Functional recovery of patients with ischemic cardiomyopathy treated with coronary artery bypass surgery and concomitant intramyocardial bone marrow mononuclear cell implantation--a long-term follow-up study.

BACKGROUND/AIM: Intramyocardial bone marrow mononuclear cells (BMMNC) implantation concomitant to coronary artery bypass grafting (CABG) surgery as an option for regenerative therapy in chronic ischemic heart failure was tested in a very few number of studies, with not consistent conclusions regarding improvement in left ventricular function, and with a follow-up period between 6 months and 1 year. This study was focused on testing of the hypothesis that intramyocardial BMMNC implantation, concomitant to CABG surgery in ischemic cardiomyopathy patients, leads to better postoperative long-term results regarding the primary end-point of conditional status-functional capacity and the secondary endpoint of mortality than CABG surgery alone in a median follow-up period of 5 years. METHODS: A total of 30 patients with ischemic cardiomyopathy and the median left venticular ejection fraction (LVEF) of 35.9 ± 4.7% were prospectively and randomly enrolled in a single center interventional, open labeled clinical trial as two groups: group I of 15 patients designated as the study group to receive CABG surgery and intramyocardial implantation of BMMNC and group II of 15 patients as the control group to receive only the CABG procedure. All the patients in both groups received the average of 3.4 ± 0.7 implanted coronary grafts, and all of them received the left internal mammary artery (LIMA) to the left anterior descending (LAD) and autovenous to other coronaries. RESULTS: The group with BMMNC and CABG had the average of 17.5 ± 3.8 injections of BMMNC suspension with the average number of injected bone marrow mononuclear cells of 70.7 ± 32.4 x 10(6) in the total average volume of 5.7 ± 1.5 mL. In this volume the average count of CD34+ and CD133+ cells was 3.96 ± 2.77 x 10(6) and 2.65 ± 1.71 x 10(6), respectively. All the patients were followed up in 2.5 to 7.5 years (median, 5 years). At the end of the follow-up period, siginificantly more patients from the group that received BMMNC were in the functional class I compared to the CABG only group (14/15 vs 5/15; p = 0.002). After 6 months the results on 6-minute walk test (6-MWT) were significantly different between the groups (435 m in the BMMNC and CABG group and 315 m in the CABG only group; p = 0.001), and continued to be preserved and improved on the final follow-up (520 m in the BMMNC and CABG group vs 343 m in the CABG only group; p < 0.001). Cardiovascular mortality was also significantly reduced in the BMMNC and CABG group (p = 0.049). CONCLUSION: Implanatation of BMMNC concomitant to CABG is a safe and feasible procedure that demonstates not only the improved functional capacity but also a reduced cardiac mortality in a 5-year follow-up in patients with ischemic cardiomyopathy scheduled for CABG surgery.

The effects of nicorandil on microvascular function in patients with ST segment elevation myocardial infarction undergoing primary PCI.

BACKGROUND: Nicorandil, as a selective potassium channel opener, has dual action including coronary and peripheral vasodilatation and cardioprotective effect through ischemic preconditioning. Considering those characteristics, nicorandil was suggested to reduce the degree of microvascular dysfunction. METHODS: Thirty-two patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention (pPCI) were included in the study. Index of microvascular resistance (IMR) was measured in all patients immediatelly after pPCI before the after administration of Nicorandil. ST segment resolution was monitored before intervention and 60 min after terminating the procedure. Echocardiographic evaluation of myocardial function and transthoracic Doppler derived Coronary flow reserve (CFR) of infarct related artery (IRA) was performed during hospitalization and 3 months later. RESULTS: IMR was significantly lower after administration of Nicorandil (9.9 ± 3.7 vs. 14.1 ± 5.1, p < 0.001). There was significant difference in ST segment elevation before and after primary PCI with administration of Nicorandil (6.9 ± 3.7 mm vs. 1.6 ± 1.6 mm, p < 0.001). Transthoracic Doppler CFR measurement improved after 3 months (2.69 ± 0.38 vs. 2.92 ± 0.54, p = 0.021), as well as WMSI (1.14 ± 0.17 vs. 1.07 ± 0.09, p = 0.004). CONCLUSION: Intracoronary Nicorandil administration after primary PCI significantly decreases IMR, resulting in improved CFR and ventricular function in patients with STEMI undergoing primary PCI.

Myocardial protection during elective coronary artery bypasses grafting by pretreatment with omega-3 polyunsaturated fatty acids.

BACKGROUND/AIM: Despite recent advances in coronary artery bypass grafting (CABG), cardioplegic cardiac arrest and cardiopulmonary bypass (CPB) are still associated with myocardial injury. Accordingly, the efforts have been made lately to improve the outcome of CPB by glucose-insulin-potassium, adenosine, Ca(2+)-channel antagonists, L-arginine, N-acetylcysteine, coenzyme Q10, diazoxide, Na+/H+ exchange inhibitors, but with an unequal results. Since omega-3 polyunsatutated fatty acids (PUFAs) have shown remarkable cardioprotection in preclinical researches, the aim of our study was to check their effects in prevention of ischemia reperfusion injury in patients with CPB. METHODS: This prospective, randomized, placebo-controlled study was performed with parallel groups. The patients undergoing elective CABG were randomized to receive preoperative intravenous omega-3 PUFAs infusion (n = 20) or the same volume of 0.9% saline solution infusion (n = 20). Blood samples were collected simultaneously from the radial artery and the coronary sinus before starting CPB and at 10, 20 and 30 min after the release of the aortic cross clamp. Lactate extraction/excretion and myocardial oxygen extraction were calculated and compared between the two groups. The levels of troponin I (TnT) and creatine kinase-myocardial band (CK-MB) were determined before starting CPB and 4 and 24 h postoperatively. RESULTS: Demographic and operative characteristics, including CPB and aortic cross-clamp time, were similar between the two groups of patients. The level of lactate extraction 10 and 20 min after aortic cross-clamp time has shown negative values in the control group, but positive values in the PUFAs group with statistically significant differences (-19.6% vs 7.9%; p < 0.0001 and -19.9% vs 8.2%; p < 0.0008, respectively). The level of lactate extraction 30 minutes after reperfusion was not statistically different between the two groups (6.9% vs 4.2%; p < 0.54). Oxygen extraction in the PUFAs group was statistically significantly higher compared to the control group after 10, 20 and 30 min of reperfusion (35.5% vs 50.4%, p < 0.0004; 25.8 % vs 48.7%, p < 0.0001 and 25.8% vs 45.6%, p < 0.0002, respectively). The level of TnT, 4 and 24 h after CPB, was significantly higher in the control group compared to PUFAs group, with statistically significant differences (11.4 vs 6.6, p < 0.009 and 12.7 vs 5.9, p < 0.008, respectively). The level of CK-MB, 4 h after CPB, was significantly higher in the control group compared to PUFAs group (61.9 vs 37.7, p < 0.008), but its level, 24 h after CPB, was not statistically different between the two groups (58.9 vs 40.6, p < 0.051). CONCLUSION: Treatment with omega-3 PUFAs administered preoperatively promoted early metabolic recovery of the heart after elective CABG and improved myocardial protection. This study showed that omega-3 emulsion should not be considered only as a nutritional supplement but also as a clinically safe and potent cardioprotective adjunct during CPB.

A young soldier with syncope, shortness of breath and palpitations.

INTRODUCTION: Coronary artery disease in people under 30 years is relatively uncommon, but once a disease occurs it brings a significant morbidity and psychological effects. CASE REPORT: We reported a 28-year-old patient presenting atypical symptoms after sincopa and non-specific changes on electrocardiogram at admission. After noninvasive and invasive cardiology diagnostic procedures were made, we concluded that he had a subtotal tubular stenosis in proximal segment of the left anterior descending coronary artery. Myocardial revascularization was successfully performed 24-hour after coronarography with the left internal mammary thoracic artery graft on the left anterior descending coronary artery and the patient had a prompt and satisfactory postoperative recovery. CONCLUSION: This case indicates the importance of a careful evaluation of young adults even if they do not experience typical anginal symptoms or do not have multiple risk factors for cardiovascular diseases.

Influence of intracoronary injections of bone-marrow-derived mononuclear cells on large myocardial infarction outcome: quantum of initial necrosis is the key.

BACKGROUND/AIM: Autologous bone-marrow-derived intra= coronary injection of mononuclear cells (MNC) modestly improved left ventricular ejection fraction (LVEF) in the selected patients after acute ST elevation myocardial infarction (STEMI). Major determinants of stem cell therapy outcome in the subacute phase of STEMI still remain unknown. Therefore, the aim of this study was to determine modifying factors for the outcome of stem cell therapy after STEMI. METHODS: Eighteen patients in the stem cell therapy group and 24 patients in the control group with the successfully reperfused first large STEMI (LVEF < or = 40%) were enrolled in the study. The stem cell group was submitted to autologous bone-marrow-derived MNC injection between 7-12 days after MI. Left ventricular ejection fraction and infarction size at baseline and after 4 months were determined by echocardiography and scintigraphy examination. Age, pain onset to reperfusion time, admission glycemia, maximum lactate dehydrogenase (LDH) activity and C-reactive protein level, baseline LVEF and infarction size, and the number of MNC injected were compared between patients with and without significant improvement of LVEF and decrease of myocardial infarct size after 4 months. RESULTS: In the stem cell group, patients with the improvement of LVEF for more than 5.1% had significantly lower levels of LDH than patients without such improvement (1689 +/- 139 vs 2133 +/- 215 IU/L, p < 0.001) and lower baseline infarction size on scintigraphy (26.7 +/- 5.2 vs 34.9 +/- 3.7%, p < 0.001). Such dependence was not found in the control group. CONCLUSION: In the patients with first large STEMI intracoronary injection of autologous bone-marrow-derived MNC leads to the significant decrease of myocardial infarction size but not the significant improvement of LVEF after four months. Higher serum LDH levels after STEMI and very large baseline infarction size are predictors of failure of stem cell therapy in our group of STEMI patients.

[Superior vena cava syndrome caused by epitheloid hemangioma].

AIM: A case is presented of the surgical treatment of epitheloid hemangioma as a rare cause of superior vena cava syndrome. CASE REPORT: A 53-year old woman was admitted to the clinic with the symptoms and signs of superior vena cava syndrome. After clinical evaluation and diagnostic tests, she was operated on through median stemotomy, and the desobliteration of the superior vena cava through longitudinal cavotomy was done. After the desobliteration b y the removal o f benign tumor from its cavity, vena cava was reconstructed with the continuous prolen suture. Pathohistologicaly, there was the evidence of epitheloid hemangioma that made the subtotal obliteration of the vena cava superior by its expansive growing at the entry in the right atrium. Postoperatively, there was a complete disappearance of the symptoms and signs of superior vena cava syndrome. After an uneventful recovery, the patient was discharged from the hospital.

[Papillary muscle rupture due to acute myocardial infarction followed by cardiogenic shock, pulmonary edema, and acute renal failure].

AIM: The case of successfull surgical treatment of anterolateral papillary muscle rupture due to acute myocardial infarction with cardiogenic shock, pulmonary edema and acute renal failure. CASE REPORT: A 62-year old male from Belgrade with chest pain, hypotension and a new heart murmur refused hospitalization at the Military Medical Academy. On the third day of his illness he was readmitted to MMA as an emergency due to hemoptysis. Examination revealed mitral valve anterolateral papillary muscle rupture. The patient, with signs of cardiogenic shock and acute renal failure, was immediately operated on. The surgery was performed using extracorporeal circulation. An artificial mitral valve was implanted, and myocardial revascularization accomplished with one venous graft of the left anterior descending artery. On the second postoperative day, hemodialysis was carried out due to acute renal failure. On the 28th postoperative day, the patient was discharged from the hospital being hemodynamically stable with normal renal function and balanced anticoagulation. The case is interesting in terms of unrecognized papillary muscle rupture that led to the development of cardiogenic shock, hemoptysis and acute renal failure. CONCLUSION: Papillary muscle rupture is a fatal complication of acute myocardial infarction. Early recognition and urgent surgical intervention were life-saving in the case of complete papillary muscle rupture. Surgical treatment, regardless of high risk, is the procedure of choice.