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.

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.

Controversy about reversibility of cysts in cystic cystitis in children.

Most cystic cystitis cases in children exhibit cysts for an extended period, even after successful treatment of the underlying infection. Not much is known about the dynamics of cyst appearance and disappearance. In long-term follow-up some clinicians suggest complete eradication of the cysts. Contrary, histological studies describe the cystic cystitis as an irreversible process in von Brunn's nests. The endoscopic differentiation from reversible follicular cystitis is hard and uncertain. A group of 21 children with cystic cystitis was diagnosed and staged in a 10-year period. All of them clinically presented with recurrent uroinfections. We examined cystoscopic changes of cystic cystitis before and during the treatment of urinary infection to find objective signs of improvement in endoscopic findings after prolonged antibiotic therapy. Control cystoscopy was performed after a period of six infection-free months. In the average period of 20 months after the beginning of treatment there were no changes in cystic cystitis stage. The examined period seems to be too short for the changes of cystic cystitis to disappear. It is unclear if prolonged antibacterial treatment bears any influence on the number of cysts.

[Surgical treatment of necrotizing enterocolitis: suspicions and dilemmas]. / Kirursko lijecenje nekrotizirajuceg enterokolitisa: sumnje i dileme.

The acute intestinal perforation is the absolute indication for surgical treatment of neonatal necrotizing enterocolitis (NEC). Other symptoms, signs and conditions suggested as indications for surgical treatment are often unclear. Since the beginning of the treatment for NEC there have been the attempts of categorisation to clear which of the patients have really needed conservative or surgical treatment. However, these categories have not been as useful in practice as it had been expected. The problem is not resolved. The indication for surgical treatment of NEC is still based on surgeon's experience in practice. The surgical treatment of NEC is based upon resection of pathologically changed intestine. Whether it performs the primary anastomosis or enterostomy depends of surgeon's estimation which operation will cause less problems to the patient suffering already. There are the attempts to preserve bowel length modificating the operative tactics in selective cases of NEC. Careful nursing and medical care greatly reduce the severity of the disease decreasing both the associated morbidity and mortality. The treatment of NEC appearing in other entities is almost always surgical. It is almost the rule that patients in such cases belong to the group of great risk. Sometimes, in bad condition of the patient only the drainage of the peritoneal cavity is performed. Performing the resection in these cases as well as giving up of the surgical treatment is the question ethics.