Manuel Galiñanes

Autotransplantation of unmanipulated bone marrow into scarred myocardium is safe and enhances cardiac function in humans.

Stem cell transplants into damaged myocardium may have the potential to improve cardiac function. We investigated the safety of transplanting unmanipulated autologous bone marrow into infarcted myocardium of patients undergoing coronary bypass surgery and assessed its efficacy to improve cardiac function. Fourteen patients with one or more areas of transmural myocardial infarction were studied. Autologous bone marrow was obtained by sternal bone aspirate at the time of surgery, diluted in autologous serum at a ratio of 1:2, and then injected 1 cm apart into the mid-depth of the left ventricular scar. There were no deaths, no perioperative myocardial infarctions, and no significant ventricular arrhythmias. Dobutamine stress echocardiography demonstrated overall improvement in the global and regional left ventricular function 6 weeks and 10 months after surgery. Of 34 infarcted left ventricular segments, 11 were injected with bone marrow alone, 13 were revascularized with a bypass graft alone, and 10 received bone marrow transplantation and a bypass graft in combination. Only the left ventricle segmental wall motion score of the areas injected with bone marrow and receiving a bypass graft in combination improved at low dose and at peak dobutamine stress. These findings suggest that transplantation of unmanipulated autologous bone marrow into scar tissue of the human heart is safe and enhances cardiac function only when used in combination with myocardial revascularization. This benefit can be seen after 6 weeks of the bone marrow transplant and is maintained after 10 months of follow-up.

Improving the Diagnosis of Infective Endocarditis in Prosthetic Valves and Intracardiac Devices With 18F-Fluordeoxyglucose Positron Emission Tomography/Computed Tomography Angiography Initial Results at an Infective Endocarditis Referral Center

Background— The diagnosis of infective endocarditis (IE) in prosthetic valves and intracardiac devices is challenging because both the modified Duke criteria (DC) and echocardiography have limitations in this population. The added value of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) and 18F-FDG PET/CT angiography (PET/CTA) was evaluated in this complex scenario at a referral center with a multidisciplinary IE unit. Methods and Results— Ninety-two patients admitted to our hospital with suspected prosthetic valve or cardiac device IE between November 2012 and November 2014 were prospectively included. All patients underwent echocardiography and PET/CT, and 76 had cardiac CTA. PET/CT and echocardiography findings were evaluated and compared, with concordant results in 54% of cases (&kgr;=0.23). Initial diagnoses with DC at admission, PET/CT, and DC+PET/CT were compared with the final diagnostic consensus reached by the IE Unit. DC+PET/CT enabled reclassification of 90% of cases initially classified as possible IE with DC and provided a conclusive diagnosis (definite/rejected) in 95% of cases. Sensitivity, specificity, and positive and negative predictive values were 52%, 94.7%, 92.9%, and 59.7% for DC; 87%, 92.1%, 93.6%, and 84.3% for PET/CT; and 90.7%, 89.5%, 92%, and 87.9% for DC+PET/CT. Use of PET/CTA yielded even better diagnostic performance values than PET/nonenhanced CT (91%, 90.6%, 92.8%, and 88.3% versus 86.4%, 87.5%, 90.2%, and 82.9%) and substantially reduced the rate of doubtful cases from 20% to 8% (P<0.001). DC+PET/CTA reclassified an additional 20% of cases classified as possible IE with DC+PET/nonenhanced CT. In addition, PET/CTA enabled detection of a significantly larger number of anatomic lesions associated with active endocarditis than PET/nonenhanced CT (P=0.006) or echocardiography (P<0.001). Conclusions— 18F-FDG PET/CT improves the diagnostic accuracy of the modified DC in patients with suspected IE and prosthetic valves or cardiac devices. PET/CTA yielded the highest diagnostic performance and provided additional diagnostic benefits.

Incidence and Clinical Consequences of Atrial Fibrillation Within 1 Year of First-Time Isolated Coronary Bypass Surgery

Background—Atrial fibrillation (AF) is the commonest complication during cardiac surgery, however, the long-term prevalence of AF following surgery and its clinical consequences remain unclear. Patients and Methods—To investigate this, 877 consecutive patients undergoing first time CABG were followed for 1 year. Rhythm disturbances were diagnosed from serial ECGs and documented notes. The arrhythmia was treated medically and/or by cardioversion. Results—Out of 877, 17 patients (1.9%) died in the hospital and out of the remaining 860 patients 844 (98.1%) had a complete 1-year follow-up. Patients were divided according to their age: Group I (50 to 59 years), Group II (60 to 69 years) and Group III (70 to 79 years). The prevalence of AF in the general population was taken from the Framingham Heart Study. Patients in groups I and II had a higher incidence of AF before the operation than the general population (1.5% versus 0.4% and 3.1% versus 1.6%, respectively, P <0.05) and also higher incidence of AF at the 1-year follow-up (2% versus 0.4% and 4.6% versus 1.6% respectively, P <0.05). The incidence of AF in group III did not differ from the general population before operation, at the 6-week and 1-year follow-ups. As expected most of the patients with preoperative AF remained in AF after 1-year of CABG surgery. Importantly, the incidence of newly developed AF was higher in patients that developed infection and renal dysfunction in the postoperative period. AF did not predict embolic events at any stage of the study. Conclusion—In conclusion, the incidence of AF for the first year following CABG is higher in patients <70 years but not in those >70 years when compared with the general population. AF was also associated to the occurrence of postoperative infection and renal dysfunction. Patients in this study were closely monitored and received timely appropriate treatment, and this may account for the absence of a relationship between AF and embolic events.

Diltiazem and progression of myocardial ischemic damage during coronary artery occlusion and reperfusion in porcine hearts

This study was designed to investigate whether a cardioprotective intervention could delay the completion of necrosis so that subsequent reperfusion would be more useful. Thirty-six pigs were randomly allocated to treatment with diltiazem (15 micrograms/kg per min) or saline solution and to a 60 or 120 minute coronary occlusion period followed by reperfusion. The treatment was begun 15 minutes before coronary occlusion and terminated 75 minutes after reperfusion. Twenty-four hours after the procedure, the heart was sliced and incubated in triphenyltetrazolium chloride. The infarct area and the maximal transmural area of extension of the infarct were calculated by planimetry. The total number of red blood cells in a transmural section was also counted. In the pigs with a 60 minute coronary occlusion, diltiazem (compared with saline solution) significantly reduced infarct size from 9.7 +/- 1.5% of left ventricular mass to 5.9 +/- 0.6% (p less than 0.05) and the percent transmural extension from 0.72 +/- 0.05 to 0.61 +/- 0.05% (p less than 0.05). Red blood cell extravasation in the infarcted area was reduced from 161,934 +/- 59,905 to 78,525 +/- 46,484 cells/mm3 (p less than 0.05) with diltiazem and the percent transmural extension of the hemorrhagic necrosis from 70 +/- 10 to 36 +/- 15% (p less than 0.05). No such differences were observed in the 120 minute coronary occlusion groups. Mean red blood cell counts and the extent of hemorrhagic necrosis did not correlate with either infarct size or transmural extension.(ABSTRACT TRUNCATED AT 250 WORDS)

PEG-SOD and myocardial protection. Studies in the blood- and crystalloid-perfused rabbit and rat hearts.

BackgroundPolyethylene glycol, covalently linked to superoxide dismutase (PEG-SOD), has a long plasma half-life (> 30 hours) and has been proposed as an effective agent for reducing free radicalmediated injury during ischemia and reperfusion. Methods and ResultsUsing an isolated rabbit heart perfused with arterial blood from a support rabbit, we have demonstrated that pretreatment with PEG-SOD (30,000 unitslkg, intravenous bolus, 12–24 hours before 60 minutes of normothermic global ischemia), combined with addition of PEG-SOD to the blood perfusion circuit (30,000 units/kg to the support rabbit) and inclusion of PEG-SOD (150 μg/ml) in a cardioplegic solution, enhanced the postischemic recovery of left ventricular developed pressure (LVDP) from 51±6 to 74±9 mm Hg (p < 0.05; n = 9 per group). In further studies we showed that, whereas maximum protection was obtained when PEG-SOD was given as a combined pretreatment and additive to both the cardioplegic and the reperfusate solutions (postischemic LVDP recovery increased from 44±4% in the control group to 70±3% in the PEG-SOD group), the administration of PEG-SOD during pretreatment plus cardioplegia or during reperfusion alone also resulted in a significant improvement in postischemic function (62±7% and 60±3%, respectively). However, the use of PEG-SOD as a cardioplegic additive alone failed to afford protection (47±4% recovery of LVDP). In dose-response studies (with 0, 3,000, 6,000, 12,000,30,000, or 60,000 units/kg; n = 8 per group), maximum recovery ofLVDP was obtained with the administration of 12,000 units/kg of PEG-SOD. Studies of the plasma activity of PEG-SOD confirmed its long half-life and showed that the treatment with PEG-SOD either 1 hour or 12–24 hours before the study resulted in similar levels of plasma activity. In an attempt to assess any involvement of blood-borne elements in the protection afforded by PEG-SOD, studies were also carried out in the crystalloid-perfused rabbit heart, and no protection was observed. Similarly, no protection was observed at any one of a variety of doses in the crystalloid-perfused rat heart. ConclusionsPEG-SOD can afford protection in the blood-perfused rabbit heart; this protection is dose dependent and probably involves some action of PEG-SOD on blood-borne elements, possibly leukocytes.

The effect of load on atrophy, myosin isoform shifts and contractile function: studies in a novel rat heart transplant preparation.

A novel heterotopic rat heart transplant preparation was used with the objective of investigating the effect of load on cardiac contractile function, mass, myosin and high energy phosphates over a 7-day period. Donor hearts were excised, arrested with a hypothermic (4 degrees C) cardioplegic solution and transplanted (90-min operation time) into the abdomens of recipient rats. The transplanted hearts were reperfused in situ for 7 days. Two groups of hearts (n = 14/group) were studied. Group 1: a conventional unloaded transplanted preparation in which the aorta and pulmonary artery were anastomosed to the abdominal aorta and inferior vena cava, respectively. Group 2: a novel loaded preparation in which, additionally, the left atrium was anastomosed to the inferior vena cava which was then ligated proximally so as to divert distal venous flow to the left ventricle of the transplanted heart. Non-transplanted, fresh hearts served as controls. Seven days after transplantation the hearts were excised and perfused aerobically for 20 min. Systolic and diastolic functions had deteriorated severely in Group 1: left ventricular developed pressure (LVDP) had fallen to 96 +/- 11 v 162 +/- 6 mmHg in fresh controls (at 12 mmHg of end-diastolic pressure) and left ventricular volume to 80 +/- 12 v 268 +/- 20 microliters (P < 0.05 in both instances). In Group 2, LVDP (134 +/- 6 mmHg) and left ventricular volume (144 +/- 6 microliters) were significantly higher than in Group 1 but were still significantly lower than in fresh controls. Coronary flow in absolute terms was similar in all groups; however, when expressed as ml/min/g wet wt, coronary flow tended to be greater in unloaded hearts (19.8 +/- 0.6) than in fresh hearts (15.0 +/- 0.8; P < 0.05) and loaded hearts (17.6 +/- 1.3; N.S.). Unloaded hearts exhibited a significant loss of left ventricular weight (0.40 +/- 0.02 g) when compared with fresh aerobic controls (0.57 +/- 0.02 g; P < 0.05). However, there was no significant weight loss in the loaded hearts (0.53 +/- 0.03 g). The content of V1 isoform of myosin in left ventricular muscle was 77.8 +/- 5.0% in fresh hearts; this was reduced to 60.0 +/- 3.6% in the unloaded hearts (P < 0.05). The value in the loaded hearts (73.2 +/- 3.4%) did not differ significantly from that in fresh controls. The adenine nucleotide pool was similar in all groups. In conclusion, imposing a load on the heterotopically transplanted heart prevents the loss of cardiac mass and the shift of myosin isoforms, however, it does not totally prevent the development of systolic and diastolic dysfunction. The contractile abnormalities do not appear to be related to high energy phosphate content but might well arise as a consequence of the denervation associated with transplantation or the transplantation procedure itself.

Protective effect of nicorandil as an additive to the solution for continuous warm cardioplegia

Experiments were designed to assess whether (1) nicorandil given before global low-flow ischemia or (2) included in low-flow continuous cardioplegia improved the recovery of cardiac function in the isolated rat heart. The first investigated the effect of nicorandil (2, 10, or 100 mumol/L), given for 3 minutes before 30 minutes of normothermic global ischemia, on recovery after 30 minutes of reperfusion. In aerobically perfused hearts, doses of 10 and 100 mumol/L significantly increased coronary flow; the dose of 100 mumol/L exerted a negative inotropic effect. These doses shortened the time to contractile arrest (282 +/- 18 and 276 +/- 22 seconds versus 354 +/- 16 seconds in the control hearts with unmodified ischemia; p < 0.05 in both instances). Nicorandil also improved the postischemic recovery of coronary flow (79.1% +/- 1.7% and 78.0% +/- 1.6%, respectively, versus 71% +/- 1.8%; p < 0.05). However, there was no significant improvement in recovery of contractile function, creatine kinase leakage, or tissue adenosine triphosphate and creatine phosphate contents. Second, pretreatment with nicorandil (10 mumol/L) was shown to increase susceptibility of the hearts to reperfusion-induced ventricular fibrillation from 0% (n = 8) in control hearts to 50% in the drug-treated group (p < 0.05). Third, nicorandil (10 mumol/L) was added to cardioplegic and noncardioplegic solutions infused into the coronary tree throughout 100 minutes of low-flow (0.7 ml/min) ischemia: in eight of nine control hearts electrical activity was maintained throughout, whereas in all nicorandil-treated hearts electrical activity was suppressed for at least part of the time. Nicorandil also reduced the prevalence of ischemic contracture to 0% during continuous infusion of cardioplegic solution (compared with 30% in nicorandil-free control hearts) and improved the recovery of contractile function after 40 minutes of reperfusion. Thus, in the noncardioplegia groups, left ventricular developed pressure recovered to 77.8% +/- 4.0% versus 51.7% +/- 2.6% in control hearts (p < 0.05) and in the cardioplegia groups to 96.2% +/- 4.2% versus 79.7% +/- 5.5% (p < 0.05). Ventricular compliance (the ventricular volume required to achieve a left ventricular end-diastolic pressure of 4 mm Hg) was better preserved in the nicorandil-containing noncardioplegia group (133 +/- 6 microliters) than in the control group (88 +/- 10 microliters; p < 0.05). In conclusion, nicorandil has been shown to (1) reduce ischemic contracture, (2) lessen the effects of ischemic arrest, and (3) improve the postischemic recovery of contractile function. In this species and preparation it may, however, enhance vulnerability to reperfusion-induced arrhythmias.

Protection against injury during ischemia and reperfusion by acadesine derivatives GP-1-468 and GP-1-668: Studies in the transplanted rat heart

BACKGROUND Acadesine (AICAr: 5-amino-4-imidazole carboxamide riboside) has been shown to afford sustained protection against injury during ischemia and reperfusion. The present studies used the heterotopically transplanted rat heart to assess the protective properties of two new acadesine analogs: GP-1-468 and GP-1-668. METHODS AND RESULTS Hearts were excised, arrested with a 2-minute infusion of cardioplegic solution, and subjected to 4 hours of global ischemia (20 degrees C) with cardioplegic reinfusion for 2 minutes every 30 minutes. The hearts were then transplanted (1 hour of additional ischemia) into the abdomens of recipient rats and reperfused in situ for 30 minutes or 24 hours. The hearts were then excised, perfused aerobically for 20 minutes, and contractile function was assessed. GP-1-468 or GP-1-668 was administered to donor rats (20 mg/kg intravenously, 30 minutes before excision). They were also added to the cardioplegic solution (10 mumol/L for GP-1-468, 5 mumol/L for GP-1-343, the active metabolite of GP-1-668) and were also given to recipient rats (20 mg/kg intravenously, 30 minutes before transplantation, so that the drugs were present during reperfusion). Nine groups of hearts were studied. Three groups of studies were carried out (n = 24 transplants for each group). The first group of hearts was reperfused for 30 minutes, the second group was reperfused for 24 hours, and the third group was transplanted but not reperfused; instead, they were frozen at the end of 5 hours of ischemia and taken for metabolite analysis. Within each group were three subgroups (n = 8 per group) receiving GP-1-468, GP-1-668, or saline solution. In the 30-minute reperfusion group the recoveries of left ventricular developed pressure were 88 +/- 4, 87 +/- 7, and 50 +/- 9 mm Hg, respectively (p < 0.05 versus saline-treated controls); left ventricular volumes (recorded at 12 mm Hg) were 112 +/- 20, 132 +/- 28, and 41 +/- 9 microliters, respectively (p < 0.05 versus saline-treated controls), and coronary flows were 13.1 +/- 0.7, 13.4 +/- 1.0, and 9.9 +/- 0.5 ml/min, respectively (p < 0.05 versus saline-treated controls). In addition to improving functional recovery, the two analogs increased the tissue content of adenosine at the end of the ischemic period (5.4 +/- 0.6 and 7.3 +/- 0.5 mumol/gm dry weight, respectively, versus 2.7 +/- 0.4 mumol/gm dry weight in the saline-treated controls; p < 0.05); however, they did not influence adenosine triphosphate or its catabolites. In the 24-hour reperfusion group the corresponding values were 77 +/- 6 and 88 +/- 6 versus 35 +/- 4 mm Hg for left ventricular developed pressure (p < 0.05), 111 +/- 9 and 121 +/- 11 versus 41 +/- 8 microliters for left ventricular volume (p < 0.05), and 13.7 +/- 0.7 and 13.0 +/- 0.6 versus 11.7 +/- 0.7 ml/min for coronary flow (no significant difference). Thus both analogs afforded an early and comparable degree of protection of contractile function that was sustained even after 24 hours of reperfusion. CONCLUSIONS Both GP-1-468 and GP-1-668 increase the rate and extent of early postischemic recovery, and this protection is sustained for at least 24 hours. These beneficial actions were associated with an increase of the tissue content of adenosine during ischemia, but they appeared to be independent of the status of the high-energy metabolism.

Diacylglycerol-induced protection against injury during ischemia and reperfusion can be achieved without activation of protein kinase C in the rat heart: Comparative studies with ischemic preconditioning

The role of protein kinase C (PKC) activation in ischemic preconditioning remains controversial. Since diacylglycerol is the endogenous activator of PKC and as such might be expected cardioprotective, we have investigated whether: (i) the diacylglycerol analog 1,2-dioctanoyl-sn-glycerol (DOG) can protect against injury during ischemia and reperfusion; (ii) any effect is mediated via PKC activation; and (iii) the outcome is influenced by the time of administration. Isolated rat hearts were perfused with buffer at 37 degrees C and paced at 400 bpm. In Study 1, hearts (n=6/group) were subjected to one of the following: (1) 36 min aerobic perfusion (controls); (2) 20 min aerobic perfusion plus ischemic preconditioning (3 min ischemia/3 min reperfusion+5 min ischemia/5 min reperfusion); (3) aerobic perfusion with buffer containing DOG (10 microM) given as a substitute for ischemic preconditioning; (4) aerobic perfusion with DOG (10 microM) during the last 2 min of aerobic perfusion. All hearts then were subjected to 35 min of global ischemia and 40 min reperfusion. A further group (5) were perfused with DOG (10 microM) for the first 2 min of reperfusion. Ischemic preconditioning improved postischemic recovery of LVDP from 24+/-3% in controls to 71+/-2% (P < 0.05). Recovery of LVDP also was enhanced by DOG when given just before ischemia (54+/-4%), however, DOG had no effect on the recovery of LVDP when used as a substitute for ischemic preconditioning (22+/-5%) or when given during reperfusion (29+/-6%). In Study 2, the first four groups of study were repeated (n=4-5/group) without imposing the periods of ischemia and reperfusion, instead hearts were taken for the measurement of PKC activity (pmol/min/mg protein+/-SEM). PKC activity after 36 min in groups (1), (2), (3) and (4) was: 332+/-102, 299+/-63, 521+/-144, and 340+/-113 and the membrane:cytosolic PKC activity ratio was: 5.6+/-1.5, 5.3+/-1.8, 6.6+/-2.7, and 3.9+/-2.1 (P=NS in each instance). In conclusion, DOG is cardioprotective but under the conditions of the present study is less cardioprotective than ischemic preconditioning, furthermore the protection does not appear to necessitate PKC activation prior to ischemia.

Diacylglycerol-induced protection against injury during ischemia and reperfusion in the rat heart:: Comparative studies with ischemic preconditioning

The role of protein kinase C (PKC) activation in ischemic preconditioning remains controversial. Since diacylglycerol is the endogenous activator of PKC and as such might be expected cardioprotective, we have investigated whether: (i) the diacylglycerol analog 1,2-dioctanoyl-sn-glycerol (DOG) can protect against injury during ischemia and reperfusion; (ii) any effect is mediated via PKC activation; and (iii) the outcome is influenced by the time of administration. Isolated rat hearts were perfused with buffer at 37 degrees C and paced at 400 bpm. In Study 1, hearts (n=6/group) were subjected to one of the following: (1) 36 min aerobic perfusion (controls); (2) 20 min aerobic perfusion plus ischemic preconditioning (3 min ischemia/3 min reperfusion+5 min ischemia/5 min reperfusion); (3) aerobic perfusion with buffer containing DOG (10 microM) given as a substitute for ischemic preconditioning; (4) aerobic perfusion with DOG (10 microM) during the last 2 min of aerobic perfusion. All hearts then were subjected to 35 min of global ischemia and 40 min reperfusion. A further group (5) were perfused with DOG (10 microM) for the first 2 min of reperfusion. Ischemic preconditioning improved postischemic recovery of LVDP from 24+/-3% in controls to 71+/-2% (P < 0.05). Recovery of LVDP also was enhanced by DOG when given just before ischemia (54+/-4%), however, DOG had no effect on the recovery of LVDP when used as a substitute for ischemic preconditioning (22+/-5%) or when given during reperfusion (29+/-6%). In Study 2, the first four groups of study were repeated (n=4-5/group) without imposing the periods of ischemia and reperfusion, instead hearts were taken for the measurement of PKC activity (pmol/min/mg protein+/-SEM). PKC activity after 36 min in groups (1), (2), (3) and (4) was: 332+/-102, 299+/-63, 521+/-144, and 340+/-113 and the membrane:cytosolic PKC activity ratio was: 5.6+/-1.5, 5.3+/-1.8, 6.6+/-2.7, and 3.9+/-2.1 (P=NS in each instance). In conclusion, DOG is cardioprotective but under the conditions of the present study is less cardioprotective than ischemic preconditioning, furthermore the protection does not appear to necessitate PKC activation prior to ischemia.