Fourteen Years' Survival After Batista Operation: The Short History of a Long Journey

Abstract A 41-year-old man with end-stage heart failure due to nonischemic dilated cardiomyopathy was submitted to the Batista procedure as an alternative to heart transplantation. With surgery, the patient showed progressive clinical amelioration, achieving long-term stable NYHA functional class II, despite gradual dilation of the heart chambers. Persistent atrial fibrillation appeared on the last year of life, his clinical condition deteriorated, and the patient died 14 years, four months, and 13 days after the operation. To the best of our knowledge this seems to be the longest reported survival for a patient submitted to Batista operation.

Trasplante cardíaco en paciente infectado con el virus de la inmunodeficiencia humana / Heart transplantation in an HIV-infected patient

Hasta la consolidación del tratamiento antirretroviral combinado, la infección por HIV constituía, debido a su mal pronóstico, una contraindicación para el trasplante de órganos sólidos. El tratamiento antirretroviral combinado prolongó la expectativa de vida de estos pacientes, pero también permitió la manifestación a largo plazo de enfermedades directa o indirectamente ligadas al HIV, como hepatopatías, nefropatías y enfermedades cardiovasculares. Se presenta un caso de miocardiopatía dilatada tratada con trasplante cardíaco en un paciente con diagnóstico reciente de infección HIV. A los 24 meses, el paciente presentó CD4 en aumento y carga viral no detectable, sin complicaciones ni signos de rechazo. En nuestro conocimiento, no existen antecedentes de trasplante cardíaco en pacientes con HIV en Sudamérica. A la luz de la buena evolución de este caso y los pocos comunicados en la bibliografía internacional, consideramos que el trasplante cardíaco es una opción terapéutica en pacientes HIV positivos adecuadamente seleccionados.

Because of its own unfavourable evolution, HIV infection was until recently considered a contraindication for organ transplantation. The introduction of highly active antiretroviral therapy prolonged the life expectancy of these patients and allowed the manifestation of disorders directly or indirectly related to HIV infection, mainly liver, kidney and cardiovascular diseases. We present a case of cardiac transplantation due to dilated cardiomyopathy that was performed in a patient with a recently detected HIV infection. At 24 month follow-up, the patient is in very good health status, his CD4 are increasing and the viral load is undetectable. He did not present transplant rejection or any other complication. To our knowledge, there is no previous publication on heart transplantation in patients with HIV in South America. In view of the successful outcome of our case and of the few cases reported in the international literature, we consider that heart transplantation is a therapeutic option in correctly selected HIV patients.

Adjuvant Pericardial Sac Restraining in Heart Failure Treatment. A Medical Hypothesis Illustrated by a Case Report

Abstract Ventricular constraint therapy has been used to prevent and reverse the progression of heart failure in ischemic and nonischemic cardiomyopathies. We hypothesized that ventricular restraint should be tried by closing the pericardium that was previously opened following left ventricle topographical projection. The surgical technique presentation is illustrated by a remarkable 13-year outcome of one patient with dilated cardiomyopathy treated surgically by mitral prosthesis, Cox/Maze III surgery to treat atrial fibrillation, and associated to the ventricular constraint using the patient's own pericardium. The ventricular pericardial restraint role is unclear, since the patient had multiple corrections that could be responsible for the good outcome; however it is viable deserving investigations.

Resultados a largo plazo del trasplante intracoronario de células mononucleares de médula ósea autólogas en pacientes con cardiopatía dilatada de diversa etiología / Long-term results of intracoronary transplantation of autologous bone marrow cells in dilated cardiomyopathy

Background: Intracoronary delivery of autologous bone marrow mononuclear cells is an interesting therapeutic promise for patients with heart failure of different etiologies. Aim: To evaluate the long-term safety and efficacy of this therapy in patients with dilated cardiomyopathy of different etiologies under optimal medical treatment. Patients and Methods: Prospective, open-label, controlled clinical trial. Of 23 consecutive patients, 12 were assigned to autologous bone marrow mononuclear cell intracoronary transplantation, receiving a mean dose of 8.19 ± 4.43 x 10(6) CD34+ cells. Mortality, cardiovascular readmissions and cancer incidence rate, changes in functional capacity, quality of life questionnaires and echocardiographic measures from baseline, were assessed at long-term follow-up (37.7 ± 9.7 months) in patients receiving or not the cells. Results: No significant differences were observed in mortality, cardiovascular readmissions or cancer incidence rate amongst groups. An improvement in functional class and quality of life questionnaires in the transplanted group was observed (p < 0.01). The treated group showed a non-significant increase in left ventricular ejection fraction at long-term follow-up (from 26.75 ± 4.85% to 34.90 ± 8.57%, p = 0.059 compared to baseline). There were no changes in left ventricular volumes. We observed no improvement of these variables in the control group. Conclusions: Intracoronary transplantation of autologous bone marrow mononuclear cells is feasible and safe in patients with dilated cardiomyopathy of diverse etiologies. This therapy was associated to persistent improvements in functional class and quality of life. There was also a non-significant long-term improvement of left ventricular function.

Autologous Transplantation of Bone Marrow Adult Stem Cells for the Treatment of Idiopathic Dilated Cardiomyopathy / Transplante Autólogo de Células-Tronco Adultas para Tratamento da Cardiomiopatia Dilatada Idiopática

Background: Morbimortality in patients with dilated idiopathic cardiomyopathy is high, even under optimal medical treatment. Autologous infusion of bone marrow adult stem cells has shown promising preliminary results in these patients. Objective: Determine the effectiveness of autologous transplantation of bone marrow adult stem cells on systolic and diastolic left ventricular function, and on the degree of mitral regurgitation in patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. Methods: We administered 4,54 x 108 ± 0,89 x 108 bone marrow adult stem cells into the coronary arteries of 24 patients with dilated idiopathic cardiomyopathy in functional classes NYHA II and III. Changes in functional class, systolic and diastolic left ventricular function and degree of mitral regurgitation were assessed after 3 months, 6 months and 1 year. Results: During follow-up, six patients (25%) improved functional class and eight (33.3%) kept stable. Left ventricular ejection fraction improved 8.9%, 9.7% e 13.6%, after 3, 6 and 12 months (p = 0.024; 0.017 and 0.018), respectively. There were no significant changes neither in diastolic left ventricular function nor in mitral regurgitation degree. A combined cardiac resynchronization and implantable cardioversion defibrillation was implanted in two patients (8.3%). Four patients (16.6%) had sudden death and four patients died due to terminal cardiac failure. Average survival of these eight patients was 2.6 years. Conclusion: Intracoronary infusion of bone marrow adult stem cells was associated with an improvement or stabilization of functional class and an improvement in left ventricular ejection fraction, suggesting the efficacy of this intervention. There were no significant changes neither in left ventricular diastolic function nor in the degree of mitral regurgitation. .

Fundamento: Pacientes portadores de cardiomiopatia dilatada idiopática apresentam alta morbimortalidade, mesmo em tratamento clínico otimizado. A infusão autóloga de células-tronco adultas da medula óssea mostrou resultados clínicos preliminares promissores nesses pacientes. Objetivo: Determinar a eficácia do transplante autólogo de células-tronco adultas da medula óssea sobre as funções sistólica e diastólica, e o grau de insuficiência mitral em pacientes portadores de cardiomiopatia dilatada idiopática em classes funcionais NYHA II e III. Métodos: Infundiram-se 4,54 x 108 ± 0,89 x 108 células-tronco adultas da medula óssea nas artérias coronárias de 24 pacientes com cardiomiopatia dilatada idiopática em classes funcionais NYHA II e III. Após 3 meses, 6 meses e 1 ano, avaliaram-se as mudanças de classe funcional, das funções ventricular esquerda sistólica e diastólica, e do grau da insuficiência mitral. Resultados: No seguimento, seis (25%) pacientes melhoraram sua classe funcional e oito (33,3%) mantiveram sua classe funcional inicial. A fração de ejeção ventricular esquerda aumentou 8,9%, 9,7% e 13,6%, após 3 e 6 meses e 1 ano (p = 0,024; p = 0,017 e p = 0,018), respectivamente. A função diastólica ventricular esquerda e o grau de insuficiência mitral não demonstraram mudanças significativas. Dois pacientes (8,3%) receberam cardioversor e ressincronizador implantável. Ocorreram quatro (16,6%) mortes súbitas e quatro (16,6%) mortes por insuficiência cardíaca terminal. A sobrevida média desses oitos pacientes foi de 2,6 anos. Conclusão: A infusão intracoronariana de células-tronco adultas da medula óssea em pacientes com cardiomiopatia dilatada idiopática promoveu melhora ...

Direct intramyocardial transthoracic transplantation of bone marrow mononuclear cells for non-ischemic dilated cardiomyopathy: INTRACELL, a prospective randomized controlled trial / Ensaio clínico prospectivo randomizado sobre terapia com células mononucleares da medula óssea para cardiomiopatia dilatada idiopática: INTRACELL

Objective: We tested the hypothesis that direct intramyocardial injection of bone marrow mononuclear cells in patients with non-ischemic dilated cardiomyopathy can improve left ventricular function and physical capacity. Methods: Thirty non-ischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% were randomized at a 1:2 ratio into two groups, control and treated. The bone marrow mononuclear cells group received 1.06±108 bone marrow mononuclear cells through mini-thoracotomy. There was no intervention in the control group. Assessment was carried out through clinical evaluations as well as a 6-min walk test, nuclear magnectic resonance imaging and echocardiogram. Results: The bone marrow mononuclear cells group showed a trend toward left ventricular ejection fraction improvement, with magnectic resonance imaging - at 3 months, showing an increase from 27.80±6.86% to 30.13±9.06% (P=0.08) and returning to baseline at 9 months (28.78%, P=0.77). Magnectic resonance imaging showed no changes in left ventricular ejection fraction during follow-up of the control group (28.00±4.32%, 27.42±7.41%, and 29.57±4.50%). Echocardiogram showed left ventricular ejection fraction improved in the bone marrow mononuclear cells group at 3 months, 25.09±3.98 to 30.94±9.16 (P=0.01), and one year, 30.07±7.25% (P=0.001). The control group showed no change (26.1±4.4 vs 26.5±4.7 and 30.2±7.39%, P=0.25 and 0.10, respectively). Bone marrow mononuclear cells group showed improvement in New York Heart Association functional class, from 3.40±0.50 to 2.41±0.79 (P=0.002); patients in the control group showed no change (3.37±0.51 to 2.71±0.95; P=0.17). Six-minute walk test improved in the bone marrow mononuclear cells group (348.00±93.51m at baseline to 370.41±91.56m at 12 months, P=0.66) and there was a non-significant decline in the control group ...

Objetivo: Testamos a hipótese de que a injeção intramiocárdica direta de células mononucleares de medula óssea em pacientes portadores de cardiomiopatia dilatada não-isquêmica pode melhorar a função ventricular e a capacidade física. Métodos: Trinta pacientes com cardiomiopatia dilatada não isquêmica e fração de ejeção 35% foram randomizados na razão 1:2 em grupos controle e tratado. Grupo células mononucleares de medula óssea recebeu 1,06 ± 108 células mononucleares de medula óssea por mini-toracotomia. Grupo controle não recebeu intervenção. Avaliação foi feita clinicamente e por teste de caminhada 6 minutos (T6m), ressonância magnética e ecocardiogramas. Resultados: Grupo células mononucleares de medula óssea mostrou tendência de melhora da Fração de ejeção - ressonância magnética aos 3 meses, 27,80±6,86% para 30,13±9,06% (P=0,08), retornando ao basal aos 9 meses (28,78%, P=0,77). Grupo controle não apresentou variação (28,00±4,32%; 27,42±7,41% e 29,57±4,50%). Ecocardiogramas - fração de ejeção melhorou no grupo células mononucleares de medula óssea aos 3 meses: 25,09±3,98 para 30,94±9,16 (P=0,01) e aos 12 meses (30,07±7,25%, P=0,001), enquanto o controle não variou: 26,1±4,4 vs. 26,5±4,7 e 30,2±7,39%, P=0,25 e 0,10, respectivamente). Células mononucleares de medula óssea melhorou classe funcional New York Heart Association: 3,40±0.50 para 2,41±0,79 (P=0,002); controles não mudaram (3,37±0,51 para 2,71±0,95; P=0,17). T6m melhorou no grupo células mononucleares de medula óssea (348,00±93,51 m inicial para 370,41±91,56 m aos 12 m, P=0,66) e declinou sem significância no ...

Experiencia clínica con 53 trasplantes cardiacos consecutivos / Clinical experience with 53 consecutive heart transplants

Introduction: Heart transplantation is the therapy of choice for advance heart failure. Our group developed two transplant programs at Instituto Nacional del Tórax and Clínica Dávila. We report our clinical experience based on distinctive clinical policies. Patients and Methods: Fifty-three consecutive patients were transplanted between November 2008 and April 2013, representing 51% of all Chilean cases. Distinctive clinical policies include intensive donor management, generic immunosuppression and VAD (ventricular assist devices) insertion. Results: Ischemic or dilated cardiomyopathy were the main indications (23 (43%) each), age 48 ± 13 years and 48 (91%) were male. Transplant listing Status: IA 14 (26%) (VAD or 2 inotropes), IB 14 (26%) (1 inotrope) and II25 (47%) (no inotrope). Mean waiting time 70 ± 83 days. Twelve (24%) were transplanted during VAD support (median support: 36 days). Operative technique: orthotopic bicaval transplant with ischemia time: 175 ± 54 min. Operative mortality: 3 (6%), all due to right ventricular failure. Re-exploration for bleeding 2 (4%), stroke 3 (6%), mediastinitis 0 (0%), pneumonia 4 (8%), and transient dialysis 6 (11%). Mean follow-up was 21 ± 14 months. Three-year survival was 86 ± 6%. One patient died of Pneumocystis jirovecii pneumonia and the other died suddenly (non-compliance). Freedom from rejection requiring specific therapy was 80 ± 7% at 3 years of follow-up. Four hundred eighty four endomyocardial biopsies were done: 11 (2.3%) had 2R rejection. All survivors are in NYHA (New York Heart Association) functional class I and all but one have normal biventricular function. Conclusion: Mid-term results are similar to those reported by the registry of the International Society for Heart and Lung Transplantation. This experience has a higher proportion of VAD support than previous national series. Rejection rates are low in spite of generic immunosuppression.

Evolução clínica e capacidade funcional de pacientes com cardiomiopatia dilatada após quatro anos do transplante / Clinical and functional capacity of patients with dilated cardiomyopathy after four years of transplantation

OBJETIVO: Avaliar a evolução do paciente miocardiopata após transplante (Tx) cardíaco, analisando sua sobrevida, complicações trans e pós-operatórias e respostas cardiovasculares após cerca de quatro anos do procedimento cirúrgico. MÉTODOS: A pesquisa foi realizada no período de fevereiro a maio de 2011, com pacientes submetidos a Tx cardíaco no Hospital Dr. Carlos Alberto Studart Gomes - Hospital de Messejana (HDM). A amostra foi composta de todos os pacientes transplantados no ano de 2007 no referido hospital. Inicialmente, foi aplicada uma ficha de avaliação, coletando dados dos prontuários, sobre a evolução do paciente no período trans e pós-operatório até a alta hospitalar. Após a coleta dessas informações, os pacientes foram submetidos ao teste da caminhada dos seis minutos (TC6). Os valores encontrados na distância percorrida foram comparados aos valores de referência esperados para a população utilizando a equação de Enright e Sherrill. RESULTADOS: Do total de 24 pacientes que realizaram Tx cardíaco no HDM no ano de 2007, 14 foram avaliados e 10 excluídos do estudo. Com relação às complicações, no período transoperatório, a mais evidenciada foi a disfunção do ventrículo direito (64,3%) e, no pós-operatório, quadro de taquicardia (64,3%). Analisando o TC6 observou-se diminuição de 11,6% na distância percorrida quando comparada à distância estimada (486 ± 55 m, 550 ± 59 m, respectivamente). CONCLUSÃO: Os resultados obtidos neste estudo perante o TC6 evidenciam que as respostas cardiovasculares dos pacientes avaliados estão abaixo do estimado, contudo dentro da faixa de normalidade estabelecida.

OBJECTIVE: To evaluate patient with cardiomyopathy's progress after cardiac transplant, by analyzing his survival, complications and cardiovascular responses after nearly four years of surgery. METHODS: The survey was conducted from February to May 2011, with patients undergoing cardiac transplantation at Dr. Carlos Alberto Studart Gomes Hospital - Messejana Hospital (HDM). The sample consisted of all transplanted patients in 2007 in this hospital. Initially an evaluation form developed by the researchers, which was based on collected data from patients' medical records, was applied, about trans and postoperative period. After collecting these informations, patients underwent the six-minute walk test (6WT). The marks found in walking distance were compared with reference marks expected for this population by using Enright and Sherrill's equation. RESULTS: From all the 24 patients who underwent cardiac transplantation in HDM in 2007, 14 were evaluated and 10 were excluded. Regarding the complications, in the trans-operatory period, the most evident was the right ventricular dysfunction (64.3%) and tachycardia (64.3%) was more evident on the postoperative period. Analyzing the 6WT it was observed a decrease of 11.6% in walking distance when compared with the estimated distance (486 ± 55 m, 550 ± 59 m, respectively). CONCLUSION: Survival of heart transplant patients was equivalent to about 70%. The results of this study before the 6WT showed that patients' cardiovascular responses are below the estimated, nevertheless within the normal range established.

Taquicardiomiopatía, causa reversible de insuficiencia cardiaca: caso clínico / Tachycardiomyopathy as a reversible cause of heart failure: Report of one case

Tachycardiomyopathy is a potentially reversible cause of heart failure. It can be induced by supraventricular or ventricular arrhythmias. When these are treated, systolic function improves or normalizes. We report a 20year-old male with deterioration of left ventricular function and dilated cardiomyopathy secondary to an incessant atrial tachycardia that was treated with radiofrequency catheter ablation. After the procedure, the patient experienced a significant improvement of his ventricular function.

An unknown complication of peripherally inserted central venous catheter in a patient with ventricular assist device.

We report an unknown complication of peripherally inserted central venous catheter in a patient with Ventricular Assist Device. This rare complication led to the failure of the right ventricular assist device, which could be detrimental in patients with dilated cardiomyopathy.

One and a half ventricular repair for Uhl's anomaly with one year follow up

Uhl's anomaly is characterized by complete or partial absence of the myocardium of the right ventricle, with apposition of the endocardium and epicardium. We report our experience with surgical treatment of this anomaly

Bloqueio simpático esquerdo por videotoracoscopia no tratamento da cardiomiopatia dilatada / Endoscopic left sympathetic blockade in the treatment for dilated cardiomyopathy / Bloqueo simpático izquierdo por videotoracoscopia en el tratamiento de la cardiomiopatía dilatada

FUNDAMENTO: O nível da atividade nervosa simpática é um dos mais importantes determinantes prognósticos em pacientes com insuficiência cardíaca. OBJETIVO: O propósito dessa investigação foi realizar um estudo de viabilidade do emprego do bloqueio simpático esquerdo por toracoscopia em pacientes com insuficiência cardíaca (IC) para avaliar a segurança e os efeitos imediatos. MÉTODOS: Quinze pacientes com cardiomiopatia dilatada e fração de ejeção do ventrículo esquerdo (FEVE) < 40 por cento, classe funcional II ou III (NYHA) e frequência cardíaca > 65 bpm, a despeito do uso adequado de beta-bloqueadores ou intolerantes a eles, forma selecionados. Dez pacientes foram submetidos à clipagem do espaço inter-espinhal em nível de T3-T4 e da porção inferior dos gânglios estrelados esquerdos através de videotoracocopia, enquanto outros cinco pacientes foram randomizados para um grupo controle. RESULTADOS: Nenhum dos pacientes operados apresentou qualquer evento cardiovascular adverso relacionado ao procedimento cirúrgico no período perioperatório. Dois pacientes do grupo cirúrgico morreram devido a tromboembolismo pulmonar ou infarto do miocárdio nos 6 meses de seguimento inicial, enquanto três pacientes do grupo controle apresentaram progressão da IC e morreram ou desenvolveram choque cardiogênico no mesmo período. Nos pacientes tratados, houve melhora na qualidade de vida, nível de atividade física e FEVE (de 25 ± 9 por cento para 32 ± 8 por cento, p=0,024) aos 6 meses de seguimento, enquanto esses parâmetros não se alteraram nos pacientes do grupo controle. CONCLUSÃO: O bloqueio simpático esquerdo via toracoscopia é factível e parece ser seguro em pacientes com IC grave. Esse estudo inicial sugere que esse procedimento pode ser uma abordagem alternativa eficaz para o bloqueio simpático no tratamento de cardiomiopatias dilatadas.

BACKGROUND: The level of sympathetic nervous activity is a major determinant of prognosis in patients with heart failure. OBJECTIVE: The purpose of this investigation was to perform a proof-of-principle trial of therapeutic endoscopic left thoracic sympathetic blockade in heart failure patients to assess safety and immediate effects. METHODS: Fifteen patients with dilated cardiomyopathy and left ventricular ejection fraction (LVEF) < 40 percent, New York Heart Association functional class II or III, and heart rate > 65 bpm, despite either adequate betablocker use or intolerant to it, were enrolled. Ten patients underwent left infra-stellate ganglion plus T3-T4 interspinal space clipping through videothoracoscopy, while the other five patients were randomized to a control group. RESULTS: None of the treated patients had any procedure-related adverse cardiovascular events at the perioperative period. Two patients from the surgical group died due to pulmonary thromboembolism or myocardial infarction within 6 months of the initial follow-up, while three patients from the control group had heart failure progression and died or developed cardiogenic shock during the same period. Treated patients presented improvement in quality of life, level of physical activity and LVEF (from 25 ± 9 percent to 32 ± 8 percent, p=0.024) at 6 months of follow-up, whereas these parameters did not change in control patients. CONCLUSION: Endoscopic left thoracic sympathetic blockade is feasible and appears to be safe in severe heart failure patients. This initial study suggests that this procedure might be an effective alternative approach to sympathetic blockade in the treatment of dilated cardiomyopathies.

FUNDAMENTO: El nivel de la actividad nerviosa simpática es uno de los más importantes determinantes pronósticos en pacientes con insuficiencia cardíaca. OBJETIVO: El propósito de esta investigación fue realizar un estudio de viabilidad del empleo del bloqueo simpático izquierdo por toracoscopia en pacientes con insuficiencia cardíaca (IC) para evaluar la seguridad y los efectos inmediatos. MÉTODOS: Quince pacientes con cardiomiopatía dilatada y fracción de eyección del ventrículo izquierdo (FEVI) < 40 por ciento, clase funcional II o III (NYHA) y frecuencia cardíaca > 65 lpm, a despecho del uso adecuado de betabloqueantes o intolerantes a ellos, fueron seleccionados. Diez pacientes fueron sometidos a clipaje del espacio interespinal a nivel de T3-T4 y de la porción inferior de los ganglios estrellados izquierdos a través de videotoracocopia, mientras que otros cinco pacientes fueron randomizados para un grupo control. RESULTADOS: Ninguno de los pacientes operados presentó ningún evento cardiovascular adverso relacionado al procedimiento quirúrgico en el período perioperatorio. Dos pacientes del grupo quirúrgico murieron debido a tromboembolismo pulmonar o infarto de miocardio en los 6 meses de seguimiento inicial, mientras tres pacientes del grupo control presentaron progresión de la IC y murieron o desarrollaron shock cardiogénico en el mismo período. En los pacientes tratados, hubo mejora en la calidad de vida, nivel de actividad física y FEVI (de 25±9 por ciento a 32±8 por ciento, p=0,024) a los 6 meses de seguimiento, mientras que esos parámetros no se alteraron en los pacientes del grupo control. CONCLUSIÓN: El bloqueo simpático izquierdo vía toracoscopia es factible y parece ser seguro en pacientes con IC grave. Este estudio inicial sugiere que este procedimiento puede ser un abordaje alternativo eficaz para el bloqueo simpático en el tratamiento de cardiomiopatías dilatadas.

A safety and feasibility study of cell therapy in dilated cardiomyopathy

The aim of this study was to determine if bone marrow mononuclear cell (BMMC) transplantation is safe for moderate to severe idiopathic dilated cardiomyopathy (IDC). Clinical trials have shown that this procedure is safe and effective for ischemic patients, but little information is available regarding non-ischemic patients. Twenty-four patients with IDC, optimized therapy, age 46 ± 11.6 years, 17 males, NYHA classes II-IV, and left ventricular ejection fraction <35 percent were enrolled in the study. Clinical evaluation at baseline and 6 months after stem cell therapy to assess heart function included echocardiogram, magnetic resonance imaging, cardiopulmonary test, Minnesota Quality of Life Questionnaire, and NYHA classification. After cell transplantation 1 patient showed a transient increase in enzyme levels and 2 patients presented arrhythmias that were reversed within 72 h. Four patients died during follow-up, between 6 and 12 weeks after therapy. Clinical evaluation showed improvement in most patients as reflected by statistically significant decreases in Minnesota Quality of Life Questionnaire (63 ± 17.9 baseline vs 28.8 ± 16.75 at 6 months) and in class III-IV NYHA patients (18/24 baseline vs 2/20 at 6 months). Cardiopulmonary exercise tests demonstrated increased peak oxygen consumption (12.2 ± 2.4 at baseline vs 15.8 ± 7.1 mL·kg-1·min-1 at 6 months) and walked distance (377.2 ± 85.4 vs 444.1 ± 77.9 m at 6 months) in the 6-min walk test, which was not accompanied by increased left ventricular ejection fraction. Our findings indicate that BMMC therapy in IDC patients with severe ventricular dysfunction is feasible and that larger, randomized and placebo-controlled trials are warranted.

Desempenho hemodinâmico e resposta inflamatória durante o uso do DAV-InCor como ponte para o transplante / Hemodynamic performance and inflammatory response during the use of VAD-InCor as a bridge to transplant

FUNDAMENTO: O transplante cardíaco enfrenta o grave problema da escassez de doadores. Estima-se que entre 20 por cento e 40 por cento dos pacientes falecem na fila de espera. Para esses pacientes, a utilização de dispositivos de assistência circulatória é, muitas vezes, a única possibilidade de sobrevivência durante a espera do doador. No Brasil, não existe nenhum programa regular de utilização desses dispositivos como ponte para transplante. OBJETIVO: Avaliar o desempenho hemodinâmico e a resposta inflamatória durante a utilização do DAV-InCor como ponte para transplante. MÉTODOS: Entre outubro de 2003 e abril de 2006, 11 pacientes, indicados em caráter de prioridade para o transplante cardíaco, evoluíram em choque cardiogênico refratário. O implante do DAV-InCor foi realizado em sete pacientes. O diagnóstico etiológico foi cardiopatia chagásica em cinco pacientes e cardiomiopatia dilatada idiopática em dois. RESULTADOS: A assistência mecânica ao ventrículo esquerdo foi mantida nos sete pacientes por períodos entre 14 e 42 dias (média 26,2). O desempenho hemodinâmico foi adequado, com a normalização do índice cardíaco, dos níveis de saturação venosa de O2 e do lactato. O transplante foi realizado em dois pacientes, os outros cinco faleceram por infecção sistêmica ou falência de múltiplos órgãos. CONCLUSÃO: O desempenho do DAV-Incor, no comportamento hemodinâmico dos pacientes estudados, foi adequado para a manutenção de uma condição circulatória satisfatória durante o período estudado. Houve melhora dos parâmetros de perfusão tecidual e manutenção de sinais de resposta inflamatória sistêmica. Houve alta incidência de complicações; contudo, não foram demonstradas complicações relacionadas ao dispositivo que comprometam a segurança da utilização do mesmo.

BACKGROUND: Cardiac transplantation faces the serious problem of lack of donors and it is estimated that 20 to 40 percent of the patients die while waiting for heart transplantation. For these patients, the use of mechanical circulatory assist devices is the only choice of survival while waiting for a donor. In Brazil, the experience with mechanical circulatory support is limited and there is no regular program regarding the use of these devices as a bridge to heart transplantation. OBJECTIVE: To evaluate the hemodynamic performance and the systemic inflammatory response during the clinical use of the InCor-type ventricular assist device (VAD-InCor) as a bridge to heart transplantation. METHODS: Between October 2003 and April 2006, 11 patients in the waiting list for heart transplantation presented hemodynamic deterioration due to refractory cardiogenic shock. Seven of these patients were submitted to VAD-InCor implantation for left ventricular assistance. The etiologic diagnosis was Chagas' disease in 5 patients and idiopathic dilated cardiomyopathy in 2. RESULTS: The duration of left ventricular assistance ranged from 14 to 42 days (mean 26.2 days). During this period, the hemodynamic performance of the DAV-InCor was adequate to support a normal hemodynamic state. There was normalization of central venous oxygen saturation and serum lactate. Two patients were submitted to heart transplantation, while the other 5 patients died under assistance due to infection and multiple organ failure. CONCLUSION: The performance of the VAD-InCor, in the hemodynamic behavior of the studied patients, was adequate for the maintenance of a satisfactory circulatory state during the studied period. There was improvement in the tissue perfusion parameters and maintenance of systemic inflammatory response signs. There was a high incidence of complications; however, complications related to the device, which could compromise the safety of its use, were not demonstrated.

Transplante cardíaco pediátrico em vigência de choque cardiogênico refratário: análise crítica da viabilidade, aplicabilidade e resultados / Pediatric heart transplantation in refractory cardiogenic shock: a critical analysis of feasibility, applicability and results

FUNDAMENTO: Considerando crianças com miocardiopatia dilatada, na lista de espera de transplante de coração, podemos avaliar a gravidade do quadro hemodinâmico desses pacientes. Alguns apresentam choque cardiogênico e um elevado índice de mortalidade. Mesmo com suporte inotrópico e respiratório, o transplante de coração é considerado uma condição de extrema gravidade. OBJETIVO: Apresentar nossa experiência com crianças na circunstância de transplante cardíaco em vigência de choque cardiogênico refratário, procurando analisar a viabilidade, a aplicabilidade e os resultados desses transplantes. MÉTODOS: De março de 2001 a fevereiro de 2004, 22 crianças com miocardiopatia dilatada, previamente registradas na lista de transplante, apresentaram choque cardiogênico, necessitando transferência para unidade de terapia intensiva (UTI) pediátrica, intubação e suporte inotrópico. As idades variaram de 11 meses a 11 anos (média = 4,3 idade), com 55 por cento do sexo masculino; 14 poderiam ser listados como prioridade clínica e os outros 8 foram excluídos da lista de espera em razão de condição clínica desfavorável. RESULTADOS: Oito transplantes de coração foram executados, 6 crianças faleceram na fila de espera (42,9 por cento). Duas crianças faleceram (25 por cento) após o transplante; as outras 6 receberam alta hospitalar com boas condições clínicas. As duas principais complicação são rejeição, em 4 casos, e infecção, em 5 casos. Dois apresentaram complicações neurológicas, com recuperação total em um dos casos. CONCLUSÃO: Crianças com miocardiopatia e choque cardiogênico necessitam de transplante imediato; somente 57,1 por cento podiam ser transplantadas, com mortalidade de 25 por cento. Daquelas que sobreviveram ao transplante, a evolução clínica foi boa, similar às crianças transplantas em cirurgias eletivas.

BACKGROUND: In children with dilated cardiomyopathy who are on the waiting list for heart transplantation, we evaluate the seriousness of their hemodynamic conditions. Some develop cardiogenic shock, and the mortality rate is high. Even with inotropic and respiratory support, heart transplantation is considered an extremely grave circumstance. OBJECTIVE: The objective of this study is to report on our experience with children in this condition, in an attempt to analyze the viability, applicability and results of heart transplantation in these children. METHODS: From March 2001 to February 2004, 22 children with dilated cardiomyopathy who were on the waiting list for heart transplantation developed cardiogenic shock, requiring transfer to pediatric intensive care unit (ICU), intubation and inotropic support. Their ages ranged from 11 months to 11 years (mean age: 4.3 years), 55 percent were males, 14 could be listed as clinical priority, and the remaining 8 were removed from the waiting list due to their unfavorable clinical conditions. RESULTS: Eight heart transplantations were performed, and 6 children died while on the waiting list (42.9 percent). Two children died (25 percent) after transplantation and the remaining 6 were discharged from hospital in good clinical condition. The two main complications were organ rejection in 4 cases and infection in 5 cases. Two patients developed neurological complications, and one of them fully recovered. CONCLUSION: Children with cardiomyopathy and cardiogenic shock require immediate heart transplantation; only 57.1 percent could be transplanted, with an early 25 percent mortality rate. Those who survived transplantation showed good clinical progress, similar to that of children transplanted on an elective basis.

Autologous transplantation of bone marrow mononuclear stem cells by mini-thoracotomy in dilated cardiomyopathy: technique and early results / Transplante autólogo de células-tronco de medula óssea por mini-toracotomia: técnica e resultados iniciais

CONTEXT AND OBJECTIVES: There are few studies concerning bone marrow mononuclear cell (BMMC) transplantation in cases of nonischemic dilated cardiomyopathy. This study describes a novel technique of BMMC transplantation and the results up to one year after the procedure. DESIGN AND SETTING: This was a case series to evaluate the safety and viability of the procedure, at Instituto de Cardiologia do Rio Grande do Sul. METHODS: Nine patients with symptomatic dilated cardiomyopathy, functional class III/IV and left ventricular ejection fraction (LVEF) < 35 percent received BMMC (9.6 ± 2.6 x 107 cells) at 20 sites in the ventricular wall, by means of thoracotomy of length 5 cm in the fifth left intercostal space. Echocardiograms and nuclear magnetic resonance (NMR) were performed. RESULTS: There were no major complications. The functional class results for the first six patients (preoperatively and at two, four, eight and twelve-month follow-ups, respectively) were: [IV-2, III-4] to [I-5, II-1] to [I-3, II-3] to [I-2, II-3] and [I-2, II-3]. Echocardiograms showed LVEF: 25.9 ± 8.2; 32.9 ± 10.4; 29.4 ± 7.2; 25.1 ± 7.9; 25.4 ± 6.8 percent (p = 0.023); and percent left ventricular (LV) fiber shortening: 12.6 ± 4.4; 16.4 ± 5.4; 14.3 ± 3.7; 12.1 ± 4.0; 12.2 ± 3.4 percent (p = 0.021). LV performance variation seen on NMR was non-significant. CONCLUSION: Intramyocardial transplantation of BMMC in dilated cardiomyopathy cases is feasible and safe. There were early improvements in symptoms and LV performance. Medium-term evaluation revealed regression of LV function, although maintaining improved functional class.

CONTEXTO E OBJETIVO: Há pouco estudos avaliando o transplante de células mononucleares da medula óssea (CMMO) na miocardiopatia dilatada não-isquêmica. O presente estudo descreve uma técnica de implante intramiocárdico de CMMO por mini-toracomia e resultados com até um ano de acompanhamento. TIPO DE ESTUDO E LOCAL: Série casos para avaliar segurança e viabilidade do procedimento, no Instituto de Cardiologia do Rio Grande do Sul. MÉTODOS: Nove pacientes com miocardiopatia dilatada, em classe funcional III/IV e fração de ejeção do ventrículo esquerdo (FEVE) < 35 por cento receberam CMMO (média 9,6 ± 2,6 x 107 células) em 20 pontos da parede livre do ventrículo esquerdo, através de toracotomia de 5 cm no quinto espaço intercostal esquerdo. Foram realizados ecocardiograma e ressonância nuclear magnética (RNM). RESULTADOS: Não ocorreram complicações maiores. Os resultados pré-operatórios aos 2, 4, 8 e 12 meses de acompanhamento dos seis primeiros pacientes são: classe funcional: IV-2, III-4 para I-5, II-1 para I-3, II-3 para I-2, II-3 e I-2, II-3. Ecocardiograma: FEVE = 25.9 ± 8.2, 32.9 ± 10.4, 29.4 ± 7.2, 25.1 ± 7.9, 25.4 ± 6.8 por cento (p = 0.023); Fração de encurtamento do ventrículo esquerdo (VE) = 12.6 ± 4.4, 16.4 ± 5.4, 14.3 ± 3.7, 12.1 ± 4.0, 12.2 ± 3.4 por cento (p = 0.021). RNM demonstrou diferenças discretas, não significativas. CONCLUSÕES: O implante intramiocárdico de células-tronco na miocardiopatia dilatada é viável e seguro. Houve melhora precoce nos sintomas e na performance de VE. Avaliação a médio prazo demonstrou regressão da função VE, mantendo, contudo, a melhora na qualidade de vida e na classe funcional.

Transplante de Células-tronco marcadas para o miocárdio de paciente com doença de chagas / Labeled stem cells transplantation to the myocardium of a patient with chagas' disease

O transplante de células-tronco é uma nova terapia com objetivo de produzir regeneração cardíaca pela diferenciação ou aumento dos miócitos cardíacos ou proliferação neovascular em pacientes no estágio final de insuficiência cardíaca congestiva secundária a cardiomiopatia dilatada¹, mas os resultados são desconhecidos2,3.

Stem cell transplantation is a new therapy applied to produce cardiac regeneration through differentiation or increase of heart myocytes or neovascular proliferation in patients in the end stage of congestive heart failure secondary to dilated cardiomyopathy¹, but the results are still unknown2,3.

High intensity exercise training programme following cardiac transplant.

A 26-year-old male patient who presented with symptoms of end stage cardiac failure as a result of dilated cardiomyopathy, had an orthotopic cardiac transplantation. A comprehensive cardiac rehabilitation programme was provided to him and he was introduced to a sport (tennis). The exercise training programme progressed from low intensity training to high intensity programme over a period of 15 months. A cardio-pulmonary exercise test done 22 months after surgery suggested that he was able to achieve the aerobic capacity comparable to that of a normal South Indian subject. He participated successfully in the World Transplant Games in Sydney and returned safely. This suggests that after a proper cardiac rehabilitation programme, patients undergoing heart transplantation can achieve normal physiological responses to lead a normal active life.

Desordem linfoproliferativa pós-transplante em paciente pediátrico / Post-transplantation lymphoproliferative disorder in pediatric patient / Post-transplantation lymphoproliferative disorder in pediatric patient

Terapias de imunossupressão, a que pacientes transplantados devem ser submetidos, os expõe a um alto risco de desenvolver desordens linfoproliferativas pós-transplante (PTLD). Descrevemos o caso de uma criança submetida a transplante cardíaco aos sete meses de idade e que acabou desenvolvendo PTLD, aos nove anos, diagnosticada por meio de retirada de nódulo pulmonar.

Immunosuppressive therapy for transplanted patients exposes them to a high risk of developing posttransplantation lymphoproliferative disorders (PTLD). We report the case of a child undergoing heart transplantation at seven months of age who developed PTLD at nine years of age, diagnosed by resection of a pulmonary nodule.