Myocardial revascularization in renal transplant patients

OBJECTIVE: To assess the results of surgical myocardial revascularization in renal transplant patients. METHODS: From 1991 to 2000, 11 renal transplant patients, whose ages ranged from 36 to 59 (47.5±8) years, 8 males and 3 females, underwent myocardial revascularization. The time interval between renal transplantation and myocardial revascularization ranged from 25 to 120 (mean of 63.8±32.7) months. RESULTS: The in-hospital mortality rate was 9%. One patient died on the 4th postoperative day from septicemia and respiratory failure. The mean graft/patient ratio was 2.7±0.8. Only 1 patient required slow hemodialysis during 24 hours in the postoperative period, and no patient had a definitive renal lesion or lost the transplanted kidney. The actuarial survival curves after 1, 2, and 3 years were, respectively, 90.9%, 56.8%, and 56.8%. CONCLUSION: Renal transplant patients may undergo myocardial revascularization with no lesion in or loss of the transplanted kidney.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

Myocardial Revascularization in Dyalitic Patients: In-Hospital Period Evaluation

Background:Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high.Objective:Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients.Methods:Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012.Results:High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality.Conclusion:Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions.Fundamentos:Atualmente, a revascularização cirúrgica do miocárdio é o melhor tratamento para o paciente dialítico com lesão coronariana multiarterial, contudo a mortalidade e a morbidade hospitalar do procedimento ainda permanecem altas.Objetivos:Avaliar os resultados e a evolução intra-hospitalar da revascularização cirúrgica do miocárdio isolada em pacientes dialíticos.Métodos:Estudo retrospectivo unicêntrico de 50 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização cirúrgica do miocárdio em um hospital terciário universitário no período de 2007 a 2012.Resultados:A casuística apresentou alta prevalência de fatores de risco cardiovasculares (100% hipertensos, 68% diabéticos e 40% dislipidêmicos). Não houve óbito intraoperatório, e 60% dos procedimentos foram feitos sem circulação extracorpórea. Houve sete (14%) óbitos intra-hospitalares. Infecção pós-operatória, insuficiência cardíaca prévia, uso de circulação extracorpórea, função ventricular anormal e reexploração cirúrgica foram os fatores associados a maior mortalidade.Conclusão:A revascularização cirúrgica do miocárdio é um procedimento factível para essa classe de pacientes, contudo com alta morbidade e mortalidade intra-hospitalar. É necessário melhor entendimento das particularidades metabólicas desses pacientes para o planejamento adequado das condutas.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUniversidade de Santo AmaroUNIFESP, EPMSciEL

Sildenafil improves right ventricular function in a cardiac transplant recipient

We report the case of a male patient who underwent orthotopic cardiac transplantation. A marginal donor was used, because the recipient's clinical condition was critical. He experienced cardiogenic shock due to right ventricular dysfunction secondary to pulmonary hypertension associated with vasoplegia. After the introduction of sildenafil, the patient recovered hemodynamically, his pulmonary vascular resistance decreased, the vasoactive drugs were withdrawn, and his right ventricular function improved.Relatamos caso de um paciente submetido a transplante cardíaco ortotópico, onde se utilizou um doador marginal pela piora clínica do receptor, que apresentava choque cardiogênico por disfunção de ventrículo direito secundária a hipertensão pulmonar associado à vasoplegia. Obtivemos recuperação hemodinâmica do paciente, com redução da resistência vascular pulmonar, retirada de drogas vasoativas e recuperação da função do ventrículo direito após a introdução de sildenafil.Universidade Federal de São Paulo (UNIFESP) Escola Paulista de MedicinaUNIFESP, EPMSciEL

The potential therapeutic use of cord blood in autologous transplants or in special patients: a review and update

Umbilical Cord Blood is a rich source of hematopoietic stem cells widely used as a substitute of bone marrow (BM) in transplants. Cells from umbilical cord blood present advantages over BM cells, mainly as they are younger and a have higher proliferative rate. Besides hematopoietic stem cells, umbilical cord blood contains endothelial and mesenchymal progenitor cells, suggesting their possible application in cell therapy protocols for different tissues. In this paper, we discuss the importance of autologous umbilical cord blood storage and the research on stem cell transplantation for degenerative diseases.O sangue de cordão umbilical e placentário (SCUP) é uma rica fonte de células-tronco (CT) hematopoéticas e é amplamente utilizado como substituto da medula óssea em casos de transplante. As células do SCUP possuem vantagens sobre as células da medula óssea (MO), principalmente por serem mais jovens e apresentarem maior taxa proliferativa. Além dos progenitores hematopoéticos, o sangue de cordão umbilical contém progenitores endoteliais e mesenquimais, sugerindo sua possível aplicação nos novos protocolos de terapia celular para diferentes tecidos. Na presente revisão, discutimos a importância do armazenamento do sangue de cordão umbilical autólogo e as pesquisas desenvolvidas para a sua aplicação em doenças degenerativas.Cryopraxis Criobiologia LtdaUniversidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina (EPM)Instituto de Traumato-ortopediaSanta Casa de São PauloHospital Samaritano de São PauloUFRJ HUCFFHospital Central do ExércitoUFRJ IPPMGUFRJCollege of Medicine Department of Neurosurgery Center of Excellence for Aging & Brain RepairUNIFESP, EPMSciEL

Cell therapy in refractory angina (ReACT) involved stem cells autologous bone marrow in patients without left ventricular dysfunction:a possible role of monocytes

Background Autologous bone marrow mononuclear cell (BMMC) transplantation has emerged as a potential therapeutic option for refractory angina patients. Previous studies have shown conflicting myocardium reperfusion results. The present study evaluated safety and efficacy of CellPraxis Refractory Angina Cell Therapy Protocol (ReACT™), in which a specific BMMC formulation was administered as the sole therapy for these patients. Methods The Phase I/IIa Non-controlled, Open label, Clinical Trial, involved eight patients with refractory angina and viable ischemic myocardium, without left ventricular dysfunction and who were not suitable for conventional myocardial revascularization. ReACT™ is a surgical procedure involving a single series of multiple injections (40-90 injections, 0.2 ml each) into ischemic areas of the left ventricle. Primary endpoints were Canadian Cardiovascular Society Angina Classification (CCSAC) improvement at the 18 month follow-up and myocardium ischemic area reduction (assessed by scintigraphic analysis) at the 12 month followup, in correlation with a specific BMMC formulation. Findings Almost all patients presented progressive improvement in angina classification beginning 3 months (p=0.008) post procedure which was sustained at the eighteenth month follow-up (p=0.004), as well as objective myocardium ischemic area reduction at 12 months (decrease of 84.4%, p<0.004). A positive correlation was found between monocyte concentration and CCSAC improvement (r = -0.759, p < 0.05). Interpretation Improvement in Canadian Cardiovascular Society Angina Classification, followed by correlated reduction in scintigraphic myocardium ischemic area strongly suggests neoangiogenesis as the main stem cell action mechanism. The significant correlation between number of monocytes and improvement strongly supports a cell related effect of ReACT™. ReACT™ appeared safe and effective.Introdução A terapia celular envolvendo o transplante de células tronco autólogas de medula óssea surgiu como uma opção terapêutica viável para o tratamento de pacientes com angina refratária. Estudos conduzidos até o momento obtiveram resultados controversos de reperfusão miocárdica. O presente estudo avaliou a segurança e eficácia do Protocolo de Terapia Celular para Angina Refratária (ReACT®), no qual uma formulação de células tronco autólogas de medula óssea foi administrada como único tratamento para estes pacientes. Métodos Este estudo clínico fase I/IIa, aberto, não controlado, envolveu 8 pacientes com angina refratária e presença de viabilidade miocárdica, sem disfunção ventricular esquerda, os quais não eram candidatos às técnicas de revascularização miocárdica convencionais. ReACT® consistiu em um procedimento operatório envolvendo uma única série de múltiplas injeções intramiocárdicas (40-90 injeções, 0,2 ml por punção), realizadas nas areas isquêmicas reversíveis do ventrículo esquerdo. Os desfechos primários foram a melhora na classificação de angina, segundo a Classificação de Angina da Sociedade Cardiovascular Canadense (CCSAC), ao final de 18 meses de seguimento pós-infusão, e a redução objetiva da area miocárdica isquêmica (avaliada por cintilografia miocárdica) após 12 meses; em correlação com a formulação de células tronco injetadas. Resultados Praticamente todos pacientes apresentaram melhora progressiva na classificação de angina, a qual iniciou-se aos 3 meses de seguimento (p=0,008) e manteve-se sustentada até 18 meses de pós-operatório (p=0,004); assim como redução objetiva da area miocárdica isquêmica aos 12 meses (diminuição de 84,4% da area isquêmica, p<0,004). Evidenciou-se também uma correlação significativamente positiva entre a concentração de monócitos no preparado celular injetado e melhora da CCSAC (r = -0,759, p < 0,05). Conclusão A melhora na Classificação de Angina da Sociedade Cardiovascular Canadense (CCSAC), concordante à redução cintilográfica da area miocárdica isquêmica sugere neoangiogênese como o principal mecanismo de ação da terapia celular deste protocolo. A correlação positiva significativa entre a concentração de monócitos e melhora clínica suporta fortemente um efeito celular do ReACT®. ReACT® pareceu ser seguro e eficaz.TED

CARDIOPULMONARY BYPASS INCREASES THE RISK OF VASOPLEGIC SYNDROME AFTER CORONARY ARTERY BYPASS GRAFTING IN PATIENTS WITH DIALYSIS-DEPENDENT CHRONIC RENAL FAILURE

Abstract Objective: Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group. Methods: A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately. Results: There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences. Conclusion: Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure