = 0.0001). CONCLUSIONS Lung resection promotes a significant improvement in the QOL of patients with noncystic fibrosis bronchiectasis without compromising their exercise capacity.

Modelo experimental ex vivo com bloco pulmonar dividido

Since they were first established, ex vivo models of lung reconditioning have been evaluated extensively. When rejected donor lungs are used, the great variability among the cases can hinder the progress of such studies. In order to avoid this problem, we developed a technique that consists of separating the lung block into right and left blocks and subsequently reconnecting those two blocks. This technique allows us to have one study lung and one control lung.

Recondicionamento pulmonar ex vivo: uma nova era para o transplante pulmonar

Lung transplantation has come to be viewed as the best treatment option for various end-stage lung diseases. The low number of viable donors continues to be a major obstacle to increasing the number of lung transplants, resulting in high mortality among patients on the waiting list. Unlike transplantation of other solid organs, lung transplantation is primarily limited not by the absolute number of donors but by the viability of the donor lungs, which can be damaged by brain death and by treatments given in the ICU. There are various proposals of ways to increase the number of lung donors: intensification of donation campaigns, use of non-heart-beating donors, living lobar lung transplantation, and adoption of more flexible criteria for donors. However, the proposal that has attracted the most attention from lung transplantation researchers is ex vivo lung perfusion, especially due to the prospect of reconditioning previously discarded lungs. This system consists of perfusion and ventilation of the isolated heart-lung block using a modified cardiopulmonary bypass circuit. Various authors have been studying this technique due to the satisfactory results obtained and the prospect of an increase in the number of organs suitable for transplantation. Researchers in Sweden, Canada, Austria, England, Spain, and Brazil have extensive experience with the method and have introduced modifications to it. The objective of this article was to review the development of, state of the art in, and future prospects for the ex vivo model of lung perfusion and reconditioning.

The Role of Videopericardioscopy in Evaluating Indeterminate Pericardial Effusions

BACKGROUND The pericardial biopsy has opened a new perspective for the etiologic diagnosis of pericardial effusions, because adequate pericardial visualization via the use of a video camera can provide more accurate results. We assessed the usefulness of videopericardioscopy for the diagnosis and treatment of pericardial effusion of indeterminate origin. METHODS We conducted a retrospective study of clinical data from patients who underwent videopericardioscopy examination for pericardial effusion without an established diagnosis. The video-assisted pericardioscopy procedure was performed through a small incision in the xiphoid area. RESULTS From January 1998 to January 2007, 101 consecutive patients underwent videopericardioscopy evaluation for pericardial effusion. Ten patients were excluded because of lack of data. Fifty men and 41 women were included (mean age, 50 years; range, 14-76 years). All of the patients had moderate or significant pericardial effusion as demonstrated by echocardiography or computed tomography. The following diagnoses for the pericardial effusions were established: nonspecific inflammation, 50 cases (54.94%); neoplastic disorders, 22 cases (24.17%); tuberculous, 11 cases (12.08%); bacterial inflammatory process, 3 cases (3.29%); chylopericardial, 2 cases (2.19%); fungal infection, 2 cases (2.19%); and viral infection, 1 case (1.09%). Pericardioscopy evaluation provided the definitive diagnosis via the pericardial biopsy in 36.26% of the cases and via the results of fluid analyses in 13.18% of the cases; the use of both methods established the definitive diagnosis in 45.05% of the cases in this group of patients. The overall morbidity rate was 4.3%, and the most common complication was arrhythmia due to intraoperative manipulation, which ceased with the removal of the instruments from the pericardial cavity. We had 1 death, by cardiac tamponade, in the perioperative period. CONCLUSION Videopericardioscopy is a safe and efficient method for obtaining a better diagnosis of and satisfactory therapeutic results for pericardial effusions of indeterminate cause, and such results are obtained via an improved exploration of the pericardial cavity.

Applications for a hybrid operating room in thoracic surgery: from multidisciplinary procedures to ­­image-guided video-assisted thoracoscopic surgery

The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases.ABSTRACT The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases.