Noedir A. G Stolf

Transplantation for Chagas' disease: an overview of immunosuppression and reactivation in the last two decades.

Bacal F, Silva CP, Pires PV, Mangini S, Fiorelli AI, Stolf NG, Bocchi EA. Transplantation for Chagas’ disease: an overview of immunosuppression and reactivation in the last two decades.
Clin Transplant 2010 DOI: 10.1111/j.1399‐0012.2009.01202.x.
© 2010 John Wiley & Sons A/S.

Randomized comparative study of radial artery and right gastroepiploic artery in composite arterial graft for CABG.

OBJECTIVES Arterial grafts have been used to achieve better long-term results and improve graft patency in coronary artery bypass grafting. Composite graft was proposed to overcome inconveniences of proximal anastomoses to the aorta and increase the use and surgical options of arterial grafts. However, lack of prospective randomized studies with this kind of grafts is evident. We compare the results of composite Y-grafts of the radial artery (RA) and the right gastroepiploic artery (RGEA) proximally anastomosed to the left internal thoracic artery (LITA) for CABG, evaluated through angiography, in a prospective randomized study. METHODS Between August 1998 and November 1999, 60 patients were randomly divided into two groups: group I (GI) received RGEA graft and group II (GII), RA graft. LITA was used to graft the left anterior descending artery and RGEA or RA was placed to obtuse marginal or first diagonal branch. The right coronary artery branches was grafted with saphenous vein graft (SVG) when necessary. All coronary arteries receiving arterial grafts had > or =75% proximal stenosis and diameter > or =1.5 mm. RESULTS GI and GII preoperative data were similar, 63 distal anastomoses were performed with the LITA, 32 with the RA and 32 with the RGEA. There were two perioperative deaths (3.3%), one in each group, none related to cardiac causes. Four (6.6%) q-wave myocardial infarctions were found and two (3.3%) patients showed low cardiac output syndrome. Angiography was performed in all surviving patients from the 8th to 15th postoperative day and showed a patency rate of 96.5% (56/58) for LITA, 89.6% (26/29) for RA and 68.9% (20/29) for RGEA, with a statistically significant difference between RGEA and RA (P=0.025). CONCLUSIONS Radial artery had better early results than right gastroepiploic artery. Use of the LITA as inflow graft seems not to affect its good patency. Use of the RGEA as composite graft should not be encouraged. Long-term follow-up with objective investigation and randomized trials is required to confirm better results of composite conduits.

Relevance of apoptosis and cell proliferation for survival of patients with dilated cardiomyopathy undergoing partial left ventriculectomy.

Background Cardiomyocyte apoptosis as well as proliferation have been described in congestive heart failure, but their clinical relevance remains unclear. In order to clarify whether apoptosis and cell proliferation occur in patients with idiopathic dilated cardiomyopathy and whether their degree in left ventricle fragments resected during partial left ventriculectomy has any influence on the outcome after this surgery, we compared their occurrence in four groups of patients: group A, short‐term survivors (n = 18); group B, deaths within 6 months of the surgery (n = 13); group C, long‐term survivors (n = 12); and Group D, deaths within 60 months (n = 19).

Refractory angina cell therapy (ReACT) involving autologous bone marrow cells in patients without left ventricular dysfunction: a possible role for monocytes.

Autologous bone marrow mononuclear cell (BMMC) transplantation has emerged as a potential therapeutic option for refractory angina patients. Previous studies have shown conflicting myocardium reperfusion results. The present study evaluated safety and efficacy of CellPraxis Refractory Angina Cell Therapy Protocol (ReACT), in which a specific BMMC formulation was administered as the sole therapy for these patients. The phase I/IIa noncontrolled, open label, clinical trial, involved eight patients with refractory angina and viable ischemic myocardium, without left ventricular dysfunction and who were not suitable for conventional myocardial revascularization. ReACT is a surgical procedure involving a single series of multiple injections (40–90 injections, 0.2 ml each) into ischemic areas of the left ventricle. Primary endpoints were Canadian Cardiovascular Society Angina Classification (CCSAC) improvement at 18 months follow-up and myocardium ischemic area reduction (assessed by scintigraphic analysis) at 12 months follow-up, in correlation with a specific BMMC formulation. Almost all patients presented progressive improvement in angina classification beginning 3 months (p = 0.008) postprocedure, which was sustained at 18 months follow-up (p = 0.004), as well as objective myocardium ischemic area reduction at 12 months (decrease of 84.4%, p < 0.004). A positive correlation was found between monocyte concentration and CCSAC improvement (r = −0.759, p < 0.05). Improvement in CCSAC, followed by correlated reduction in scintigraphic myocardium ischemic area, strongly suggests neoangiogenesis as the main stem cell action mechanism. The significant correlation between number of monocytes and improvement strongly supports a cell-related effect of ReACT. ReACT appeared safe and effective.

Behavior profile of family members of donors and nondonors of organs.

UNLABELLED Organ transplant shortage is a global problem caused by several factors, most of which are related to members of the family, who play a major role in the donation process. OBJECTIVE We sought to determine the most determinant features in the donor profile that relate to positive decisions versus refusal of donation. MATERIAL AND METHODS Fifty-six families who were approached by the Organ Procurement Organization (OPO) from November 2004 to April 2006 agreed to participate in this work. To assess donor profiles, we used a structured interview. RESULTS Parental involvement directly in decisions about donation lead to significantly less frequent consent (P = .005), young donor age was associated with a reduced probability of donation (P = .002), violent death negatively influenced donation consent, excluding suicide (P = .004). CONCLUSION The present study showed violent death, young patient age, and parental donation consent to be the most important factors that make it harder to obtain consent organ donation. When a collateral relative (sibling/uncle) or children were responsible for the donation decision, there was more success of consent.

Validation of a cutoff value on echo Doppler analysis to replace right heart catheterization during pulmonary hypertension evaluation in heart transplant candidates.

BACKGROUND Heart transplantation (OHT) has traditionally been contraindicated in the presence of severe pulmonary hypertension (PH), as detected by right heart catheterization. Noninvasive methods are still not reliably accurate to make this evaluation. OBJECTIVES Determine the efficacy of echo Doppler analysis for the diagnosis of severe PH. METHODS One hundred thirty patients (mean age = 42 +/- 15 years, 82 men) showed severe left ventricular dysfunction (mean ejection fraction = 29 +/- 12%; functional class III-IV). We excluded patients with atrial fibrillation, heart failure secondary to congenital disease, and valvulopathy. The pulmonary parameters defined as severe PH were: systolic pulmonary artery pressure (sPAP) >or= 60 mm Hg; a mean transpulmonary gradient >or= 15; or pulmonary vascular resistance >or= 5 Wood units. Patients underwent a right heart catheterization using a Swan-Ganz catheter to measure hemodynamic parameters and to noninvasively estimate right-sided pressures from spectral Doppler recordings of tricuspid regurgitation velocity (right ventricular systolic pressure [RVsP]). A Pearson correlation of sPAP was obtained with RVsP by; the sensitivity of RVsP for the diagnosis of PH was determined by a receiver operating characteristic (ROC) curve. RESULTS A good correlation between sPAP and RVsP was obtained by Pearson correlation analysis (r = 0.64; 95% confidence interval [CI] 0.50-0.75; P < .001). The ROC curve analysis showed a sensitivity of 100%, a specificity of 37.2%, (95% CI 0.69-0.83, P < .0001) of a RVsP < 45 mm Hg (cutoff) on the exclusion of severe PH. CONCLUSIONS The cutoff of RVsP < 45 mm Hg, on noninvasive echo Doppler evaluation of PH is an efficient method to replace invasive heart catheterization in OHT candidates.

Partial left ventriculectomy in severe idiopathic dilated cardiomyopathy: Assessment of short-term results and their impact on late survival by magnetic resonance imaging

We evaluated short‐term effects of partial ventriculectomy on left ventricular (LV) parameters and its impact on late survival by magnetic resonance imaging (MRI). Twenty patients and 10 normal volunteers were studied, and LV volumes (EDV, ESV), ejection fraction (EF), short‐ and long‐axis dimensions (SA, LA), wall thickness (Wth), shape (LA/SA), geometry (Wth/SA), a geometry index (Phi), and wall‐motion score index (WMSI) were evaluated pre‐ and postoperatively. Also, we compared results and survival of patients with preoperative EF ≤17% vs. EF >17%. Short‐term results showed significant changes (P < 0.001) in: EF (17.3 ± 7.3% vs. 30.4 ± 9.5%), EDV (391.9 ± 118 vs. 272.7 ± 90 mL); ESV (308.2 ± 102.8 vs. 190.3 ± 68.4 mL); SA (80.5 ± 10.4 vs. 71.7 ± 7.8 mm); LA/SA (1.13 ± 0.1 vs. 1.34 ± 0.1); Wth (8.35 ± 0.99 vs. 9.75 ± 1.41 mm); Wth/SA (0.10 ± 0.01 vs. 0.14 ± 0.02), diastolic( 0.80 ± 0.16 vs. 0.58 ± 0.13) and systolic (0.78 ± 0.18 vs. 0.55 ± 0.12) Phi; and WMSI (−2 vs. −1) (P = 0.032). The EF division showed differences in: LA/SA (1.26 ± 0.10 vs. 1.49 ± 0.12) (P < 0.001); Wth/SA (0.13 ± 0.02 vs. 0.15 ± 0.02) (P = 0.023); diastolic (0.65 ± 0.11 vs. 0.48 ± 0.11) and systolic (0.63 ± 0.09 vs. 0.46 ± 0.09) Phi (P < 0.001); and WMSI (−2 vs. −1) (P = 0.033). Finally, correlation between pre/postoperative EF showed for EF < 17%, r = 0.32 and for EF >17%, r = 0.83, which had different late survival. Our study showed significant changes on LV parameters after ventriculectomy. Patients with EF >17% showed better EF correlation between pre/postoperative values and higher survival rate. J. Magn. Reson. Imaging 2001;13:781–786.

Correlation of bacterial coinfection versus matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 expression in aortic aneurysm and atherosclerosis.

BACKGROUND We searched for any relationship between Chlamydophila pneumoniae, Mycoplasma pneumoniae, matrix metalloproteinase 9 (MMP-9), and tissue inhibitor of metalloproteinase 1 (TIMP-1) in aneurysmatic atherosclerotic lesions, and whether this relationship differed from that in atherosclerotic nonaneurysmatic lesions. METHODS Twenty-eight tissue samples paired by age and sex were grouped as follows: group 1 included 14 nonaneurysmal atherosclerotic fragments obtained from abdominal aortas collected from necropsies; group 2 included 14 aneurysmatic atherosclerotic aortic fragments obtained from patients during corrective surgery. Immunohistochemistry reactions were evaluated for C pneumoniae, M pneumoniae, MMP-9, and TIMP-1 antigens. Both groups were compared using the Mann-Whitney test, and the correlations among variables were obtained using the Spearman correlation test. P ≤ 0.05 was considered statistically significant. RESULTS C pneumoniae and M pneumoniae antigens were detected in 100% of cases. A higher amount of C pneumoniae (P = 0.005), M pneumoniae (P = 0.002), and MMP-9 (P = 0.021) was found in adventitia of group 2 with aneurysm. A positive correlation was found in the aneurysm group, as follows: intima C pneumoniae versus adventitia thickness (r = 0.70; P = 0.01), media C pneumoniae versus adventitia C pneumoniae (r = 0.75; P = 0.002), intima C pneumoniae versus media C pneumoniae (r = 0.8; P = 0.00), and adventitia C pneumoniae versus intima M pneumoniae (r = 0.54; P = 0.05); negative correlations were as follows: adventitia thickness and adventitia M pneumoniae (r = -0.65; P = 0.01), media MMP-9 and media thickness (r = -0.55; P = 0.04), TIMP-1 media versus adventitia C pneumoniae (r = -0.86; P = 0.00), and TIMP-1 media versus M pneumoniae intima (r = -0.67; P = 0.03). Nonaneurysmal atherosclerotic group 1 results are as follows: adventitia C pneumoniae versus TIMP-1 media (r = 0.75; P = 0.01) and media C pneumoniae and adventitia C pneumoniae (r = 0.59; P = 0.03). CONCLUSIONS The present work favors a role for coinfection of both M pneumoniae and C pneumoniae in the development of aortic atherosclerotic aneurysm, with increased adventitial inflammation, inhibition of TIMP-1 activity, and increased collagen degradation.

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.

Analysis of hemodynamic performance of the bovine pericardium valved conduit, implanted in the aortic position in ovines.

OBJECTIVE The necessity for replacement of the valve, ascending aorta and aortic with coronary reimplantation in patients where anti-coagulation is undesirable, is increasing. We evaluated the hemodynamic performance of an aortic valved conduit made with glutaraldehyde treated bovine pericardium (AVCP) in animals. METHODS Therefore, AVCPs were implanted in eight young ovine and explanted after 150 days. Angiographic and hemodynamic study was performed at pre-operative and prior the explant. EchoDopplercardiograms were performed at day 30 and 150 of post-operative (test) and also in five nonoperated ovines. After explanted, AVCPs were submitted to a macroscopical, radiological and histological evaluation by optic microscopy. RESULTS In the hemodynamic analysis the arterial and pulmonary capillary pressure increased (P<0.05) between day 0 and 150. In the echoDoppercardiographic analysis, the test group presented higher values in the diastolic and systolic diameters of the left ventricle (P<0.05). In the test group, between day 30 and 150, occurred an increase of weight, thickness of the left ventricle walls, maximum transvalvar gradient, medium transvalvar gradient, left ventricle diastolic diameter and a decrease in the ejection function (P<0.05). Two animals with endocarditis explain those differences, how we can see with the statistical analysis without this sample. Macroscopy showed calcification in variable degrees. Optic microscopy revealed data similar to literature with the use of glutaraldehyde treated bovine pericadium. CONCLUSIONS These data indicate that the AVCPs allows the performance of this kind of experiment in the proposed model and that the hemodynamic outcomes found are similar to physiological parameters.