Chronic Chagas' disease cardiomyopathy patients display an increased IFN-gamma response to Trypanosoma cruzi infection

One-third of all Trypanosoma cruzi -infected patients eventually develop chronic Chagas' disease cardiomyopathy (CCC), a particularly lethal inflammatory dilated cardiomyopathy, where parasites are scarce and heart-infiltrating mononuclear cells seem to be the effectors of tissue damage. Since T. cruzi is a major inducer of interleukin-12 production, the role of inflammatory cytokines in the pathogenesis of CCC was investigated. We assayed cytokine production by peripheral blood mononuclear cells (PBMC) from CCC and asymptomatic T. cruzi -infected (ASY) individuals, as well as by T cell lines from endomyocardial biopsies from CCC patients. PBMC from CCC and ASY patients produced higher IFN-gamma levels than normal (N) individuals in response to B13 protein and phytohaemagglutinin PHA; IFN-gamma high responders (> or =1 ng/ml) were 2-3 fold more frequent among CCC patients than ASY individuals. Conversely, IL-4 production in response to the same stimuli was suppressed among T. cruzi -infected patients. The frequency of PHA-induced IFN gammaproducing cells on PBMC was significantly higher among CCC than ASY and N individuals. IFN-gamma and TNF-alpha were produced by ten out of ten PHAstimulated T cell lines from CCC patients; IL-2 and IL-10 were produced by four out of ten and one out of ten lines, respectively; IL-4, IL-1alpha, IL-1beta, IL-6 and IL-12 were undetectable. Our results suggest that CCC and ASY patients may respond differentially to the IFN-gamma-inducing stimulus provided by T. cruzi infection. Given the T(1)-type cytokine profile of heart-infiltrating T cell lines from CCC patients, the ability to mount a vigorous IFN-gamma response may play a role on the differential susceptibility to CCC development.

The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi. First Guidelines Group for Heart Transplantation of the Brazilian Society of Cardiology

BACKGROUND

Donor supply limits heart transplantation (HT) and relative priority should be given to cases with greater chances of success. The objectives of this multicenter study were (1) to determine the survival rate after heart transplantation for patients with Chagas' heart disease (ChHD) in comparison with other causes; and (2) to identify the causes of death specifically due to reactivation of the Trypanosoma cruzi infection.

METHODS

We studied 720 patients who had undergone orthotopic heart transplantation and were followed in 16 heart transplantation centers. The etiology was idiopathic dilated cardiomyopathy in 407 patients, ischemic cardiomyopathy in 196 patients, and ChHD in 117 patients.

RESULTS

Follow-up was 2.87 +/- 3.05 years (from 1 month to 13.85 years). Survival of ischemic recipients at 1, 4, 8, and 12 years was 59%, 44%, 34%, and 22%, respectively; for idiopathic dilated cardiomyopathy it was 69%, 57%, 40%, and 32%; and for ChHD it was 71%, 57%, 55%, and 46% (p < 0.027). In ischemic recipients the most frequent causes of death were infection (15.3%), acute graft failure (13.3%), and graft coronary artery disease/sudden death (7.7%). In idiopathic dilated cardiomyopathy the causes were infection (11.1%), rejection (9.6%), and acute graft failure (9.1%). In ChHD the causes were infection (10.3%), rejection (10.3%), and neoplasm (4.3%). In ChHD, reactivation of the cruzi infection was the cause of death in 2 patients.

CONCLUSIONS

The survival results after heart transplantation are paradoxical according to the usually high expected death rates for Chagas' disease. Heart transplantation for ChHD should be regarded as a valuable treatment option.

The Brazilian experience with heart transplantation: a multicenter report

BACKGROUND

The results of heart transplantation in developing countries are influenced by the high incidence of marginal donors and the large number of recipients with characteristics of alternative list. The purpose of this multicenter report was to determine the rate of survival after heart transplantation in a developing country. Also we studied the causes of death, the results based on the year of transplant, the influence of gender and age, the numbers of transplants per year, and the etiology of the cardiomyopathy causing the heart failure.

METHODS

We studied 792 (632 male) patients who underwent orthotopic heart transplantation at 16 centers. The mean age of the patients was 42 +/- 16 years. Etiology included idiopathic dilated cardiomyopathy in 407 patients, ischemia in 196 patients, Chagas disease in 117 patients, and various other in 72 patients. Cyclosporine was the cornerstone of the immunosuppression administered.

RESULTS

Survival for the entire population at 3 months and 1, 4, 8, and 12 years was 72%, 66%, 54%, 40%, and 27%, respectively. There was an improvement in survival from 1991 to 1995 compared with before 1991. Age and gender did not influence the results. Unexpected early mortality was observed, but the late results were satisfactory. The most prevalent causes of death were infection in 23%, acute graft failure in 19%, and rejection in 18%.

CONCLUSIONS

Heart transplantation has become feasible in developing countries and the survival rate has improved without the influence of gender and age recipients. A chagasic etiology was found to be the third-leading indication for heart transplantation. The impact of increment of donors with appropriate care for reduction of marginal donors, perhaps associated with better recipient selection and postoperative care, should be investigated for improving early results.

Partial left ventriculectomy in severe idiopathic dilated cardiomyopathy: assessment of short-term results and their impact on late survival by magnetic resonance imaging

We evaluated short-term effects of partial ventriculectomy on left ventricular (LV) parameters and its impact on late survival by magnetic resonance imaging (MRI). Twenty patients and 10 normal volunteers were studied, and LV volumes (EDV, ESV), ejection fraction (EF), short- and long-axis dimensions (SA, LA), wall thickness (Wth), shape (LA/SA), geometry (Wth/SA), a geometry index (Phi), and wall-motion score index (WMSI) were evaluated pre- and postoperatively. Also, we compared results and survival of patients with preoperative EF <or=17% vs. EF >17%. Short-term results showed significant changes (P < 0.001) in: EF (17.3 +/- 7.3% vs. 30.4 +/- 9.5%), EDV (391.9 +/- 118 vs. 272.7 +/- 90 mL); ESV (308.2 +/- 102.8 vs. 190.3 +/- 68.4 mL); SA (80.5 +/- 10.4 vs. 71.7 +/- 7.8 mm); LA/SA (1.13 +/- 0.1 vs. 1.34 +/- 0.1); Wth (8.35 +/- 0.99 vs. 9.75 +/- 1.41 mm); Wth/SA (0.10 +/- 0.01 vs. 0.14 +/- 0.02), diastolic( 0.80 +/- 0.16 vs. 0.58 +/- 0.13) and systolic (0.78 +/- 0.18 vs. 0.55 +/- 0.12) Phi; and WMSI (-2 vs. -1) (P = 0.032). The EF division showed differences in: LA/SA (1.26 +/- 0.10 vs. 1.49 +/- 0.12) (P < 0.001); Wth/SA (0.13 +/- 0.02 vs. 0.15 +/- 0.02) (P = 0.023); diastolic (0.65 +/- 0.11 vs. 0.48 +/- 0.11) and systolic (0.63 +/- 0.09 vs. 0.46 +/- 0.09) Phi (P < 0.001); and WMSI (-2 vs. -1) (P = 0.033). Finally, correlation between pre/postoperative EF showed for EF < 17%, r = 0.32 and for EF >17%, r = 0.83, which had different late survival. Our study showed significant changes on LV parameters after ventriculectomy. Patients with EF >17% showed better EF correlation between pre/postoperative values and higher survival rate. J. Magn. Reson. Imaging 2001;13:781-786.

Histoplasmosis as a late infectious complication following heart transplantation in a patient with Chagas' disease

Infectious complications following heart transplantation are an important cause of morbidity and mortality. Generally, bacterial infections are predominant; however, fungal infections can be responsible for up to 25% of infectious events. We report the case of a patient who presented with histoplasmosis as an infectious complication five years after heart transplantation due to a chagasic cardiopathy. This association has rarely been reported in the international literature.

Current perspectives of partial left ventriculectomy in the treatment of dilated cardiomyopathy

OBJECTIVES

Partial left ventriculectomy has been performed as an alternative to heart transplantation in the treatment of severe cardiomyopathies. This investigation documents the clinical and left ventricular (LV) function effects of this procedure, associated, when necessary, with mitral insufficiency correction, in 43 patients with idiopathic dilated cardiomyopathy.

METHODS

Eighteen patients were in New York Heart Association class III and 25 in class IV. Seven of them were operated in cardiogenic shock. The procedure was associated with mitral annuloplasty in 32 patients and mitral replacement in three.

RESULTS

Nine patients (20.9%) died during the hospital period and the cause of death was associated with ventricular failure in seven patients. The other patients were followed up from 2 to 57 months (mean, 28.3 months). At 6 months of follow-up, eight patients were in functional class I, 13 in class II, three in class III and one patient was in class IV (P<0.001). On the other hand, nine patients died during the first 6 months and another six in the later postoperative period. The cause of late death was progressive heart failure in eight patients, and seven patients died because of arrhythmia related events. The actuarial survival was 58.1+/-7.5% at 1 year and 43.9+/-8.1% at 4 years of follow-up. Regarding ventricular function modifications, the LV diastolic volume decreased by around 25% and the LV ejection fraction increased from 17.8+/-4.7 to 22.3+/-7.9% (P<0.001), whereas significant changes in the cardiac index, stroke index and pulmonary pressures were also found 1 month after the operation. In the later follow-up, despite the maintenance of hemodynamic improvement, the LV diastolic volume tended to increase and returned to preoperative levels at 4 years, while a concomitant decrease in the LV ejection fraction was also observed.

CONCLUSION

Partial left ventriculectomy associated with mitral insufficiency correction improves LV function and ameliorates congestive heart failure in patients with idiopathic cardiomyopathy. Otherwise, the LV function benefits seem to be restricted by the possibility of progressive LV redilatation. Furthermore, the clinical application of this procedure is limited by the high mortality observed in the first postoperative months and by the possibility of heart failure progression and arrhythmia related events at late follow-up.

Noninvasive diagnosis of allograft vascular disease after heart transplantation

OBJECTIVE

To determine the predictive values of noninvasive tests for the detection of allograft vascular disease.

METHODS

We studied 39 patients with mean ages of 48+/-13 years and a follow-up period of 86+/-13 months. The diagnosis of allograft vascular disease was made by cine-coronary arteriography, and it was considered as positive if lesions existed that caused > or =50% obstruction of the lumen. Patients underwent 24h Holter monitoring, thallium scintigraphy, a treadmill stress test, and dobutamine stress echocardiography. Sensitivity, specificity, and positive and negative predictive values were determined in percentages for each method, as compared with the cine-coronary arteriography results.

RESULTS

Allograft vascular disease was found in 15 (38%) patients. The Holter test showed 15.4% sensitivity, 95.5% specificity. For the treadmill stress test, sensitivity was 10%, specificity was 100%. When thallium scintigraphy was used, sensitivity was 40%, specificity 95.8%. On echocardiography with dobutamine, we found a 63.6% sensitivity, 91.3% specificity. When the dobutamine echocardiogram was associated with scintigraphy, sensitivity was 71.4%, specificity was 87%.

CONCLUSION

In this group of patients, the combination of two noninvasive methods (dobutamine echocardiography and thallium scintigraphy) may be a good alternative for the detection of allograft vascular disease in asymptomatic patients with normal ventricular function.

Analysis of the risk factors for allograft vasculopathy in asymptomatic patients after cardiac transplantation

OBJECTIVE

To study the influence of immune and nonimmune risk factors on the development of allograft vasculopathy after cardiac transplantation.

METHODS

We studied 39 patients with a mean age of 46+/-12 years. The following variables were analyzed: weight (kg), body mass index (kg/m2), donor's age and sex, rejection episodes in the first and second years after transplantation, systolic and diastolic blood pressures (mmHg), total cholesterol and fractions (mg/dL), triglycerides (mg/dL), diabetes, and cytomegalovirus infection. The presence of allograft vasculopathy was established through coronary angiography.

RESULTS

Allograft vasculopathy was observed in 15 (38%) patients. No statistically significant difference was observed between the two groups in regard to hypertension, cytomegalovirus infection, diabetes, donor's sex and age, rejection episodes in the first and second years after transplantation, and cholesterol levels. We observed a tendency toward higher levels of triglycerides in the group with disease. Univariate and multivariate analyses showed statistically significant differences between the two groups when we analyzed the body mass index (24.53+/-4.3 versus 28.11+/-4.6; p=0.019).

CONCLUSION

Body mass index was an important marker of allograft vasculopathy in the population studied.

Left ventricular regional wall motion, ejection fraction, and geometry after partial left ventriculectomy. Influence of associated mitral valve repair

OBJECTIVE

Left partial ventriculectomy has been proposed for treatment of heart failure. We investigated the effects of isolated left partial ventriculectomy and left partial ventriculectomy associated with mitral annuloplasty on refractory heart failure due to idiopathic dilated cardiomyopathy.

METHODS

Nineteen patients underwent partial left partial ventriculectomy associated with mitral annuloplasty and six patients isolated left partial ventriculectomy. In two patients the left partial ventriculectomy associated with mitral annuloplasty was combined with tricuspid annuloplasty. We evaluated before and after the surgery (24+/-14 days): the functional class, left ventricular ejection fraction (LVEF), right ventricular ejection fraction (EF), regional wall motion, hemodynamics, mitral regurgitation, left ventricular geometry and coronary angiography.

RESULTS

For the overall group LVEF improved from 14.5+/-8.0 to 30.3+/-12.2% (P<0.0002) and right ventricular EF from 21.2+/-7.1 to 28.4+/-8.3% (P<0.002). In patients who underwent left partial ventriculectomy associated with mitral annuloplasty LVEF increased from 14.5+/-8.6 to 29.5+/-12.2% (P<0. 002). Isolated left partial ventriculectomy increased LVEF from 13. 5+/-7.5 to 31.5+/-11.1% (P<0.04). Distal segments of marginal branches of the circumflex artery were not visualized by coronary angiography. Left partial ventriculectomy associated with mitral annuloplasty reduced the wedge pressure from 25.0+/-12.1 to 18.0+/-7. 0 mmHg (P<0.03) and increased cardiac output from 3.8+/-0.8 to 4. 6+/-1.1 l/min (P<0.004), while isolated left partial ventriculectomy increased cardiac output from 3.7+/-1.0 to 4.8+/-1.3 l/min (P<0.03). Regional wall motion increment was more evident in anterolateral region from 4.2+/-6.8 to 14+/-8.3% (P<0.002) except in two patients. Left ventricular geometry changed in most patients, but a homogeneous pattern was not identified. Seven patients died during a mean follow-up of 546+/-276 days. Survivors had improvement in functional class. Augmentation of LVEF >5% was associated with a favorable clinical outcome with improvement in clinical status without death.

CONCLUSIONS

Effects of left partial ventriculectomy are not necessarily dependent upon reduction of mitral regurgitation or changes in left ventricular geometry. However, risk of death after the surgery must be reduced for a clinical application.

Mediastinitis after cardiac transplantation

OBJECTIVE

Assessment of incidence and behavior of mediastinitis after cardiac transplantation.

METHODS

From 1985 to 1999, 214 cardiac transplantations were performed, 12 (5.6%) of the transplanted patients developed confirmed mediastinitis. Patient's ages ranged from 42 to 66 years (mean of 52.3 +/- 10.0 years) and 10 (83.3%) patients were males. Seven (58.3%) patients showed sternal stability on palpation, 4 (33.3%) patients had pleural empyema, and 2 (16.7%) patients did not show purulent secretion draining through the wound.

RESULTS

Staphylococcus aureus was the infectious agent identified in the wound secretion or in the mediastinum, or both, in 8 (66.7%) patients. Staphylococcus epidermidis was identified in 2 (16.7%) patients, Enterococcus faecalis in 1 (8.3%) patient, and the cause of mediastinitis could not be determined in 1 (8.3%) patient. Surgical treatment was performed on an emergency basis, and the extension of the débridement varied with local conditions. In 2 (16.7%) patients, we chose to leave the surgical wound open and performed daily dressings with granulated sugar. Total sternal resection was performed in only 1 (8.3%) patient. Out of this series, 5 (41.7%) patients died, and the causes of death were related to the infection. Autopsy revealed persistence of mediastinitis in 1 (8.3%) patient.

CONCLUSION

Promptness in diagnosing mediastinitis and precocious surgical drainage have changed the natural evolution of this disease. Nevertheless, observance of the basic precepts of prophylaxis of infection is still the best way to treat mediastinitis.

Effects of carvedilol in heart failure due to dilated cardiomyopathy. Results of a double-blind randomized placebo-controlled study (CARIBE study)

OBJECTIVE

To assess the effects of carvedilol in patients with idiopathic dilated cardiomyopathy.

METHODS

In a double-blind randomized placebo-controlled study, 30 patients (7 women) with functional class II and III heart failure were assessed. Their ages ranged from 28 to 66 years (mean of 43 +/- 9 years), and their left ventricular ejection fraction varied from 8% to 35%. Carvedilol was added to the usual therapy of 20 patients; placebo was added to the usual therapy of 10 patients. The initial dose of carvedilol was 12.5 mg, which was increased weekly until it reached 75 mg/day, according to the patient's tolerance. Clinical assessment, electrocardiogram, echocardiogram, and radionuclide ventriculography were performed in the pretreatment phase, being repeated after 2 and 6 months of medication use.

RESULTS

A reduction in heart rate (p = 0.016) as well as an increase in left ventricular shortening fraction (p = 0.02) and in left ventricular ejection fraction (p = 0.017) occurred in the group using carvedilol as compared with that using placebo.

CONCLUSION

Carvedilol added to the usual therapy for heart failure resulted in better heart function.

Autopsy findings in early and late postoperative death after partial left ventriculectomy

BACKGROUND

Partial left ventriculectomy (PLV) is an alternative to heart transplantation for patients with severe heart failure. However, this procedure is accompanied by high morbidity and mortality. Therefore, we studied the hearts of 12 patients who underwent this procedure to increase our understanding of the causes of bad outcome.

METHODS

We analyzed the autopsy hearts of 11 of 16 patients who died after PLV, and one heart from a patient who underwent heart transplantation.

RESULTS

Six patients died less than 30 days postoperatively, 4 of cardiogenic shock, 1 of arrhythmia, and 1 of coagulopathy. Five patients died from 36 to 120 days after the procedure, 4 of cardiogenic shock and 1 of arrhythmia. The patient who underwent heart transplantation had a cardiogenic shock 230 days after PLV. Ten hearts weighed more than 500 g and nine had myocardial infarction that extended to the papillary muscles. Four patients had infarction of both papillary muscles and 3 of them had episodes of arrhythmia, suggesting some relation between these events.

CONCLUSIONS

We found several important morphologic clues for bad outcome: infarction of both papillary muscles, which may be associated with the development of arrhythmia, and myocardial infarction and pericardial hemorrhage, which may contribute to the outcome of heart failure.

Treatment of persistent rejection with methotrexate in stable patients submitted to heart transplantation

OBJECTIVE

To evaluate the use of methotrexate for the treatment of recurrent rejection in heart transplant recipients.

METHODS

We studied 6 patients submitted to heart transplantation that showed rejection grade >/= 3A (ISHLT) in two consecutive endomyocardial biopsy specimens. The dose was 11.26+/-3.75 mg/week. The evaluated data were: ventricular function, endomyocardial biopsy, white cell count and number of rejection episodes before and after methotrexate administration.

RESULTS

There was a reduction in the number of rejection episodes (5.17+/-1.47 before methotrexate; 2.33+/-1.75 after 6 months and 3.17+/-2.99 after 12 months of treatment, p=0. 0193). The ventricular function was normal with ejection fraction of 76.5+/-4.80 before and 75.6+/-4.59 after methotrexate (p=0.4859). One patient did not finish the treatment because he showed signs of rejection associated with severe pericardial effusion. Five patients had a reduction in the white cell count (8,108+/-23.72 before and 5650+/-1350 after methotrexate, p=0.0961). One pulmonary infection with complete resolution after antibiotic treatment was observed.

CONCLUSION

Methotrexate in low doses is an effective adjunct therapy in the treatment of recurrent rejection after heart transplantation.

Permanent and temporary pacemaker implantation after orthotopic heart transplantation

PURPOSE

To determine the indication for and incidence and evolution of temporary and permanent pacemaker implantation in cardiac transplant recipients.

METHODS

A retrospective review of 114 patients who underwent orthotopic heart transplantation InCor (Heart Institute USP BR) between March 1985 and May 1993. We studied the incidence of and indication for temporary pacing, the relationship between pacing and rejection, the need for permanent pacing and the clinical follow-up.

RESULTS

Fourteen of 114 (12%) heart transplant recipients required temporary pacing and 4 of 114 (3.5%) patients required permanent pacing. The indication for temporary pacing was sinus node dysfunction in 11 patients (78.5%) and atrioventricular (AV) block in 3 patients (21.4%). The indication for permanent pacemaker implantation was sinus node dysfunction in 3 patients (75%) and atrioventricular (AV) block in 1 patient (25%). We observed rejection in 3 patients (21.4%) who required temporary pacing and in 2 patients (50%) who required permanent pacing. The previous use of amiodarone was observed in 10 patients (71.4%) with temporary pacing. Seven of the 14 patients (50%) died during follow-up.

CONCLUSION

Sinus node dysfunction was the principal indication for temporary and permanent pacemaker implantation in cardiac transplant recipients. The need for pacing was related to worse prognosis after cardiac transplantation.

Growth hormone for optimization of refractory heart failure treatment

It has been reported that growth hormone may benefit selected patients with congestive heart failure. A 63-year-old man with refractory congestive heart failure waiting for heart transplantation, depending on intravenous drugs (dobutamine) and presenting with progressive worsening of the clinical status and cachexia, despite standard treatment, received growth hormone replacement (8 units per day) for optimization of congestive heart failure management. Increase in both serum growth hormone levels (from 0.3 to 0.8 microg/l) and serum IGF-1 levels (from 130 to 300ng/ml) was noted, in association with clinical status improvement, better optimization of heart failure treatment and discontinuation of dobutamine infusion. Left ventricular ejection fraction (by MUGA) increased from 13 % to 18 % and to 28 % later, in association with reduction of pulmonary pressures and increase in exercise capacity (rise in peak VO2 to 13.4 and to 16.2ml/kg/min later). The patient was "de-listed" for heart transplantation. Growth hormone may benefit selected patients with refractory heart failure.

Exercise and heart failure. Relation of the severity of the disease to the anaerobic threshold and the respiratory compensation point

OBJECTIVE - To identify, the anaerobic threshold and respiratory compensation point in patients with heart failure. METHODS - The study comprised 42 Men,divided according to the functional class (FC) as follows: group I (GI) - 15 patients in FC I; group II (GII) - 15 patients in FC II; and group III (GIII) - 12 patients in FC III. Patients underwent a treadmill cardiopulmonary exercise test, where the expired gases were analyzed. RESULTS - The values for the heart rate (in bpm) at the anaerobic threshold were the following: GI, 122+/-27; GII, 117+/-17; GIII, 114+/-22. At the respiratory compensation point, the heart rates (in bpm) were as follows: GI, 145+/-33; GII, 133+/-14; GIII 123+/-22. The values for the heart rates at the respiratory compensation point in GI and GIII showed statistical difference. The values of oxygen consumption (VO2) at the anaerobic threshold were the following (in ml/kg/min): GI, 13. 6+/-3.25; GII, 10.77+/-1.89; GIII, 8.7+/-1.44 and, at the respiratory compensation point, they were as follows: GI, 19.1+/-2. 2; GII, 14.22+/-2.63; GIII, 10.27+/-1.85. CONCLUSION - Patients with stable functional class I, II, and III heart failure reached the anaerobic threshold and the respiratory compensation point at different levels of oxygen consumption and heart rate. The role played by these thresholds in physical activity for this group of patients needs to be better clarified.

Determinants of midterm outcome of partial left ventriculectomy in dilated cardiomyopathy

BACKGROUND

Partial left ventriculectomy has been proposed for treatment of severe cardiomyopathies. This study reports midterm results of this procedure in 37 patients with dilated cardiomyopathy.

METHODS

All patients were in New York Heart Association class III (16) or IV (21). Partial ventriculectomy was associated with mitral annuloplasty in 27 patients and with mitral replacement in 2.

RESULTS

There were seven operative deaths (18.9%). During a mean follow-up of 18.2+/-9.3 months, 9 more patients died. Actuarial survival was 56.7%+/-8.1% at 6 and 24 months. Analysis of factors influencing outcome showed that midterm survival was significantly affected only by myocardial cell diameter. Otherwise, functional class improved from 3.5+/-0.5 to 1.8+/-0.9 in the survivors (p < 0.001). Furthermore, left ventricular diastolic volume decreased from 523+/-207 to 380+/-148 mL (p < 0.001), and left ventricular ejection fraction increased from 17.1%+/-4.6% to 23%+/-8% (p < 0.001), whereas significant changes in cardiac index, stroke index, and pulmonary pressures were found at 1 month of follow-up. Although left ventricular diastolic volume tended to increase in the late postoperative period, left ventricular ejection fraction and hemodynamic variables did not change significantly.

CONCLUSIONS

Partial ventriculectomy improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy for up to 24 months of follow-up. Nevertheless, this procedure's clinical application is limited by the high mortality observed in the first postoperative months. Otherwise, new perspectives may be advised by the identification that partial ventriculectomy results seem to be influenced by compromised myocardial cells.

[Effects of carvedilol (beta 1, beta 2, alpha 1 bloker) on refractory congestive heart failure]

PURPOSE

The effects of beta-blockers on severe heart failure are not well known. We investigated the effects of carvedilol (beta 1, beta 2, alpha 1-blocker) on symptoms, functional class (FC), and left ventricular function in patients with refractory heart failure.

METHODS

We studied 21 patients, mean age 56 +/- 10 years, 9 in FC IV, e 12 in FC III (intermittently with class IV). The initial dosage was 6.25 mg, and it was increased progressively as tolerated. The mean dose was 42 +/- 11 mg. The patients were submitted to routine clinical evaluation, and electrocardiogram. We determined after 196 +/- 60 days of follow-up the left ventricular end diastolic dimension (by echocardiogram), and left ventricular ejection fraction (using MUGA).

RESULTS

Carvedilol was well tolerated by 16 (76%) patients. One patient is in FC II during increment of the dosage. Eight patients were in FC I, and 7 in FC II at 196 +/- 60 days of follow-up. Heart rate decreased from 96 +/- 15 to 67 +/- 10 bpm (p < 0.0001), left ventricular end diastolic diameter from 73 +/- 13 to 66 +/- 12 mm (p < 0.009), and the left ventricular ejection fraction increased from 0.21 +/- 0.06 to 0.34 +/- 0.12 (p < 0.0003).

CONCLUSION

Carvedilol may have beneficial effects on cardiac function, remodeling process, and FC. If tolerated, it seems to be a potential alternative option in the medical treatment of refractory heart failure. However, investigations are still necessary to clarify the long-term effects of carvedilol on this specific subgroup of patients.

Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy

OBJECTIVE

This study reports initial results of partial left ventriculectomy performed with preservation of the mitral valve in the treatment of 27 patients with idiopathic dilated cardiomyopathy.

METHODS

Patients were in New York Heart Association class III or IV. Partial ventriculectomy was performed as an isolated procedure in four patients and associated with mitral annuloplasty in 23 patients. There were four hospital deaths (14.8%) and the remaining patients were followed for 11.2 +/- 6 months.

RESULTS

Decrease of left ventricular diastolic diameter (81.8 +/- 8.7 to 68.5 +/- 7.6 mm, p < 0.001) and improvement of left ventricular wall shortening (12% +/- 3.1% to 18.1% +/- 3.9%, p < 0.001) were demonstrated by echocardiography after the operation. Left ventricular radioisotopic angiography showed reduction of diastolic volume (495 +/- 124 ml to 352 +/- 108 ml, p < 0.001) and increase of ejection fraction (17.7% +/- 4.6% to 23.7% +/- 8.8%, p < 0.001). Right-sided heart catheterization demonstrated improvement of stroke index (24.3 +/- 7.7 ml/m2 to 28.3 +/- 7.6 ml/m2, p < 0.01) and decrease of pulmonary wedge pressure (23.2 +/- 8.8 mm Hg to 17 +/- 7 mm Hg, p < 0.01). Similar results were documented at 6 and 12 months of follow-up. Functional class improved from 3.6 +/- 0.5 to 1.4 +/- 0.6 (p < 0.001). However, seven patients died at midterm follow-up because of heart failure progression or arrhythmia-related events, and survival rate was 59.2% +/- 9.4% from 6 to 24 months of follow-up.

CONCLUSIONS

Partial left ventriculectomy performed with preservation of the mitral valve improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy. Nevertheless, the high incidences of heart failure progression and arrhythmia-related deaths observed after this procedure preclude its wide clinical application.

Higher incidence of malignant neoplasms after heart transplantation for treatment of chronic Chagas' heart disease

BACKGROUND

Heart transplantation is a new therapeutic procedure to treat heart failure resulting from Chagas' disease. Experimental studies have demonstrated neoplastic effects of benznidazole, which is used for treatment of Trypanosoma cruzi infection. We compared the incidence and characteristics of neoplasia after heart transplantation for treatment of chronic Chagas' disease with those of other diseases.

METHODS

Sixteen patients with Chagas' disease and 75 patients with other diseases underwent heart transplantation. Benznidazole was administered to 14 patients with Chagas's disease either for prophylaxis (4 patients) or for treatment of Chagas' disease reactivation (10 patients).

RESULTS

The survival rate of patients in the nonchagasic group was 90% at 1 year and 82.4% at 2 years, and the survival rate in the chagasic group was 63% at 1 year and 57% at 2 years. Six of 16 patients (37.5%) with Chagas' disease had malignant tumors after a mean follow-up time of 25.3+/-2.1 months in contrast to 2 of 75 patients (2.7%) in the nonchagasic group after 34.6+/-3.6 months of follow-up. In the chagasic group, lymphoproliferative disorder was diagnosed in three patients, Kaposi's sarcoma in two, and squamous cell carcinoma in one patient. Reactivation of T. cruzi infection was diagnosed in all patients who had lymphoproliferative disorder. One patient without Chagas' disease had lymphoproliferative disorder in the lung, and another had malignant schwannoma affecting the skin.

CONCLUSIONS

We found a higher incidence of malignant neoplasia after heart transplantation for treatment of chronic Chagas' disease. It is likely that the neoplasia is the result of chronic infection with an immunomodulator protozoan, immunosuppression, reactivation of the T. cruzi infection, or the toxicity of therapeutic intervention with benznidazole.

Clinical outcome after left ventricular surgical remodeling in patients with idiopathic dilated cardiomyopathy referred for heart transplantation: short-term results

BACKGROUND

Left ventricular partial ventriculectomy (LVPV), an unconventional operation to reverse some aspects of the cardiac remodeling, has been proposed for treatment of congestive heart failure.

METHODS AND RESULTS

Twenty-four patients (age 46+/-9 years) referred to heart transplantation underwent isolated LVPV or LVPV associated to valve annuloplasty. Patients were in New York Heart Association functional class IV (15) or III (9) due to idiopathic dilated cardiomyopathy. Functional class, left and right ventricular ejection fraction (radionuclide), left ventricular end-diastolic and end-systolic diameter, and fractional shortening (by echocardiography), and hemodynamic variables were determined. The mean follow-up was 474+/-174 days. Survival at 30, 180, and 365 days was 92+/-6%, 67+/-10%, and 63+/-10%, respectively. Nine patients died, and the cause was associated with arrhythmias in 4 patients. The left ventricular end-diastolic diameters before and at 23+/-14 days, 188+/-27, and 365+/-14.8 days of follow-up were 82.6+/-9.8, 68.9+/-7.8, 69.9+/-6.9, and 70+/-5.3 mm, respectively (P=0.0001). The left ventricular end-systolic diameters were 73.5+/-7.4, 55.9+/-7.5, 57.4+/-7.8, and 55+/-5.5 mm (P=.0001). Fractional shortenings were 13+/-3, 19+/-4, 18+/-5, and 22+/-2%, respectively (P=.0001). The left ventricular ejection fractions before and 18+/-14, 188+/-26, and 369+/-3.6 days after the surgery were 17.2+/-4.7, 24.5+/-8.3, 24.5+/-7.4, and 23.7+/-6.1%, respectively (P=.004). The right ventricular ejection fractions were 20.5+/-6.2, 27.9+/-8.4, 28.2+/-10.1, and 27.4+/-7.3% (P=0.02). Pressures were unchanged. There was improvement in cardiac index from 2.11+/-0.52 to 2.53+/-0.64 L/min (P=.0037). Norepinephrine blood levels reduced from 702+/-258 to 439+/-307 pg/mL (P=.001). Most surviving patients presented improvement in functional class. Sustained ventricular tachycardias were observed in 9 patients (38%).

CONCLUSIONS

The left ventricular partial ventriculectomy may improve the left and right ventricular function, functional class, and cardiac output. These initial results were associated to high prevalence of sustained ventricular tachycardia. The ventriculectomy introduces the concept that reduction of left ventricular chamber diameter may improve cardiac function in heart failure. Further progress is necessary to improve the results and evaluate its proper role in the management of heart failure.

[Long-term course and complications of arterial hypertension after heart transplantation]

PURPOSE

To evaluate the progression of arterial hypertension (AH) and its consequences, in patients submitted to cardiac transplantation (CT) in use of cyclosporine (CY).

METHODS

In 65 patients submitted to orthotopic CT, we evaluated blood pressure, serum creatinine and blood levels of CY before, 15 and 30 days, and 6, 12, 24, 48 and 60 months after CT; in 20 patients we analyzed cardiac index and systemic vascular resistance pre-CT, 15 and 30 days, 6 and 12 months after CT; in 33 patients, we studied anatomic and functional modifications by echocardiography, 24 +/- 13 months after CT.

RESULTS

Thirty days after CT, AH was present in 58.5% (50% mild), and after one year, 93% of patients were hypertensives (85% moderate-to-severe), remaining unchanged during the rest of follow-up. The serum creatinine progressively increased, reaching values significantly higher than those pre-CT after one year, persisting with a mild increment until 60 months. Echocardiography showed left ventricle hypertrophy in 54% of patients, all of which had normal function. Two patients died as a direct consequence of hypertensive complications.

CONCLUSION

AH in patients submitted to CT on CY use occurs early, increases in prevalence and severity during the follow-up and is mediated by an increase in vascular resistance. Also, the AH does not correlate to CY blood levels or nefrotoxicity, but it can impair renal function and compromise longevity of transplantation by inducing ventricular hypertrophy.

Nitric oxide inhalation reduces pulmonary tidal volume during exercise in severe chronic heart failure

Multiple mechanisms have been proposed to explain the hyperventilation and the limited exercise capacity in congestive heart failure (CHF) including increased intrapulmonary pressures, total pulmonary resistance, and airway abnormalities. We investigated the hypothesis that inhalation of nitric oxide could influence the maximum exercise capacity and excessive ventilatory response to exercise in CHF. Fifteen patients in CHF (mean age 48 +/- 12 years) underwent a control and a nitric oxide inhalation progressive treadmill exercise test with 30 ppm. We determined the maximum oxygen consumptiom (peak VO2), CO2 production (VCO2), minute pulmonary ventilation (VE), respiratory rate, tidal volume (VT), ventilatory equivalent for oxygen (VE/VO2), ventilatory equivalent for carbon dioxide (VE/VCO2), estimated physiologic dead space/tidal volume ratio (VD/VT), VE/VCO2 slope, heart rate, systemic arterial pressure, VE/exercise time slope, and VT/exercise time slope during every incremental exercise. Mean maximum exercise values of heart rate, systolic systemic arterial pressure, diastolic systemic arterial pressure, VD/VT, respiratory rate, peak VO2, VO2/heart rate, VE/CO2, and maximum exercise time were unchanged by inhalation of nitric oxide. There was a strong trend toward reduction of VE/VO2 from 53 +/- 15 to 47 +/- 12 (p = 0.051) and in maximum VE from 58 +/- 21 to 48 +/- 17 L x min(-1) (p = 0.059). Maximum VT decreased from 1639 +/- 556 to 1406 +/- 479 ml (p = 0.04). The VE/VCO2 slope was reduced from 43 +/- 12 to 35 +/- 8 (p = 0.018). Two patients had signs of pulmonary congestion during peak exercise or the recovery period with inhalation of nitric oxide. The VE/exercise time slope and VT/exercise time slope during incremental exercise were reduced by inhalation of nitric oxide, demonstrating a statistically significant minor increase in VE and VT. Inhalation of nitric oxide attenuated the excessive increase in VT response to exercise in CHF. The L-arginine-nitric oxide pathway may be involved in mechanisms contributing to hyperventilation during exercise in CHF.