Graft pathology at the time of harvest: impact on long-term survival / Patologia do enxerto no momento da coleta: impacto na sobrevida a longo prazo

Objective: This study aims to present the graft pathology at the time of harvest and its impact on long-term survival. Methods: The remnants of the bypass grafts from 66 consecutive patients with coronary artery disease receiving a coronary artery bypass grafting were investigated pathologically, and pertinent predictive risk factors and survival were analyzed. Results: Medial degenerative changes with or without intimal proliferation were present in 36.8%, 37.8% and 35.6% of left internal mammary artery (IMA), radial artery and saphenous vein grafts. There were 2 (3.0%) hospital deaths and 9 (14.1%) late deaths. Multinomial logistic regression revealed left IMA pathological changes, dyslipidemia, history of percutaneous transluminal coronary angioplasty/stent deployment and Y-graft were significant predictive risk factors negatively influencing the patients’ long-term survival. Kaplan-Meier survival analysis revealed that the long-term survival of patients with left IMA pathological changes were significantly reduced compared with those without (74.1% vs. 91.4%, P=0.002); whereas no differences were noted in long-term survivals between patients with and without pathological changes of the radial arterial or saphenous vein grafts. Conclusion: Pathological changes may be seen in the bypass graft at the time of harvest. The subtle ultrastructural modifications and the expressions of vascular tone regulators might be responsible for late graft patency. The pathological changes of the left IMA at the time of harvest rather than those of the radial artery or saphenous vein graft affect significantly longterm survival. Non-traumatic maneuver of left IMA harvest, well-controlled dyslipidemia and avoidance of using composite grafts can be helpful in maintaining the architecture of the grafts. .

Objetivo: Este estudo tem como objetivo apresentar a patologia do enxerto no momento da coleta e do impacto na sobrevida a longo prazo. Métodos: Os remanescentes de pontes de safena de 66 pacientes consecutivos com doença arterial coronária que receberam uma cirurgia de revascularização coronariana foram investigados patologicamente, e os fatores de risco preditivos e a sobrevivência foram analisados. Resultados: Alterações degenerativas da artéria medial, com ou sem proliferação da íntima estavam presentes em 36,8%, 37,8% e 35,6% de pontes da artéria torácica interna esquerda (ATIE), artéria radial e veia safena. Houve dois (3,0%) óbitos hospitalares e nove (14,1%) óbitos tardios. A regressão logística multinomial revelou que alterações patológicas na ATIE, dislipidemia, história de angioplastia/stent implantação coronariana transluminal percutânea e Y-enxerto foram significativos fatores de risco preditivos que influenciam negativamente a sobrevivência a longo prazo dos pacientes. Análise de sobrevida de Kaplan- Meier revelou que a sobrevivência a longo prazo de pacientes com alterações patológicas da ATIE foi significativamente reduzida em comparação com aqueles sem (74,1% vs. 91,4%, P=0,002), considerando que não foram observadas diferenças na sobrevivência de longo prazo entre pacientes com e sem alterações patológicas dos enxertos da artéria radial ou de veia safena. Conclusão: As alterações patológicas podem se desenvolver na revascularização no momento da coleta. As modificações ultraestruturais sutis e as expressões de reguladores do tônus vascular podem ser responsáveis pela patência tardia do enxerto. As alterações patológicas da ATIE no momento da coleta, em vez do enxerto da artéria radial ou da veia safena, podem afetar significativamente a sobrevida de longo prazo. Manobra não traumática da ATIE na coleta, bom controle da dislipidemia e para evitar uso de enxertos compostos pode ser útil na manutenção da arquitetura dos enxertos. .

Transforming growth factor-β in graft vessels: histology and immunohistochemistry

OBJECTIVES: The biological functions of transforming growth factor-β signaling that involves Smad proteins have not been previously investigated with respect to coronary artery bypass grafts. The aim of the present study was to observe the immunostaining of proteins that are related to this signaling pathway. METHODS: Fifteen remnants of coronary artery bypass grafts, including nine saphenous veins, three radial arteries and three mammary arteries, were collected from 12 patients who were undergoing coronary artery bypass. Hematoxylin and eosin, Masson's trichrome, and immunohistochemical staining of transforming growth factor-β1, type I receptor of transforming growth factor-β, Smad2/3, Smad4, and Smad7 were performed. RESULTS: The saphenous veins showed more severe intimal degeneration, more severe smooth muscle cell proliferation and more collagen deposition than the arterial grafts, as evidenced by hematoxylin and eosin and Masson's trichrome stainings. Immunohistochemical assays demonstrated that the majority of the transforming growth factor-β1 signaling cytokines were primarily localized in the cytoplasm in the medial layers of all three types of grafts, whereas ectopic transforming growth factor-β1, type I receptor of transforming growth factor-β, and Smad7 overexpressions in the interstices were observed particularly in the saphenous vein and radial arterial grafts. CONCLUSION: Enhanced transforming growth factor-β1 signal transduction with medial smooth muscle cell proliferation and ectopic transforming growth factor-β1, the presence of the type I receptor of transforming growth factor-β, and Smad7 overexpressions in the extracellular matrix may provide primary evidence for early or late graft failure.

Inflamação sistêmica causada pela periodontite crônica em pacientes vítimas de ataque cardíaco isquêmico agudo / Systemic inflammation caused by chronic periodontite in patients victims of acute ischemic heart attack

OBJETIVO: Processos inflamatórios e infecciosos mediados por bactérias em sítios distantes têm sido descritos como fator de risco à doença coronariana isquêmica aguda (DCIA). MÉTODOS: Cento e oitenta e um pacientes com DCIA, com e sem periodontites crônicas, foram incluídos neste estudo. Os pacientes foram admitidos no HC da UNICAMP e estratificados em três grupos: grupo 1 - pacientes com periodontite crônica grave (31 homens e 19 mulheres; média de idade 55,1 ± 11,29 anos); grupo 2 - pacientes com periodontite crônica leve (40 homens e 28 mulheres; média de idade 54,8 ± 10,37 anos); grupo 3 - pacientes desdentados (43 homens e 20 mulheres; média de idade 67,5 ± 8,55 anos). Amostras sanguíneas foram coletadas para mensurar os perfis lipídico, hematológico e glicêmico. Além disso, biópsias de 17 artérias coronárias com aterosclerose e igual número de artérias mamárias internas sem degeneração aterosclerótica no grupo 1 foram investigadas. Para análise estatística utilizou-se a análise de variância (ANOVA) e o teste de Scheffé para comparações múltiplas. RESULTADOS: Triglicérides e LDL estavam elevados no grupo 1 em relação ao grupo 2. O HDL apresentou-se reduzido em 20 por cento dos pacientes do grupo 1, e em 8 por cento nos desdentados. A glicemia estava elevada no grupo 1. DNA de bactérias periodontais foram detectados em 58,8 por cento das artérias coronárias. CONCLUSÕES: Pacientes com DCIA e periodontite crônica grave podem apresentar perfil lipídico alterado, como também microorganismos associados com as periodontites crônicas graves podem permear dentro de vasos coronarianos.

OBJECTIVE: Infectious and inflammatory processes mediated by bacteria in distant sites have been described as a risk factor for acute ischemic heart disease (AIHD). METHODS: One hundred one patients with AIHD with and without chronic periodontitis (CP) were included in this study. Patients were admitted to the HC UNICAMP and stratified into three groups: in group 1, we selected patients with severe chronic periodontitis (31 men and 19 women, mean age 55.1 ± 11.29 years old); the group 2 with mild chronic periodontitis (40 men and 28 women, mean age 54.8 ± 10.37 years old) and group 3 represented by the toothless (43 men and 20 women, mean age 67.5 ± 8.55 years old). Blood samples were collected to measure the lipid profiles, hematological and blood glucose levels. In addition, biopsies of seventeen coronary arteries with atherosclerosis and an equal number of internal mammary arteries without atherosclerotic degeneration in group 1 were investigated. Statistical analysis by analysis of variance (ANOVA) and Scheffé test for multiple comparisons was performed. RESULTS: Triglyceride and LDL levels were elevated in group 1 than in group 2. HDL were reduced by 20 percent in group 1 and remained reduced by 8 percent in toothless. Blood glucose was higher in group 1. DNA of periodontal bacteria was detected in 58.8 percent of the coronary arteries. CONCLUSIONS: Patients with (AIHD) and severe chronic periodontitis may have altered lipid profile, as well as microorganisms associated with CP can permeate into coronary vessels.

Internal mammary lymph nodes identification from isolated sternum of human cadaver

PURPOSE: To identify the lymph nodes positioned along the internal mammary vessels in isolated sternum of human cadaver and to standardize the surgical approach to those nodes, in order to establish anatomical landmarks to be used with the current techniques of mammary gland sentinel lymph node detection. METHODS: Ten sternum plates removed from unclaimed cadavers were used in this study. Sternal plates were removed using bilateral incisions of the ribs at the midclavicular lines. The characterization of the internal mammary vessels and the anatomical integrity of the parietal pleura were indispensable requirements during the procedure. RESULTS: A total of 29 lymph nodes were removed from the 2nd (13) and the 3rd (16) intercostals spaces. Almost 50 percent of all nodes collected were located medially to the vessels. CONCLUSION: The approach used is a reliable surgical technique for removing lymph node from sternal plates. The model is therefore valuable for breast surgeons training in sentinel node biopsy, an important procedure for breast cancer patients.

OBJETIVO: Identificar os linfonodos localizados ao longo dos vasos mamários internos em esternos isolados de cadáveres e padronizar a abordagem cirúrgica desses linfonodos, registrando os pontos de reparo a serem utilizados nas técnicas atuais de pesquisa do linfonodo sentinela da mama. MÉTODOS: Estudaram-se dez esternos isolados de cadáveres humanos. Os esternos foram obtidos através de secção bilateral do gradil costal ao nível das linhas hemiclaviculares. A individualização e a integridade anatômica da pleura parietal e dos vasos mamários internos foram requisitos imprescindíveis durante a dessecação das peças. RESULTADOS: Um total de 29 linfonodos foram removidos do 2° e 3° espaços intercostais (13 e 16 linfonodos respectivamente). Quase 50 por cento dos linfonodos removidos se situavam em posição medial aos vasos mamários. CONCLUSÃO: A abordagem cirúrgica usada neste estudo demonstrou ser uma técnica adequada para a exérese de linfonodos esternais. Conclui-se assim que o modelo utilizado se presta ao treinamento para o procedimento de biópsia de linfonodo sentinela, de grande valor na abordagem das pacientes portadoras de câncer da mama.

Liberación de neuropéptido tirosina (NPY) de los terminales nerviosos en vasos mamarios / Liberation of tyrosine neuropeptide (NPY) from mammary vessels nerve endings

En este estudio caracterizamos la liberación de NPY de biopsias de la arteria y vena mamaria. Se induce la liberación de los neurotransmisores por medio de despolarización eléctrica de los nervios simpáticos perivasculares. Con estímulo de 70 V, 0,5 msec, 40 Hz por 5 min, segmentos de la arteria mamaria liberan 17,7 ñ 6,7 fmol (n=4) de NPY, la vena libera 4,3 ñ 1,5 fmol (n=4), valores que corresponden a un 1-2 por ciento del NPY en la biopsia. El NPY liberado por estímulo eléctrico no es metabolizado en la sinapsis neuroefectora. La liberación del NPY al medio de superfusión tiene un curso temporal lento, la máxima liberación ocurre a los 10 min del estímulo. La liberación del NPY es dependiente de la duración del estímulo (coeficiente de correlación = 0,647, p<0,01); y de la frecuencia de estimulación (coeficiente de correlación = 0,611, p<0,05), indicando que la liberación es un proceso controlado por la frecuencia de la descarga y por la intensidad del estímulo simpático vasomotor. El proceso de liberación es dependiente del calcio, ya que en ausencia de calcio extremo, la liberación de NPY se reduce en 78 por ciento. El NPY actúa sobre receptores postsinápticos, donde produce un efecto facilitador significativo de la acción vasomotora de NA y ATP. En conclusión, NPY se libera al espacio sináptico por exocitosis, donde participa junto a NA y ATP en la regulación del tono vasomotor simpático

Dimensions of potential arterial grafts for coronary artery bypass grafting in Indians--an autopsy evaluation study.

Total revascularization of the heart using as many arterial grafts as possible is the trend of the day. We have chosen two commonly used arterial grafts to evaluate their efficiency in myocardial revascularization in Indian subjects. An autopsy study was conducted in 25 cases. Both internal mammary arteries with their branches and the right gastroepiploic artery were harvested. These arteries were distended with heated Gelatin, deep frozen and their diameters were measured. In 56% of subjects diameter of internal mammary artery was 1.5 to 2.0 mm (n = 14). However 36% of subjects had diameter above 2.0 mm (n = 9). Musculo-phrenic and superior epigastric arteries had 1.85 and 1.65 mm internal diameters respectively. The mean internal diameter of right gastro-epiploic artery was 2.3 mm. When these diameters were indexed to the body surface area, they were comparable with similar figures from western subjects.