Combined transepicardial and transseptal implantation of autologous CD 133+ bone marrow cells during bypass grafting improves cardiac function in patients with low ejection fraction

OBJECTIVES

Autologous CD133+ bone marrow stem cells may improve cardiac function. This randomized, single-blind clinical trial inquired whether a combined transepicardial and transseptal implantation of CD133+ stem cells during coronary artery bypass grafting (CABG) improve cardiac function with ejection fraction (EF) changes as a primary endpoint in patients with low EF.

METHODS

Thirty patients with coronary heart disease and EF <35% were randomized to undergo CABG alone or CABG with transseptal and transepicardial implantation of CD133+. Cardiac function was evaluated using cardiac magnetic resonance imaging (MRI) before and 6 months after CABG.

RESULTS

Preoperative EF was lower in the intervention group (25.88% ± 5.66%) than in the control group (30.18% ± 3.85%; P = .04). The adverse event incidence was similar between both groups. At 6 months, EF changes were significantly higher (8.69% ± 9.49; P = .04) in the CD133+ group than in the CABG-only group. Compared to the control group, significant improvements were seen in the wall motion score index (P = .003) and scar size proportion (P = .047) in the CD133+ group. The quality of life (QOL), assessed by a 6-minute walking test, showed considerable improvement in the CD133+ group compared to that in the control group (P = .03). The Minnesota Living with Heart Failure Questionnaire (MLHFQ) scale did not show improvement in the intervention group (P = .09, vs control).

CONCLUSION

Combined transepicardial and transseptal autologous CD133+ BMC implantation during bypass grafting improved cardiac function in low EF coronary artery disease patients.

The effect of a smartphone-based perioperative nursing intervention: prayer, education, exercise therapy, hypnosis, and music toward pain, anxiety, and early mobilization on cardiac surgery

Background: Cardiac surgery can elicit both physical and psychological responses. Prayer, exercise therapy, education, hypnosis, and music are expected to be able to overcome pain, anxiety, and immobilization in the cardiac surgery. This study was to create a smartphone-based peri-operative nursing intervention model that was able to reduce pain, anxiety, and increase early mobilization cardiac surgery patients.

Design and methods: This study consisted of three stages. The first stage was research and development, the second was true experimental design, and the third was cross sectional design. The samples size was 86 respondents. The intervention models for the treatment group comprised of a smartphone-based therapy of prayer, education, exercise, hypnosis, and music. The control group was given standard hospital intervention according to the clinical pathway.

Results: The majority of respondents were adults, male, high school graduate in the treatment group and bachelor graduate in the control group, CABG type of surgery, and having pain history. The intervention had a significant effect on reducing pain scale and anxiety level as well as increasing early mobilization (p<0.05). The intervention had a direct effect on pain and anxiety, but it had no direct effect on early mobilization. However, it gave indirect effect on early mobilization that was mediated by anxiety.

Conclusions: The models can be used by nurses to reduce pain, anxiety and to increase early mobilization on cardiac surgery patients.

Intramyocardial Stem Cell Transplantation during Coronary Artery Bypass Surgery Safely Improves Cardiac Function: Meta-Analysis of 20 Randomized Clinical Trials

IMSC transplantation during CABG is considered one of the most promising methods to effectively deliver stem cells and has been widely studied in many trials. But the results of outcomes and safety of this modality still vary widely. We conducted this meta-analysis of randomized controlled trials (RCTs) to evaluate not only the outcome but also the safety of this promising method. A meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A comprehensive literature search was undertaken using the PubMed, Scopus, and Cochrane databases. Articles were thoroughly evaluated and analyzed. Twenty publications about IMSC during CABG were included. Primary outcomes were measured using LVEF, LVESV, LVESVI, LVESD, LVEDV, LVEDVI, LVEDD, WMSI, and 6-MWT. Safety measures were depicted by total deaths, MACE, CRD, CVA, myocardial infarction, ventricular arrhythmia, and cardiac-related readmission. IMSC transplantation during CABG significantly improved LVEF (MD = 3.89%; 95% CI = 1.31% to 6.46%; p = 0.003) and WMSI (MD = 0.28; 95% CI = 0.01-0.56; p = 0.04). Most of the other outcomes showed favorable results for the IMSC group but were not statistically significant. The safety analysis also showed no significant risk difference for IMSC transplantation compared to CABG alone. IMSC during CABG can safely improve cardiac function and tend to improve cardiac volumes and dimensions. The analysis and application of influencing factors that increase patients' responses to IMSC transplantation are important to achieve long-term improvement.

CD133+ Stem Cell Therapy Effects on Myocardial Regeneration Through Increased Vascular Endothelial Growth Factor Correlate with Cardiac Magnetic Resonance Imaging Results in Coronary Artery Bypass Graft Surgery Patients with Low Ejection Fraction

BACKGROUND

Stem cell implantation has become a promising therapy for heart failure due to coronary heart disease (CHD). CD133+ stem cell therapy, together with increases of vascular endothelial growth factor (VEGF) and other growth hormones, can induce myocardial repair.

OBJECTIVE

To prove that VEGF plays a role in cardiac regeneration.

METHODS

Twenty-six patients with CHD and ejection fractions <35% from Harapan Kita Heart and Vascular Center, Jakarta, Indonesia, from 2016 to 2018 were randomized into 2 groups. The treatment group underwent coronary artery bypass graft (CABG) + CD133+ implantation, and the control group underwent CABG only. Six months later, perfusion and myocardial function were assessed by ejection fraction, wall motion score index (WMSI), ventricular dimensions, and scar size using cardiovascular magnetic resonance imaging. VEGF was assessed with enzyme-linked immunosorbent assay.

RESULTS

There was significant improvement in ejection fraction (8.69% ± 9.49% versus 1.43% ± 7.87%, P = .04), WMSI (0.51 ± 0.48 versus -0.01 ± 0.21, P = .003), and scar size (25.46 ± 12.91 versus 27.32  ± 12.92 mm, P = .047) and a significant increase in blood VEGF levels  (61.05 ± 63.01 versus 19.88 ± 33.78 pg/mL, P = .01). Improvements in perfusion defects (13.69 ± 5.03 versus 11.53 ± 5.81 P = .32) and ventricular dimensions (-27.59 ± 84.48 versus -19.08 ± 36.79 mm, P = .06) were not statistically significant.

CONCLUSION

CD133+ stem cell implantation improves myocardial function. The increase in VEGF levels is expected to continue improving restoration of myocardial function when myocardial perfusion improvement is still not optimal.

A 48-Year-Old Man at Low Risk for SARS-CoV-2 Infection Who Underwent Planned Elective Triple-Vessel Coronary Artery Bypass Graft Surgery at a National Heart Center in Indonesia Followed by a Fatal Case of COVID-19

Patient: Male, 48-year-old

Final Diagnosis: Chronic kidney disease • coronary artery disease • COVID-19

Symptoms: Chest pain • fever • shorthness of breath

Medication: —

Clinical Procedure: Coronary artery bypass graft surgery

Specialty: Cardiac surgery

No-touch technique for saphenous vein graft harvesting in coronary artery bypass surgery safely improves graft patency: a meta-analysis of randomized controlled trials

Objective

The no-touch (NT) technique for saphenous vein graft (SVG) harvesting has been gaining popularity as several trials have shown its superiority in maintaining graft patency. However, this technique's clinical outcome and safety are still disputed and the results vary widely. The aim of this meta-analysis of randomized controlled trials (RCTs) was to assess the effectiveness and safety of this method.

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were conducted for this systematic review and meta-analysis. A comprehensive search of the literature was carried out with Embase, Scopus, and PubMed databases. The articles underwent extensive evaluation and analysis.

Results

Six RCTs comparing the NT and conventional (CON) techniques were included. Primary outcomes were measured using graft occlusion. Graft failure rates and clinical outcomes including major adverse cardiac and cerebrovascular events (MACCE), all-cause death, myocardial infarction, repeat revascularization, and leg wound complications were evaluated as secondary outcomes. The NT technique significantly decreased graft occlusion (risk ratio (RR) = 0.58; 95% confidence interval (CI) = 0.46 to 0.72; p < 0.001) and failure (RR = 0.65; 95% CI = 0.54 to 0.77; p < 0.001). Safety analysis also showed no significant risk difference for clinical outcomes, and although significantly higher, leg complications in the NT technique are minor and avoidable.

Conclusion

The NT technique increases long-term graft patency with no significant risk difference for clinical outcomes compared to the CON technique. However, the leg wound complications are significantly higher in the NT technique compared to the CON technique.

Graphical Abstract

Giant lipoma in superior vena cava: A case report and literature review

INTRODUCTION

Intravascular lipomas are rare occurrences, especially in major vessels. This tumour is composed of adipocytes in a fibrous capsule that has a slow growth rate and usually shows no symptoms. There were only eight reports in the literature regarding intravascular lipoma located in the superior vena cava.

CASE PRESENTATION

A 54-year-old man had episodes of supraventricular tachycardia and atrial flutter for over a year. Preoperative radiological findings showed a giant mass that arose from the superior vena cava to the right atrium and a biopsy catheter showed that there were no signs of malignancy. The patient then underwent surgery through median sternotomy and the mass was extirpated on the highest part of the stalk that could be reached. The patient was stable and remained to show no symptoms or evidence of residual mass or stalk in 2 years follow-up.

CONCLUSION

The surgical approach in excising lipoma in SVC should be considered wisely with the support of adequate preoperative diagnosis. Since lipoma is a very slow-growing tumour, extensive manipulation that could increase surgical technique difficulty or postoperative morbidity and mortality is not necessary.

Effectivity of dexamethasone in patients undergoing off-pump coronary artery bypass surgery

BACKGROUND

Based on our previous pilot study, systemic inflammatory response syndrome is more common in off-pump compared to on-pump coronary artery bypass. Therefore, we conducted a clinical trial of dexamethasone in patients undergoing off-pump coronary artery bypass.

METHODS

Sixty consecutive patients undergoing off-pump coronary artery bypass were enrolled from August 2018 to January 2019 and randomized to a dexamethasone or placebo group of 30 each. Clinical outcomes were analyzed.

RESULTS

There was a lower incidence of major adverse cardiac events in the dexamethasone group compared to the placebo group (17% versus 43%, p = 0.024). Clinical outcomes in the dexamethasone group were better than those in the placebo group, in terms of duration of mechanical ventilation (p = 0.029), intensive care unit stay (p = 0.028), hospital stay (p = 0.04), and vasoactive-inotropic score (p = 0.045). There were significant differences in inflammatory markers between the two groups: interleukin-6 (p = 0.0001), procalcitonin (p = 0.0001), and C-reactive protein (p = 0.0001) were lower in the dexamethasone group. There was a significant association between the incidence of major adverse cardiac events and both interleukin-6 (p = 0.005) and procalcitonin (p = 0.007).

CONCLUSION

Preoperative dexamethasone in patients undergoing off-pump coronary artery bypass is effective in improving clinical outcomes and controlling the postoperative inflammatory reaction.

Cell sheet transplantation for ischemic heart disease: a systematic review

Objective

Cell sheet transplantation is emerging as an appealing alternative for ischemic heart disease patients as it potentially can increase stem cell viability and retention. But the outcomes and safety of this treatment are still limited in literature and the result varies widely. We conduct a systematic review to look at the efficacy and safety of this promising transplantation method.

Methods

A systematic review was performed according to PRISMA guidelines. A comprehensive literature search was undertaken using the PubMed, Scopus, and Embase databases. Articles were thoroughly evaluated and analyzed.

Results

Seven publications about cell sheet transplantation for ischemic heart disease patients were included. The primary outcomes measured were left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) class. Safety measurement was depicted by cardiac-related readmission and deaths. The follow-up time ranged from 3 to 36 months for clinical outcomes and 8.5 years for safety outcomes. Cell sheet transplantation showed improvement in LVEF and NYHA class in most studies. Cardiac-related readmission and adverse events of cell sheet transplantation range from 0 to 30.4%, all were nonfatal as no cardiac-related death was reported. Patient preoperative status seems can affect the patient's response to cell sheet therapy.

Conclusion

Cell sheet transplantation can safely improve LVEF and NYHA class in ischemic heart disease patients, even in very low ejection fraction patients with unsuccessful standard therapy before. Further studies with better patient inclusion, larger population, and long-term follow-up required to confirm these results.

Complete Revascularization Showed A Better Cardiac Function Improvement In Patients With Low Ejection Fraction

Purpose: This study aimed to compare postoperative ejection fraction (EF) in response to coronary artery bypass grafting (CABG) among patients with preoperative EF <35% and >35%. Methods: A retrospective study was conducted in a single institution using clinical data of 660 patients undergoing elective on-pump CABG in 2018-2019. Patients were classified into two groups based on preoperative left ventricle ejection fraction (<35% and >35%). The primary endpoint was the change of postoperative ejection fraction. Results: In this study, 72 patients had preoperative left ventricle ejection fraction <35% (group A) while the other 588 patients had ejection fraction >35% (group B). Among both groups, the duration of cardiopulmonary bypass (CPB) and aortic clamp (AxC) were not significantly different (P > 0.05). The transformation of pre- and postoperative EF in groups A and B was significantly different (2.91+10.31 vs. -0.14+4.57, P < 0.001). There was a significant difference in the duration of ICU stay (73.42+112.55 vs. 34.43+64.99, P < 0.001) and postoperative ventilatory support (25.54+43.92 vs. 16.42+45.87, P < 0.008) between group A and B. Conclusion: Low preoperative EF showed better improvement in cardiac function after surgery. We concluded that the result could be affected by revascularization of hibernating myocardium. 

Initial Thrombocyte Concentrate Transfusion in Woman with Chronic Immune Thrombocytopenia Purpura (ITP) Who Underwent Mitral Valve Replacement Surgery: A Case Report

BACKGROUND Chronic immune thrombocytopenia purpura (ITP) is associated with a higher incidence of adverse outcomes, increased morbidity and mortality rates, and higher health care costs, especially in open-heart surgery. The information regarding managing chronic ITP in patients undergoing mitral valve replacement (MVR) surgery is scarce, and reported cases are limited. CASE REPORT A 42-year-old woman with more than 20 years of history of immune thrombocytopenia purpura (ITP) had episodes of breathing difficulties in the last 4 years. The patient was diagnosed with severe mitral stenosis (MS) and moderate mitral regurgitation (MR). Laboratory examination before surgery showed thrombocytopenia (49 000/µL). Therefore, the surgery was postponed until the platelet count exceeded 100 000/µL. The patient was given 10 units of thrombocyte concentrate 1 day before surgery and 500 mg of methylprednisolone 3 times a day orally for 5 days as preoperative management. Under a total cardiopulmonary bypass, MVR was performed using a bioprosthetic valve. Postoperative transthoracic echocardiography (TTE) showed no valvular leakage in the surrounding of the prosthetic valve and that the valve was functioning normally. Platelet monitoring was conducted, and the platelet count increased to 147 000/µL on the third day. CONCLUSIONS Our case report shows that aggressive preoperative platelet count correction and treatment may lower the risk associated with a low and unstable platelet count and reduce the risk of mortality and morbidity in patients with ITP who undergo MVR procedures.

An “Unusual” Diverticulated Appearance in Adult Direct Gerbode Defect: A Case Report

Patient: Male, 46-year-old

Final Diagnosis: Gerbode VSD • tricuspid regurgitation

Symptoms: Fatigue • shortness of breath

Medication: —

Clinical Procedure: De Vega procedure • defect closure

Specialty: Cardiac Surgery