Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors´ Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship -emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors´ Network of the European Society of Cardiology.

Data sharing: A new editorial initiative of the International Committee of Medical Journal Editors. Implications for the editors' network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship -emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors' Network of the European Society of Cardiology.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors' Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship - emphasizing the importance of responsibility and accountability - have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors' Network of the European Society of Cardiology.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors' Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship -emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors' Network of the European Society of Cardiology.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors' Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship - emphasizing the importance of responsibility and accountability -, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors' Network of the European Society of Cardiology.

Data Sharing: A New Editorial Initiative of the International Committee of Medical Journal Editors. Implications for the Editors´ Network

The International Committee of Medical Journal Editors (ICMJE) provides recommendations to improve the editorial standards and scientific quality of biomedical journals. These recommendations range from uniform technical requirements to more complex and elusive editorial issues including ethical aspects of the scientific process. Recently, registration of clinical trials, conflicts of interest disclosure, and new criteria for authorship - emphasizing the importance of responsibility and accountability-, have been proposed. Last year, a new editorial initiative to foster sharing of clinical trial data was launched. This review discusses this novel initiative with the aim of increasing awareness among readers, investigators, authors and editors belonging to the Editors´ Network of the European Society of Cardiology. Resumo O Comitê Internacional de Editores de Revistas Médicas (ICMJE) fornece recomendações para aprimorar o padrão editorial e a qualidade científica das revistas biomédicas. Tais recomendações variam desde requisitos técnicos de uniformização até assuntos editoriais mais complexos e elusivos, como os aspectos éticos do processo científico. Recentemente, foram propostos registro de ensaios clínicos, divulgação de conflitos de interesse e novos critérios de autoria, enfatizando a importância da responsabilidade e da responsabilização. No último ano, lançou-se uma nova iniciativa editorial para fomentar o compartilhamento dos dados de ensaios clínicos. Esta revisão discute essa nova iniciativa visando a aumentar a conscientização de leitores, investigadores, autores e editores filiados à Rede de Editores da Sociedade Europeia de Cardiologia.

Potential of Entomopathogenic Fungi as Biological Control Agents of Diamondback Moth (Lepidoptera: Plutellidae) and Compatibility With Chemical Insecticides

The objectives were to evaluate the efficiency of entomopathogenic fungi against Plutella xylostella (L.) and the compatibility of the most virulent isolates with some of the insecticides registered for use on cabbage crops. Pathogenicity tests used isolates of Beauveria bassiana, Metarhizium rileyi, Isaria fumosorosea, Isaria sinclairii, and Lecanicillium muscarium standardized at a concentration of 10(7) conidia/ml. Cabbage leaf discs were immersed in these suspensions, and after evaporation of the excess water, were placed 10 second-instar larvae of P. xylostella, totaling 10 leaf discs per treatment. Mortality was assessed 7 d after treatment, and the isolates that caused mortality>80% were used to estimate LC50 and LT50. The compatibilities of the most virulent isolates and the insecticides were tested from the mixture of these into the culture medium, and after solidifying, the medium was inoculated with an aliquot of the isolated suspension. The following parameters were evaluated: growth of the colony, number and viability of conidia after 7 d. The isolated IBCB01, IBCB18, IBCB66, and IBCB87 of B. bassiana, LCMAP101 of M. rileyi, and ARSEF7973 of I. sinclairii caused mortality between 80 and 100%, with LC50 and LT50 between 2.504 to 6.775×10(4) conidia/ml and 52.22 to 112.13 h, respectively. The active ingredients thiamethoxam and azadirachtin were compatible with the entomopathogenic fungi. The results suggest that the use of these isolates is an important alternative in the pesticidal management of P. xylostella, with the possible exception of the associated use of chemical controls using the active ingredients thiamethoxam or azadirachtin.

Previous percutaneous coronary intervention as risk factor for coronary artery bypass grafting

BACKGROUND

Percutaneous coronary intervention (PCI) has increased as the initial revascularization strategy in chronic coronary artery disease. Consequently, more patients undergoing coronary artery bypass grafting (CABG) have history of coronary stent.

OBJECTIVE

Evaluate the impact of previous PCI on in-hospital mortality after CABG in patients with multivessel coronary artery disease.

METHODS

Between May/2007 and June/2009, 1099 consecutive patients underwent CABG on cardiopulmonary bypass. Patients with no PCI (n=938, 85.3%) were compared with patients with previous PCI (n=161, 14.6%). Logistic regression models and propensity score matching analysis were used to assess the risk-adjusted impact of previous PCI on in-hospital mortality.

RESULTS

Both groups were similar, except for the fact that patients with previous PCI were more likely to have unstable angina (16.1% x 9.9%, P=0.019). In-hospital mortality after CABG was higher in patients with previous PCI (9.3% x 5.1%, P=0.034) and it was comparable with EuroSCORE and 2000 Bernstein-Parsonnet risk score. Using multivariate logistic regression analysis, previous PCI emerged as an independent predictor of postoperative in-hospital mortality (odds ratio 1.94, 95% CI 1.02-3.68, P=0.044) as strong as diabetes (odds ratio 1.86, 95% CI 1.07-3.24, P=0.028). After computed propensity score matching based on preoperative risk factors, in-hospital mortality remained higher among patients with previous PCI (odds ratio 3.46, 95% CI 1.10-10.93, P=0.034).

CONCLUSIONS

Previous PCI in patients with multivessel coronary artery disease is an independent risk factor for in-hospital mortality after CABG.This fact must be considered when PCI is indicated as initial alternative in patients with more severe coronary artery disease.

Conventional versus biventricular pacing in heart failure and bradyarrhythmia: the COMBAT study

BACKGROUND

Worsening in clinical and cardiac status has been noted after chronic right ventricular pacing, but it is uncertain whether atriobiventricular (BiVP) is preferable to atrio-right ventricular pacing (RVP). Conventional versus Multisite Pacing for BradyArrhythmia Therapy study (COMBAT) sought to compare BiVP versus RVP in patients with symptomatic heart failure (HF) and atrioventricular (AV) block.

METHODS AND RESULTS

COMBAT is a prospective multicenter randomized double blind crossover study. Patients with New York Heart Association functional class (FC) II-IV, left ventricular ejection fraction (LVEF) <40%, and AV block as an indication for pacing were enrolled. All patients underwent biventricular system implantation and then were randomized to receive successively (group A) RVP-BiVP-RVP, or (group B) BiVP-RVP-BiVP. At the end of each 3-month crossover period, patients were evaluated according to Quality of Life (QoL), FC, echocardiographic parameters, 6-Minute Walk Test (6MWT), and peak oxygen consumption (VO(2 max)). Sixty patients were enrolled, and the mean follow-up period was 17.5 +/- 10.7 months. There were significant improvements in QoL, FC, LVEF, and left ventricular end-systolic volume with BiVP compared with RVP. The effects of pacing mode on 6MWT and VO(2 max) were not significantly different. Death occurred more frequently with RVP.

CONCLUSION

In patients with systolic HF and AV block requiring permanent ventricular pacing, BiVP is superior to RVP and should be considered the preferred pacing mode.

The cone reconstruction of the tricuspid valve in Ebstein’s anomaly. The operation: early and midterm results

OBJECTIVES

We sought to describe a new technique for tricuspid valve repair in Ebstein's anomaly and to report early echocardiographic results, as well as early and midterm clinical outcomes.

METHODS

From November 1993 through August 2005, 40 consecutive patients with Ebstein's anomaly (mean age, 16.8 +/- 12.3 years) underwent a new surgical repair modified from Carpentier's procedure, the principal details of which are as follows. The anterior and posterior tricuspid valve leaflets are mobilized from their anomalous attachments in the right ventricle, and the free edge of this complex is rotated clockwise to be sutured to the septal border of the anterior leaflet, thus creating a cone the vertex of which remains fixed at the right ventricular apex and the base of which is sutured to the true tricuspid valve annulus level. Additionally, the septal leaflet is incorporated into the cone wall whenever possible, and the atrial septal defect is closed in a valved fashion.

RESULTS

There was 1 (2.5%) hospital death and 1 late death. Early postoperative echocardiograms have shown good right ventricular morphology and reduction in tricuspid regurgitation grade from 3.6 +/- 0.5 to 1.2 +/- 0.5 (P < .0001). After mean follow-up of 4 years, the functional class (New York Heart Association) improved from 2.6 +/- 0.7 to 1.2 +/- 0.4 (P < .0001). Two patients required late tricuspid valve re-repair, and there was neither atrioventricular block nor tricuspid valve replacement at any time.

CONCLUSIONS

This surgical technique for Ebstein's anomaly can be performed with low mortality and morbidity. Early echocardiograms showed significant reduction of tricuspid insufficiency, and the follow-up showed improvement in patients' clinical status and low incidence of reoperation.

Normalization of Right Ventricular Performance and Remodeling Evaluated by Magnetic Resonance Imaging at Late Follow-up of Heart Transplantation: Relationship Between Function, Exercise Capacity and Pulmonary Vascular Resistance

BACKGROUND

Right ventricular (RV) dysfunction remains one of the most prominent complications during the period immediately after heart transplantation (HT); however, late adaptation of the RV has not been well described. The aim of our study was to evaluate RV function and remodeling using magnetic resonance imaging (MRI) and to correlate it with exercise capacity and also with hemodynamic data obtained before HT.

METHODS

We prospectively evaluated RV function of 25 heart-transplanted patients, without cardiac allograft vasculopathy, who were documented by negative dobutamine stress echocardiography during late follow-up (Group 1, 6 +/- 4.3 years) using MRI. We then compared Group 1 with a control group consisting of 10 patients, who were < or =1 year post-HT (Group 2), hemodynamically stable, and with the same pre-operative hemodynamic features as Group 1. Their pulmonary arterial systolic blood pressure (PSBP) varied from 17 to 67 mm Hg (43.2 +/- 15.3) and pulmonary vascular resistance (PVR) from 1.0 to 5.4 Wood units (2.5 +/- 1.12). The following parameters were studied: RV end-diastolic volume (EDV) and systolic volume (ESV); stroke volume (SV); ejection fraction (EF); and mass (M). We also evaluated the VO2 peak and slope VE/VCO2 values during a treadmill test. Data were analyzed and correlated with the hemodynamic values of PVR and PSBP obtained pre-HT.

RESULTS

In Group 1, treadmill evaluation data showed exercise VO2 peak (19.9 +/- 3.19 ml/kg/min) and slope VE/VCO2 (36.9 +/- 4.5) values comparable to those of sedentary individuals; RV variables according to MRI were within normal ranges, with the following mean values for Groups 1 and 2, respectively: RVEDV, 99.6 +/- 4.0 ml vs 127 +/- 16 ml (p = 0.03); RVESV, 42 +/- 2 ml vs 58.5 +/- 9 ml (p = 0.01); RVSV, 57 +/- 3 ml vs 71 +/- 10 ml (p = 0.1); RVEF, 58 +/- 1.4% vs 54 +/- 3.8% (p = 0.29); and RVM, 43.4 +/- 1.9 g vs 74 +/- 8.8 g (p = 0.001). There was no correlation between hemodynamic pulmonary values before HT or any other index of late RV performance, including RV remodeling and hypertrophy, in our study population (p = not significant).

CONCLUSIONS

In contrast to what we would expect for heart transplant patients at late follow-up, the RV may adapt to pulmonary pressure and resistance, with reverse remodeling characterized by volume and mass reduction, leading to normalization of RV function despite abnormal hemodynamic pulmonary values being measured before HT. There was no influence on the low exercise capacity observed in these patients, in the absence of cardiac allograft vasculopathy.

Relevance of apoptosis and cell proliferation for survival of patients with dilated cardiomyopathy undergoing partial left ventriculectomy

BACKGROUND

Cardiomyocyte apoptosis as well as proliferation have been described in congestive heart failure, but their clinical relevance remains unclear. In order to clarify whether apoptosis and cell proliferation occur in patients with idiopathic dilated cardiomyopathy and whether their degree in left ventricle fragments resected during partial left ventriculectomy has any influence on the outcome after this surgery, we compared their occurrence in four groups of patients: group A, short-term survivors (n = 18); group B, deaths within 6 months of the surgery (n = 13); group C, long-term survivors (n = 12); and Group D, deaths within 60 months (n = 19).

DESIGN

Apoptotic cardiomyocytes and interstitial cells were quantified in left ventricle fragments from 31 patients with idiopathic-dilated cardiomyopathy using the TUNEL assay. Cell proliferation was quantified in parallel sections by KI-67 immunohistochemistry.

RESULTS

Apoptotic cells were present in the majority of cases (n = 24) and proliferative cells in all cases. Whereas there was no significant difference regarding all parameters examined between Groups A and B, there was a highly significant difference between Groups C and D in the number of apoptotic cardiomyocytes (P = 0.012) and apoptotic interstitial cells (P = 0.006). There was no significant relationship between apoptotic cardiomyocytes and KI-67-positive cardiomyocytes, but a negative correlation between apoptotic interstitial cells and KI-67-positive interstitial cells (r = -0.383; P = 0.028).

CONCLUSION

Cardiomyocyte apoptosis and proliferation occur in the majority of patients with idiopathic-dilated cardiomyopathy. High numbers of apoptotic cardiomyocytes and apoptotic interstitial cells are significantly related to a bad late outcome after partial left ventriculectomy.

p53 protein in esophageal mucosa of individuals at high risk of squamous cell carcinoma of the esophagus

Squamous cell carcinoma of the esophagus (SCCE) is diagnosed late and carries a poor prognosis. Biomarkers such as p53 protein expression may be present in the esophageal mucosa long before esophageal symptoms or lesions appear and may point toward early diagnosis. Asymptomatic subjects at high risk for SCEE (consumption of more than 80 g of ethanol and 10 cigarettes/day for at least 10 years) underwent upper gastrointestinal endoscopy with biopsies of the esophageal mucosa, and expression of p53 protein was compared with conventional histologic findings. In 182 subjects studied, p53 protein was expressed in a stepwise fashion according to the severity of the histologic findings: normal mucosa (12/103 or 11.7%), mild chronic esophagitis (6/43 or 14%), moderate chronic esophagitis (4/18 or 22.2%), severe chronic esophagitis (1/3 or 33.3%), low-grade dysplasia (4/11 or 36.4%), high-grade dysplasia (2/2 or 100%), and squamous cell carcinoma (2/2 or 100%) (P=0.00025). The odds ratio and confidence intervals were calculated by logistic regression, with multivariate adjustment for potentially confounding variables. The risk for p53 expression was twofold for moderate and severe chronic esophagitis and 10-fold for dysplasia and cancer (P=0.001). p53 protein was expressed not only in cancerous lesions, high-grade and low-grade dysplasia, as expected, but also in mucosa considered normal or with chronic esophagitis using conventional histology. Smokers and alcohol drinkers with normal mucosa or chronic esophagitis that express p53 protein may represent an unrecognized subgroup of individuals that may benefit from surveillance. Follow-up studies of these asymptomatic subjects and molecular analysis of the p53 gene are needed to clarify this point.

Dynamic cardiomyoplasty as a therapeutic alternative: current status

Dynamic cardiomyoplasty was proposed as an alternative surgical treatment for severe cardiomyopathies and has been performed worldwide in more than 1,000 patients. Patients indicated for this procedure are specifically those with dilated or ischemic cardiomyopathies. The ventricular function improvement observed after dynamic cardiomyoplasty derived from the direct action of synchronized skeletal muscle flap contraction and from a girdling effect that helps to reverse chamber remodeling and to decrease ventricular wall stress. Although long-term benefits of this procedure may be limited by skeletal muscle flap ischemic compromise, technological advances incorporated in the new myostimulators will possibly decrease this complication incidence. Clinical improvement has been reported as a consistent finding in cardiomyoplasty follow-up and the overall 5-year survival after this procedure ranges from 39 % to 54 %. On the other hand, the mortality after cardiomyoplasty has been significantly higher for patients in persistent New York Heart Association functional class IV, showing that this procedure needs to be indicated earlier than the heart transplantation. In this regard, only the results of an ongoing randomized trial will potentially define cardiomyoplasty influence on the survival of patients with severe heart failure. In the meantime, however, there are clearly several functional class III patients whose quality of life and exercise capacity have worsened despite the use of maximum medical therapy, justifying dynamic cardiomyoplasty indication.

Total inversion of the left lung circulation: morphologic and functional analyses

BACKGROUND

An experimental model for total inversion of left lung circulation was developed. With this model, the authors demonstrate that it is possible to reverse the pulmonary circulation and preserve the normal function and morphology of the lung.

METHODS

Eight dogs had their left pulmonary circulation reversed. The blood from the pulmonary artery trunk was diverted to the pulmonary veins, and returned from the pulmonary artery into the left atrium. In order to monitor the flow through the reversed system, color Doppler echocardiography was performed on the ninth postoperative day. The dogs were reoperated after 15 days for re-evaluation. Blood gas analyses from the aorta and the pulmonary artery were used to study the functional status of the lung in both operations. The morphology was studied by comparing biopsies of the lung performed before and after reversal of flow.

RESULTS

Blood gas analysis showed no significant difference between the samples of from the aorta and pulmonary artery. Color Doppler echocardiography was a reliable method for the study of the inverted circulation. The histological study showed no differences in the morphology of the lung after the reversed circulation.

CONCLUSIONS

Left pulmonary circulation was fully reversed. Pulmonary function and morphology remained normal.

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.

Histopathological findings in skeletal muscle used in human dynamic cardiomyoplasty

Patients submitted to dynamic cardiomyoplasty had an initial clinical improvement followed by a decrease in cardiac failure indices. A histopathological study of the skeletal muscle was undertaken to explain this. Latissimus dorsi fragments from 15 patients submitted to dynamic cardiomyoplasty in a 1:1 (heart beat:muscle stimulation) conditioning were analysed by light microscopy. The interval between surgery and obtaining the specimens (13 from necropsies, two from heart transplants) ranged from 37 days to 6 years. Nuclear clumps and internalization, the presence of round fibres, inflammation, and fibrosis were analysed semi-quantitatively; the thickness of muscle fibres and the percentage of tissue fat were measured by image analysis. The quantitative data were also compared, in 12 cases, with gender- and age-matched necropsy controls. The mean thickness of muscle fibres in cases and controls was 27.21+/-5.33 and 40.84+/-9.42 microm, respectively (p=0.001). The percentage of tissue fat in cases and controls was 12.04+/-12.66% and 0.93+/-0.91%, respectively (p=0.008). The duration of grafts correlated positively with the quantity of nuclear clumps (R=0.80, p<0.001) and round fibres (R=0.53, p=0.04), as well as with the percentage of tissue fat (R=0.68, p=0.005). Accordingly, a negative correlation was found between the duration of grafts and the mean diameter of fibres, characterizing muscle atrophy (R=-0.66, p=0.01). The longer the post-surgical period, the more intense the degenerative lesions. This study shows that skeletal muscle used in human dynamic cardiomyoplasty may atrophy and be replaced by fat when stimulation is synchronized to every cardiac beat. These findings could play a role in explaining the long-term results of this surgical procedure.

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.

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.

Ischemic preconditioning in myocardial revascularization with intermittent aortic cross-clamping

BACKGROUND

This study tests the hypothesis that initial brief periods of ischemia can increase the protection obtained by intermittent aortic cross-clamping.

METHODS

In the control group (n = 18), the procedure was performed under intermittent aortic cross-clamping at 32 degrees C. Patients in the preconditioned gorup (n = 17) received a stimulus of two 3-minute periods of cross-clamping followed by 2 minutes of reperfusion prior to standard operation. CKMB, troponin 1, adenosine, and lactate were obtained from the great cardiac vein at the onset of cardiopulmonary bypass (CPB), at the end of the first anastomosis, and at the end of CPB.

RESULTS

CKMB and troponin I were slightly higher at the end of CPB in the control group, while there was no difference between adenosine and lactate levels. [table: see text].

CONCLUSION

There was no difference between groups in terms of myocardial protection.

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.

Influence of biopump with and without intraaortic balloon on the coronary and carotid flow

BACKGROUND

The objective of this study was to evaluate the influence of biopump used for left ventricular assistance on the coronary and carotid flows in dogs with normal heart. The efficacy of the simultaneous use of an intraaortic balloon pump to compensate the possible deleterious effects of the circulatory assistance with continuous flow was also analyzed.

METHODS

Fifteen dogs were studied. The hemodynamic evaluation included serial measurements of the classic parameters. Carotid and coronary blood flows were obtained by electromagnetic transducers.

RESULTS

The hemodynamic evaluation did not show significant statistical changes. The use of circulatory-isolated assistance with biopump shows reduction (24.6% +/- 6.1%) in coronary flow, in relation to the control situation and the concomitant use of biopump and intraaortic balloon pump showed similar coronary flow. Regarding carotid flow, a similar trend was observed in relation to the positive influence of the pulsatile flow with an intraaortic balloon pump without statistical significance (p = 0.0582).

CONCLUSIONS

The biopump reduces the coronary flow in dogs. The use of intraaortic balloon pump with the biopump increases the coronary flow significantly, reaching similar values to those observed without the circulatory assistance.

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.

Myocardial fiber diameter as a good indicator of outcome in Batista's operation

BACKGROUND

Despite the initial promissory results of partial left ventriculectomy, or Batista's operation, the postoperative mortality associated with the procedure has been too high. We described a histopathologic study performed to identify histological parameters that could help to determine outcomes of patients undergoing this procedure.

METHODS AND RESULTS

Myocardial fiber diameter, myocardial fibrosis, thickness of the compact wall, and number of cells presenting from the endocardium to epicardium were analyzed in 32 patients with idiopathic dilated cardiomyopathy who underwent Batista's operation. Data were grouped by patients who died < or = 6 months and patients who survived for > 6 months after the surgical procedure. Additional analyses were performed to compare results according the causes of death and to test the application of these results to biopsy.

RESULTS

Myocardial fiber diameter was the only index that could distinguish the two groups. Myocardial fiber diameter < 22 microm distinguished the group of patients who survived the 6-month postoperative period from patients who died during that time with sensitivity of 85.7 and specificity of 72.2. The subendocardial region of the compact wall and the trabecular portion of the wall exhibited comparable results.

CONCLUSION

Our results indicate that the myocardial fiber diameter of samples from the trabecular or subendocardial compact wall regions may help predict the outcome of left ventriculectomy. Samples from the trabecular or subendocardial compact wall regions were used for analysis. Further prospective studies involving left ventricular endomyocardial biopsies are necessary to confirm if the use of myocardial fiber diameter in the selection of patients for surgery improves the index of success of Batista's operation. Other factors that are involved remain unclear.

Lymphovascular and neural invasion in low-lying rectal carcinoma

We have previously demonstrated that lymphovascular infiltration was correlated with an increased risk for developing lymph node metastasis in rectal adenocarcinomas confined within the submucosal layer. In another study, lymphovascular infiltration was also correlated with poor prognosis for patients with advanced rectal cancers. Considerations that low rectal tumors have an increased risk to develop recurrence and neural invasion have been recently implicated with a more localized pattern of tumor spread. We therefore assessed the lymphovascular and neural invasion in 65 specimens from patients with low rectal cancers who underwent curative operation to determine its implications in the treatment and prognosis. Lymphovascular invasion was noted in 60%, and neural invasion was found in 27% of the cases. Five-year survival rates (Kaplan-Meier method) were significantly decreased in patients with lymphovascular invasion (31 vs. 67%; p < 0.01) or neural invasion (30 vs. 58%; p < 0.01). Neither lymphovascular nor neural invasion was noted in Dukes' stage A tumors. There was no recurrence or distant metastasis in these patients. However, lymphovascular and neural invasion increased with tumor stage. Local recurrence and distant metastasis occurred respectively in three and four, and five and five patients with Dukes' B and C tumors, respectively. Both Dukes' B and C cases with local recurrence had a higher incidence of neural invasion as compared with the disease-free group. These results suggest that postoperative assessment of venous and neural invasion may provide valuable information to better determine which patients with low rectal cancers would benefit from adjuvant treatment.

Paraplegia following intraaortic balloon circulatory assistance

Intraaortic balloon counterpulsation is frequently used in patients experiencing severe ventricular dysfunction following maximal drug therapy. However, even with the improvement of percutaneous insertion techniques, the procedure has always been followed by vascular; infectious, and neurological complications. This article describes a case of paraplegia due to intraaortic balloon counterpulsation in the postoperative period of cardiac surgery.

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.

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.

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.

Respiratory mechanics and morphometric changes during pneumoperitoneum in normal rats

Pneumoperitoneum may give rise to several respiratory changes; nevertheless, no comprehensive analysis of respiratory mechanics has been performed under this condition. Respiratory mechanics and thoracoabdominal morphometry were evaluated in six sedated, anaesthetized, paralysed, and mechanically-ventilated rats before (control) and during pneumoperitoneum. After airway occlusion at end-inspiration, respiratory system, pulmonary, and chest wall resistive pressures (deltaP1,rs, deltaP1,L and deltaP1,cw, respectively) and viscoelastic/inhomogeneous pressures (deltaP2,rs, deltaP2,L and deltaP2,cw, respectively) were determined. Total pressure changes (deltaPtot) were calculated as the sum of deltaP1 and deltaP2, yielding the values of deltaPtot,rs, deltaPtot,L and deltaPtot,cw, respectively. Respiratory system, lung, and chest wall static (Est,rs, Est,L and Est,cw, respectively), and dynamic elastances (Edyn,rs, Edyn,L and Edyn,cw, respectively), and the corresponding changes in elastance (deltaE) (calculated as Edyn-Est) were also obtained. Chest wall configuration both at functional residual capacity (FRC) and end-inspiration (FRC + tidal volume (VT)) was also evaluated in another four rats. Pneumoperitoneum significantly increased deltaPtot,rs, deltaPtot,cw, deltaP2,rs, deltaP2,cw, deltaErs, deltaEcw, Est,rs, Est,L and Est,cw. Lateral and anteroposterior diameters increased significantly, with the exception of lateral diameters at the level of crista iliaca. Cephalocaudal diameter and FRC decreased. In conclusion, pneumoperitoneum augments elastances and increases the pressure dissipated against viscoelasticity/inhomogeneity of the respiratory system and chest wall. These changes are related to a cephalad displacement of the diaphragm plus changes in thoracoabdominal configuration.

Evolution of circadian organization in vertebrates

Circadian organization means the way in which the entire circadian system above the cellular level is put together physically and the principles and rules that determine the interactions among its component parts which produce overt rhythms of physiology and behavior. Understanding this organization and its evolution is of practical importance as well as of basic interest. The first major problem that we face is the difficulty of making sense of the apparently great diversity that we observe in circadian organization of diverse vertebrates. Some of this diversity falls neatly into place along phylogenetic lines leading to firm generalizations: i) in all vertebrates there is a "circadian axis" consisting of the retinas, the pineal gland and the suprachiasmatic nucleus (SCN), ii) in many non-mammalian vertebrates of all classes (but not in any mammals) the pineal gland is both a photoreceptor and a circadian oscillator, and iii) in all non-mammalian vertebrates (but not in any mammals) there are extraretinal (and extrapineal) circadian photoreceptors. An interesting explanation of some of these facts, especially the differences between mammals and other vertebrates, can be constructed on the assumption that early in their evolution mammals passed through a "nocturnal bottleneck". On the other hand, a good deal of the diversity among the circadian systems of vertebrates does not fall neatly into place along phylogenetic lines. In the present review we will consider how we might better understand such "phylogenetically incoherent" diversity and what sorts of new information may help to further our understanding of the evolution of circadian organization in vertebrates.

Long-term outcome, survival analysis, and risk stratification of dynamic cardiomyoplasty

METHODS

To analyze the long-term outcome of dynamic cardiomyoplasty, we retrospectively studied 127 consecutive patients who underwent this procedure in Paris, France (n = 76), São Paulo, Brazil (n = 37), and Portland, Oregon (n = 14). Preoperative data were collected for patients operated on between January 1985 and June 1994 and examined with respect to effect on long-term survival. Patients had a mean age of 50 +/- 13 years and were predominantly male (82%). In 46% the cause of disease was ischemic. Concomitant operations were performed in 22 patients.

RESULTS

Operative mortality was 12% (15/127). Kaplan-Meier survival +/- standard error at 1 through 5 years was 73% +/- 4%, 57% +/- 5%, 49% +/- 6%, 44% +/- 6%, and 40% +/- 7%, respectively. There was a distinct improvement at 6 months in New York Heart Association functional class (3.2 +/- 0.05 vs 1.7 +/- 0.07, p < 0.0001) and a small but significant increase in left ventricular ejection fraction (20% +/- 0.8% vs 23% +/- 1.5%, p = 0.04). Ninety-day mortality was associated with low right ventricular ejection fraction, a blunted hemodynamic response to exercise testing, and requirement for an intraaortic balloon pump at the time of the operation. Using a stepwise Cox regression method of multivariable survival analysis (n = 101), we determined that atrial fibrillation, New York Heart Association class IV, high pulmonary capillary wedge pressure, and balloon pump use were independent variables simultaneously associated with poor overall survival. When metabolic testing variables were added to this model, peak oxygen consumption eliminated both pulmonary capillary wedge pressure and functional class from the model, albeit with fewer (n = 74) patients.

CONCLUSION

Dynamic cardiomyoplasty is an evolving therapy for symptomatic congestive heart failure, the results of which may be enhanced by intelligent, risk-sensitive patient selection.

Mid-term results of heart transplantation, cardiomyoplasty, and medical treatment of refractory heart failure caused by idiopathic dilated cardiomyopathy

BACKGROUND

Heart transplantation is the surgical procedure of choice for treatment of refractory heart failure. However, it benefits a small number of patients because of the limited number of donors and selection criteria of recipients. Cardiomyoplasty is an alternative surgical procedure for heart failure. The aim of this investigation was to report our experience with heart transplantation, cardiomyoplasty, and clinical treatment of heart failure caused by idiopathic dilated cardiomyopathy.

METHODS

Ninety patients with refractory heart failure caused by idiopathic dilated cardiomyopathy were observed from May 1988 to March 1993. The patients had New York Heart Association functional class III or IV symptoms. The patients were divided in three groups according to the treatment received: heart transplantation (33 patients), cardiomyoplasty (25 patients), or medical treatment (32 patients). We studied the event-free curve, the New York Heart Association functional class, the left ventricular ejection fraction, and the morbidity of the groups in the follow-up of 19 +/- 16 months. We considered as an event death or crossover to another group because of severe symptoms.

RESULTS

The event-free rate in the cardiomyoplasty group was 92%, 88%, 79%, 74%, and 62% at 3, 9, 12, 18, and 24 months of follow-up, respectively. The event-free rate after heart transplantation was 82%, 78%, 82%, 75%, and 69% at 3, 9, 12, 18, and 24 months, respectively. The event-free rate in the medical treatment group was 78%, 65%, 61%, 48%, and 48% at 3, 9, 12, 18, and 24 months, respectively. All surviving patients in the heart transplantation group had functional class I symptoms. After cardiomyoplasty 90% of surviving patients had class I or II symptoms and 10% had class III symptoms. However, in the medical treatment group 27% of surviving patients had class I or II symptoms and 67% had class III or IV symptoms. In the cardiomyoplasty group left ventricular ejection fraction increased from 20% +/- 3% to 24.4% +/- 6.3% at 6 months (p < 0.05). In the heart transplantation group the left ventricular ejection fraction normalized, and the mean value of the left ventricular ejection fraction did not change in the medical treatment group. The need for endomyocardial biopsy and the incidence of rejection and infection were characteristics of the heart transplantation group.

CONCLUSIONS

In properly selected patients, cardiomyoplasty and heart transplantation seem to be associated with improvement in survival and functional class at mid-term follow-up. Heart transplantation was more effective than cardiomyoplasty for functional class improvement.

Right internal thoracic artery through the transverse sinus in myocardial revascularization

BACKGROUND

This study presents the late patency rate of the right internal thoracic artery (ITA) used in situ through the pericardium transverse sinus to the circumflex artery and its branches.

METHODS

From April 1983 to December 1994, 2,642 patients were submitted to myocardial revascularization; 201 of them had bilateral ITAs. The right ITA through the transverse sinus was grafted to obtuse marginal artery in 170 patients (84.5%) and the left ITA was grafted to the anterior descending artery in 188 patients (93.5%). Angiographic studies were performed in 80 patients, 44 patients in the immediate postoperative period and 36 patients in the late follow-up (mean, 51.6 months).

RESULTS

The right ITA was patent in 75 patients (93.7%) and the left ITA was patent in 77 (96.2%). At the late postoperative period, the right ITA was patent in 33 patients (91.6%) and the left ITA was patent in 34 (94.4%).

CONCLUSIONS

The right ITA placed through the pericardium transverse sinus has a good long-term patency rate, similar to that observed with the left ITA and superior to that of saphenous vein grafts for myocardial revascularization.

Dynamic cardiomyoplasty in the treatment of dilated cardiomyopathy: current results and perspectives

BACKGROUND

The purpose of this article is to provide an overview of the current indications, results, and perspectives of dynamic cardiomyoplasty in the treatment of patients with dilated cardiomyopathy. Particular emphasis is placed on the clinical experience with 36 patients operated at the São Paulo Heart Institute between 1988 and 1995.

METHODS

Based on several clinical reports, the mechanisms of action of dynamic cardiomyoplasty in these patients include the enhancement of left ventricular systolic function, by the direct action of synchronized skeletal muscle flap contraction and the reversion of chamber remodeling. Moreover, both mechanisms seem to be responsible for improved diastolic function properties and for the decrease of ventricular wall stress. Besides the acceptable hospital mortality observed for patients with dilated cardiomyopathy ranging from 0% to 8% with this surgical procedure, clinical improvement after dynamic cardiomyoplasty has been demonstrated as a prevailing and significant outcome.

RESULTS

Nevertheless, the 1-year survival for these patients ranges from 82% to 86% and the 5-year survival on the order of 41% to 49%. In addition, the analysis of factors influencing the outcome showed that cardiomyoplasty long-term survival was significantly affected by the severity of preoperative clinical compromise and cardiac function impairment. On the other hand, patients with dilated cardiomyopathy who were operated in functional Class III or intermittent Class IV and with pulmonary vascular resistance below 4 Wood units, present survival rates on the order of 79% at 2 years and of 64% at 5 years of follow-up, which are similar to those reported after cardiac transplantation.

CONCLUSIONS

Furthermore, technological advances incorporated in the new cardiomyostimulators may ameliorate skeletal muscle flap performance at long term. Other developments are also discussed in this field.