P. Álvarez

Mid term results after bone marrow laser revascularization for treating refractory angina

BackgroundTo evaluate the midterm results of patients with angina and diffuse coronary artery disease treated with transmyocardial revascularization in combination with autologous stem cell therapy.MethodsNineteen patients with diffuse coronary artery disease and medically refractory class III/IV angina were evaluated between June 2007 and December 2009 for sole therapy TMR combined with intramyocardial injection of concentrated stem cells. At the time of surgery, autologous bone marrow (120cc) was aspirated from the iliac crest. A cardiac MRI and an isotopic test were performed before and after the procedure. Follow-up was performed by personal interview.ResultsThere were no perioperative adverse events including no arrhythmias. Mean number of laser channels was 20 and the mean total number of intramyocardially injected cells per milliliter were: total mononuclear cells(83.6 × 106), CD34+ cells(0.6 × 106), and CD133+ cells(0.34 × 106). At 12 months mean follow-up average angina class was significantly improved (3.4 ± 0.5 vs 1.4 ± 0.6; p = 0.004). In addition, monthly cardiovascular medication usage was significantly decreased (348 ± 118 vs. 201 ± 92; p = 0.001). At six months follow up there was a reduction in the number of cardiac hospital readmissions (2.9 ± 2.3 vs. 0.5 ± 0.8; p < 0.001). MRI showed no alterations regarding LV volumes and a 3% improvement regarding ejection fraction.ConclusionsThe stem cell isolator efficiently concentrated autologous bone marrow derived stem cells while the TMR/stem cell combination delivery device worked uneventfully. An improvement in clinical status was noticed in the midterm follow-up. Images test showed no morphological alterations in the left ventricle after the procedure.

Cell saving systems do not reduce the need of transfusion in low-risk patients undergoing cardiac surgery.

OBJECTIVES Cell saving systems have been widely used to reduce blood loss and need of transfusions. These device are mainly indicated in complex cardiac surgery procedures and in those patients with a high risk of bleeding. However, it is not clear if there is a benefit of a cell saver (CS) system in low-risk patients undergoing cardiac surgery. Our aim was to analyze if the use of CS systems reduce the need of blood products in low-risk patients undergoing cardiac surgery. METHODS Between February and June 2009 all low-risk patients (EuroSCORE<10%) undergoing coronary or valve procedure were selected (n=63). Exclusion criteria were: combined procedure, aorta procedure, redo surgery, emergency procedures, creatinine levels>2 mg/ml, anemic patients and patients with a body surface area (BSA)<1.6 m2. Patients were randomized to undergo cardiac surgery with a cell saving system (group CS) (n=34) or without (control group, CO) (n=29). All patients received tranexamic acid during the procedure. Need of blood products and clinical outcomes were analyzed in both groups. RESULTS Mean age was 64.7±12.3 years old with 33% of female patients. Baseline clinical characteristics and preoperative blood count cell were similar in both groups. Mean CS blood reinfused was 461±174 ml (maximum: 985 minimum: 259). A total of 59 red blood packages were transfused in 25 patients (mean 1.02±1.3; range: 0-5). The proportion of patients being transfused was similar in both groups (CS: 40% vs. CO: 46.4%; P=0.79). Eleven plasma packages were transfused (CS: 8 vs. CO: 3; P=0.77) and three platelet pools were used in group CS and none in group CO (P=0.08). Multivariate analysis showed that preoperative hemoglobin levels>13.3 g/dl [relative risk (RR): 0.29; confidence interval (CI): 0.09-0.99] and BSA>1.74 (RR: 0.19; CI: 0.54-0.68) were protective against blood transfusion. CONCLUSIONS In low-risk patients CS system did not reduce the need of blood transfusion. Clinical outcomes were similar regardless of the use of a cell saver system. A low preoperative hemoglobin level and a low BSA were related with the use of blood products.

Adjustable Segmental Tricuspid Annuloplasty: Technical Advantages and Midterm Results

BACKGROUND Adjustable segmental tricuspid annuloplasty is a new recently published procedure. The purpose of this prospective study was to present the technical advantages of this new tricuspid annuloplasty and analyze its early and midterm results. METHODS Between January 2004 and December 2006, 17 patients who had moderate or severe pure functional tricuspid regurgitation (TR) underwent adjustable segmental tricuspid annuloplasty. The mean age of the patients was 64.3 +/- 10.4 years and the majority were female (94%). All patients had recent preoperative transthoracic echocardiography (TTE). Three postoperative TTE were performed: (I) before the hospital discharge; (II) between 3 and 6 months after surgery; and (III) at a mean 30.4 +/- 13.8 months of follow-up. We studied the tricuspid valve, right ventricle, and left ventricle. RESULTS No hospital mortality was reported. Progressive overall clinical improvement was observed. Serial postoperative TTE revealed the following: (1) 13 patients with mild or less than mild TR, 1 patient with residual moderate TR, 1 patient with early moderate TR related to poor left ventricular function, and 1 patient with late severe TR due to a transvenous pacemaker lead; (2) the indexed tricuspid annulus diameter normalized in all patients; (3) pulmonary hypertension gradually regressed; and (4) right ventricular end-diastolic diameter and inferior vena cava diameter gradually decreased throughout the study. CONCLUSIONS Adjustable segmental tricuspid annuloplasty is an improved and efficient procedure for functional TR because it is more selective, more adjustable and more resistant. It may be adversely influenced by poor left ventricular function and by the presence of a pacemaker lead.

Restoration of atrial contractility after surgical cryoablation: clinical, electrical and mechanical results

To assess the electrical sinus rhythm (SR) recovery and the mechanical effectiveness of the atrial contraction by echocardiography is essential in patients undergoing atrial fibrillation (AF) surgery. Between September 2006 and May 2008, patients with chronic AF (n=33; permanent=23 or paroxysmal=10) underwent mitral surgery and surgical cryoablation for AF. Exclusion criteria were: AF that has persisted for 10 years and left atrium (LA) >65 mm. Echocardiography study was performed at six months after surgery. Mean age was 62 years (22 female, 11 male). Mean AF duration was three years (range 0.5-7.4). Mean atria size was 52.4+/-5.6 mm. Mitral valve surgery involved 32 prosthetic replacements and one mitral valve repair. There was no surgical mortality. Success rate for SR at three and six months was 90% and 82%, respectively. The only predictor of conversion to SR at six months was being at SR when discharge from the hospital. In patients in SR, echocardiographic study provided mechanical effectiveness of the atria in 100% of right atrium and 70% of the LA. Cryoablation for AF is an effective technique to recover electrocardiographic SR while being able to recover atrial contraction effectiveness.

eComment. Cardiac bioprostheses: new focuses for new times

We have read the article by Niclauss et al. [1] with great interest, given that it involves a subject that is debated in the cardiac surgeons day-to-day practice: the choice of the type of prosthesis for patients, in whom valve repair is impossible and where the choice is complex and basically determined by patient age.