1
|
Batista MA, de Lima Teixeira dos Santos AVT, do Nascimento AL, Moreira LF, Souza IRS, da Silva HR, Pereira ACM, da Silva Hage-Melim LI, Carvalho JCT. Potential of the Compounds from Bixa orellana Purified Annatto Oil and Its Granules (Chronic ®) against Dyslipidemia and Inflammatory Diseases: In Silico Studies with Geranylgeraniol and Tocotrienols. Molecules 2022; 27:molecules27051584. [PMID: 35268686 PMCID: PMC8911567 DOI: 10.3390/molecules27051584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/03/2022] [Accepted: 02/10/2022] [Indexed: 11/16/2022]
Abstract
Some significant compounds present in annatto are geranylgeraniol and tocotrienols. These compounds have beneficial effects against hyperlipidemia and chronic diseases, where oxidative stress and inflammation are present, but the exact mechanism of action of such activities is still a subject of research. This study aimed to evaluate possible mechanisms of action that could be underlying the activities of these molecules. For this, in silico approaches such as ligand topology (PASS and SEA servers) and molecular docking with the software GOLD were used. Additionally, we screened some pharmacokinetic and toxicological parameters using the servers PreADMET, SwissADME, and ProTox-II. The results corroborate the antidyslipidemia and anti-inflammatory activities of geranylgeraniol and tocotrienols. Notably, some new mechanisms of action were predicted to be potentially underlying the activities of these compounds, including inhibition of squalene monooxygenase, lanosterol synthase, and phospholipase A2. These results give new insight into new mechanisms of action involved in these molecules from annatto and Chronic®.
Collapse
Affiliation(s)
- Mateus Alves Batista
- Laboratory of Pharmaceutical and Medicinal Chemistry (PharMedChem), Federal University of Amapá, Amapá, Macapá 68902-280, Brazil; (M.A.B.); (L.I.d.S.H.-M.)
| | - Abrahão Victor Tavares de Lima Teixeira dos Santos
- Laboratory of Drugs Research, Biology and Healthy Sciences Department, Pharmacy Faculty, Federal University of Amapá, Rod. JK, km 02, Amapá, Macapá 68902-280, Brazil; (A.V.T.d.L.T.d.S.); (A.L.d.N.); (L.F.M.); (H.R.d.S.)
| | - Aline Lopes do Nascimento
- Laboratory of Drugs Research, Biology and Healthy Sciences Department, Pharmacy Faculty, Federal University of Amapá, Rod. JK, km 02, Amapá, Macapá 68902-280, Brazil; (A.V.T.d.L.T.d.S.); (A.L.d.N.); (L.F.M.); (H.R.d.S.)
| | - Luiz Fernando Moreira
- Laboratory of Drugs Research, Biology and Healthy Sciences Department, Pharmacy Faculty, Federal University of Amapá, Rod. JK, km 02, Amapá, Macapá 68902-280, Brazil; (A.V.T.d.L.T.d.S.); (A.L.d.N.); (L.F.M.); (H.R.d.S.)
| | - Indira Ramos Senna Souza
- Diamantina Chapada Regional Hospital, Avenida Francisco Costa, 350-468, Vasco Filho, Bahia, Seabra 46900-000, Brazil;
| | - Heitor Ribeiro da Silva
- Laboratory of Drugs Research, Biology and Healthy Sciences Department, Pharmacy Faculty, Federal University of Amapá, Rod. JK, km 02, Amapá, Macapá 68902-280, Brazil; (A.V.T.d.L.T.d.S.); (A.L.d.N.); (L.F.M.); (H.R.d.S.)
| | - Arlindo César Matias Pereira
- Faculty of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), São Paulo, Ribeirão Preto 05508-000, Brazil;
| | - Lorane Izabel da Silva Hage-Melim
- Laboratory of Pharmaceutical and Medicinal Chemistry (PharMedChem), Federal University of Amapá, Amapá, Macapá 68902-280, Brazil; (M.A.B.); (L.I.d.S.H.-M.)
| | - José Carlos Tavares Carvalho
- Laboratory of Drugs Research, Biology and Healthy Sciences Department, Pharmacy Faculty, Federal University of Amapá, Rod. JK, km 02, Amapá, Macapá 68902-280, Brazil; (A.V.T.d.L.T.d.S.); (A.L.d.N.); (L.F.M.); (H.R.d.S.)
- Correspondence:
| |
Collapse
|
2
|
Duarte RT, Gonçalves KC, Espinosa DJL, Moreira LF, De Bortoli SA, Humber RA, Polanczyk RA. Potential of Entomopathogenic Fungi as Biological Control Agents of Diamondback Moth (Lepidoptera: Plutellidae) and Compatibility With Chemical Insecticides. J Econ Entomol 2016; 109:594-601. [PMID: 26850733 DOI: 10.1093/jee/tow008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
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.
Collapse
|
3
|
Zilberstein B, Malheiros C, Lourenço LG, Kassab P, Jacob CE, Weston AC, Bresciani CJC, Castro O, Gama-Rodrigues J, Borin AA, Buchpiegel C, Montagnini A, Leite CV, Deutsch CR, Kruel CDP, Mucerino D, Wohnrath D, Ilias E, Mrué F, Maluf-Filho F, Rocha F, de Souza F, Tomasich FS, Ishak G, Laporte G, de Souza HP, Cecconello I, Eisig J, Ohana J, Sabagga J, del Grande JC, de Jesus JP, Soares J, Dias LAN, Moreira LF, Correa M, Carvalho M, Andreollo NA, Áquila ND, Czeczko NG, Kruel N, Forones NM, da Motta OM, Malafaia O, Assumpção P, Leonardi P, Sakai P, Rocha PRS, Colleoni R, Gurgel R, Coral RP, Chalub S, Ribeiro- Junior U, Alves VAF, Vasquez VDL, Nadalin V. Brazilian consensus in gastric cancer: guidelines for gastric cancer in Brazil. Arq Bras Cir Dig 2014; 26:2-6. [PMID: 23702862 DOI: 10.1590/s0102-67202013000100002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 11/16/2012] [Indexed: 12/18/2022]
Abstract
BACKGROUND In Brazil, gastric cancer is the fourth most common malignancy among men and sixth among women. The cause is multivariate and the risks are well known. It has prognosis and treatment defined by the location and staging of the tumor and number of lymph nodes resected and involved. AIM The Brazilian Consensus on Gastric Cancer promoted by ABCG was designed with the intention to issue guidelines that can guide medical professionals to care for patients with this disease. METHODS Were summarized and answered 43 questions reflecting consensus or not on diagnosis and treatment that may be used as guidance for its multidisciplinary approach. The method involved three steps. Initially, 56 digestive surgeons and related medical specialties met to formulate the questions that were sent to participants for answers on scientific evidence and personal experience. Summaries were presented, discussed and voted in plenary in two other meetings. They covered 53 questions involving: diagnosis and staging (six questions); surgical treatment (35 questions); chemotherapy and radiotherapy (seven questions) and anatomopathology, immunohistochemistry and perspective (five questions). It was considered consensus agreement on more than 70% of the votes in each item. RESULTS All the answers were presented and voted upon, and in 42 there was consensus. CONCLUSION It could be developed consensus on most issues that come with the care of patients with gastric cancer and they can be transformed in guidelines.
Collapse
|
4
|
Moreira LF, de Vasconcelos Lanza MR, Tanaka AA, Taboada Sotomayor MDP. Selective UV-filter detection with sensors based on stainless steel electrodes modified with polyaniline doped with metal tetrasulfonated phthalocyanine films. Analyst 2009; 134:1453-61. [DOI: 10.1039/b902273b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
5
|
Metzger M, Higuchi ML, Moreira LF, Chaves MJF, Castelli JB, Silvestre JML, Bocchi E, Stolf N, Ramires JA. Relevance of apoptosis and cell proliferation for survival of patients with dilated cardiomyopathy undergoing partial left ventriculectomy. Eur J Clin Invest 2002; 32:394-9. [PMID: 12059983 DOI: 10.1046/j.1365-2362.2002.00998.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- M Metzger
- Heart Institute (InCor), University of São Paulo Medical School, Brazil.
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Fagundes RB, Mello CR, Tollens P, Pütten AC, Wagner MB, Moreira LF, Barros SG. p53 protein in esophageal mucosa of individuals at high risk of squamous cell carcinoma of the esophagus. Dis Esophagus 2002; 14:185-90. [PMID: 11869317 DOI: 10.1046/j.1442-2050.2001.00183.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
Collapse
Affiliation(s)
- R B Fagundes
- Gastroenterology Service, Pathology Department of the Faculdade de Medicina da Universidade Federal do Rio Grande do Sul, RS, Brazil.
| | | | | | | | | | | | | |
Collapse
|
7
|
Moreira LF, Leirner AA. Dynamic cardiomyoplasty: a new summing up. Artif Organs 2001; 25:857-61. [PMID: 11903135 DOI: 10.1046/j.1525-1594.2001.00876.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
8
|
Abstract
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.
Collapse
Affiliation(s)
- L F Moreira
- Heart Institute (Incor), University of São Paulo Medical School, São Paulo, SP, Brazil.
| | | |
Collapse
|
9
|
Mulinari LA, Tyszka AL, de Carvalho RG, da Rocha Loures DR, Moreira LF, Stolf NA. Total inversion of the left lung circulation: morphologic and functional analyses. Heart Surg Forum 2001; 2:206-10; discussion 210-1. [PMID: 11276476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
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.
Collapse
Affiliation(s)
- L A Mulinari
- Heart Institute, Hospital das Clínicas, Medical School, University of São Paulo, Brazil
| | | | | | | | | | | |
Collapse
|
10
|
Parga JR, Avila LF, Bacal F, Moreira LF, Stolf NG, Ramires JA, Bocchi EA. Partial left ventriculectomy in severe idiopathic dilated cardiomyopathy: assessment of short-term results and their impact on late survival by magnetic resonance imaging. J Magn Reson Imaging 2001; 13:781-6. [PMID: 11329201 DOI: 10.1002/jmri.1108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- J R Parga
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil.
| | | | | | | | | | | | | |
Collapse
|
11
|
Gutierrez PS, Pires WO, Marie SK, Moreira LF, Mady C, Higuchi ML, Stolf NA, Ramires JA. Histopathological findings in skeletal muscle used in human dynamic cardiomyoplasty. J Pathol 2001; 194:116-21. [PMID: 11329150 DOI: 10.1002/path.836] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
Collapse
Affiliation(s)
- P S Gutierrez
- Heart Institute (InCor), University of São Paulo Medical School, Av. Dr Enéas C. Aguiar 44, 05403-000 São Paulo SP, Brazil.
| | | | | | | | | | | | | | | |
Collapse
|
12
|
Moreira LF, Stolf NA, de Lourdes Higuchi M, Bacal F, Bocchi EA, Oliveira SA. Current perspectives of partial left ventriculectomy in the treatment of dilated cardiomyopathy. Eur J Cardiothorac Surg 2001; 19:54-60. [PMID: 11163561 DOI: 10.1016/s1010-7940(00)00617-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
MESH Headings
- Adult
- Aged
- Cardiomyopathy, Dilated/mortality
- Cardiomyopathy, Dilated/physiopathology
- Cardiomyopathy, Dilated/surgery
- Female
- Follow-Up Studies
- Heart Valve Prosthesis Implantation
- Heart Ventricles/physiopathology
- Heart Ventricles/surgery
- Hemodynamics/physiology
- Humans
- Male
- Middle Aged
- Mitral Valve Insufficiency/mortality
- Mitral Valve Insufficiency/physiopathology
- Mitral Valve Insufficiency/surgery
- Postoperative Complications/mortality
- Postoperative Complications/physiopathology
- Shock, Cardiogenic/mortality
- Shock, Cardiogenic/physiopathology
- Shock, Cardiogenic/surgery
- Survival Analysis
- Ventricular Dysfunction, Left/mortality
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/surgery
- Ventricular Function, Left/physiology
Collapse
Affiliation(s)
- L F Moreira
- Heart Institute (Incor), São Paulo University Medical School, Avenue Dr Enéas Carvalho Aguiar, 44, SP 05403-000, São Paulo, Brazil.
| | | | | | | | | | | |
Collapse
|
13
|
Bacal F, Stolf NA, Veiga VC, Chalela WA, Grupi C, Rodrigues AC, Martinez EE, Fiorelli AI, Moreira LF, Bocchi EA, Bellotti G, Ramires JA. Noninvasive diagnosis of allograft vascular disease after heart transplantation. Arq Bras Cardiol 2001; 76:29-42. [PMID: 11175482 DOI: 10.1590/s0066-782x2001000100004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- F Bacal
- Instituto do Coração do Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, 05403-000, Brazil
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Bocchi EA, Esteves-Filho A, Bellotti G, Bacal F, Moreira LF, Stolf N, Ramires JF. Left ventricular regional wall motion, ejection fraction, and geometry after partial left ventriculectomy. Influence of associated mitral valve repair. Eur J Cardiothorac Surg 2000; 18:458-65. [PMID: 11024385 DOI: 10.1016/s1010-7940(00)00496-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- E A Bocchi
- Heart Institute-Incor, University of São Paulo Medical School, São Paulo, Brazil.
| | | | | | | | | | | | | |
Collapse
|
15
|
Pêgo-Fernandes PM, Jatene FB, Kwasnicka K, Hueb AC, Moreira LF, Gentil AF, Stolf NA, Oliveira SA. Ischemic preconditioning in myocardial revascularization with intermittent aortic cross-clamping. J Card Surg 2000; 15:333-8; discussion 339-40. [PMID: 11599826 DOI: 10.1111/j.1540-8191.2000.tb00467.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- P M Pêgo-Fernandes
- Heart Institute (InCor), University of São Paulo Medical School, SP, Brazil.
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Cury PM, Higuchi ML, Gutierrez PS, Moreira LF, Bocchi EA, Stolf NA, Jatene AD. Autopsy findings in early and late postoperative death after partial left ventriculectomy. Ann Thorac Surg 2000; 69:769-73. [PMID: 10750759 DOI: 10.1016/s0003-4975(99)01365-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- P M Cury
- Heart Institute (InCor), University of São Paulo Medical School, SP, Brazil.
| | | | | | | | | | | | | |
Collapse
|
17
|
Pêgo-Fernandes PM, Stolf NA, Moreira LF, Fabri HA, Leirner AA, Oliveira SA, Jatene AD. Influence of biopump with and without intraaortic balloon on the coronary and carotid flow. Ann Thorac Surg 2000; 69:536-40. [PMID: 10735694 DOI: 10.1016/s0003-4975(99)01335-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
Collapse
|
18
|
Bacal F, Bocchi EA, Vieira ML, Lopes N, Moreira LF, Fiorelli A, Costa R, Martinelli M, Stolf NA, Bellotti G, Ramires JA. Permanent and temporary pacemaker implantation after orthotopic heart transplantation. Arq Bras Cardiol 2000; 74:5-12. [PMID: 10935288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- F Bacal
- Instituto do Coração do Hospital das Clínicas, FMUSP, Brazil
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Higuchi ML, Moreira LF, Silvestre JM, Gutierrez PS, Savalli C, Stolf N, Bellotti G, Ramires JA, Jatene A. Myocardial fiber diameter as a good indicator of outcome in Batista's operation. J Card Surg 1999; 14:401-7. [PMID: 11021364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
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.
Collapse
Affiliation(s)
- M L Higuchi
- Service of Pathology, Heart Institute (InCor), University of São Paulo Medical School, SP, Brazil.
| | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Stolf N, Moreira LF, Scanavacca M, Frota Filho JD, Gontijo Filho B, Teixeira Filho GF, Braile DM. [I Guidelines of the Brazilian Cardiology Society for Heart Transplantation: VI. Alternatives or bridge to heart transplantation]. Arq Bras Cardiol 1999; 73 Suppl 5:38-44. [PMID: 10883481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
|
21
|
Abstract
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.
Collapse
Affiliation(s)
- L F Moreira
- First Department of Surgery, Okayama University Medical School, Japan
| | | | | | | | | |
Collapse
|
22
|
Benício A, Moreira LF, Auler Junior JO, Stolf NA, Jatene AD. Paraplegia following intraaortic balloon circulatory assistance. Arq Bras Cardiol 1999; 72:487-92. [PMID: 10531693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- A Benício
- Instituto do Coração do Hospital das Clínicas-FMUSP
| | | | | | | | | |
Collapse
|
23
|
Stolf NA, Moreira LF, Bocchi EA, Higuchi ML, Bacal F, Bellotti G, Jatene AD. Determinants of midterm outcome of partial left ventriculectomy in dilated cardiomyopathy. Ann Thorac Surg 1998; 66:1585-91. [PMID: 9875756 DOI: 10.1016/s0003-4975(98)00959-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- N A Stolf
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo, SP, Brazil
| | | | | | | | | | | | | |
Collapse
|
24
|
Moreira LF, Stolf NA, Bocchi EA, Bacal F, Giorgi MC, Parga JR, Jatene AD. Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy. J Thorac Cardiovasc Surg 1998; 115:800-7. [PMID: 9576213 DOI: 10.1016/s0022-5223(98)70358-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- L F Moreira
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | | | | | | | | | | | | |
Collapse
|
25
|
Bocchi EA, Bellotti G, Vilella de Moraes A, Bacal F, Moreira LF, Esteves-Filho A, Fukushima JT, Guimarães G, Stolf N, Jatene A, Pileggi F. Clinical outcome after left ventricular surgical remodeling in patients with idiopathic dilated cardiomyopathy referred for heart transplantation: short-term results. Circulation 1997; 96:II-165-71; discussion II-171-2. [PMID: 9386093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
Collapse
Affiliation(s)
- E A Bocchi
- Heart Institute, São Paulo University Medical School, Brazil
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
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.
Collapse
Affiliation(s)
- L F Moreira
- Laboratory of Respiration Physiology, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Ilha do Fundão, Brazil
| | | | | | | | | |
Collapse
|
27
|
Abstract
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.
Collapse
Affiliation(s)
- M Menaker
- NSF Center for Biological Timing, University of Virginia, Charlottesville 22903, USA.
| | | | | |
Collapse
|
28
|
Furnary AP, Chachques JC, Moreira LF, Grunkemeier GL, Swanson JS, Stolf N, Haydar S, Acar C, Starr A, Jatene AD, Carpentier AF. Long-term outcome, survival analysis, and risk stratification of dynamic cardiomyoplasty. J Thorac Cardiovasc Surg 1996; 112:1640-9; discusion 1649-50. [PMID: 8975856 DOI: 10.1016/s0022-5223(96)70023-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
Collapse
Affiliation(s)
- A P Furnary
- Providence St. Vincent Hospital and Medical Center, Portland, Ore. 97225, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Kamikawa Y, Naomoto Y, Moreira LF, Orita K. Mucosal stripping in the treatment of a major leak from an oesophagojejunostomy. Eur J Surg 1996; 162:925-7. [PMID: 8956965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Y Kamikawa
- Okayama University Medical School, First Department of Surgery, Japan
| | | | | | | |
Collapse
|
30
|
Bocchi EA, Bellotti G, Moreira LF, Bacal F, de Moraes AV, Fiorelli A, Mansur A, Stolf N, Jatene A, Pileggi F. Mid-term results of heart transplantation, cardiomyoplasty, and medical treatment of refractory heart failure caused by idiopathic dilated cardiomyopathy. J Heart Lung Transplant 1996; 15:736-45. [PMID: 8820791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- E A Bocchi
- Heart Institute, São Paulo University Medical School, Brazil
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Gerola LR, Puig LB, Moreira LF, Cividanes GV, Gemha GP, Souto RC, Oppi EC, Souza AH. Right internal thoracic artery through the transverse sinus in myocardial revascularization. Ann Thorac Surg 1996; 61:1708-12; discussion 1712-3. [PMID: 8651771 DOI: 10.1016/0003-4975(96)00080-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
Collapse
Affiliation(s)
- L R Gerola
- Hospital Beneficência Portuguesa de São Paulo, Brazil
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
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.
Collapse
Affiliation(s)
- L F Moreira
- Heart Institute of São Paulo Unversity Medical School, Brazil
| | | | | | | | | |
Collapse
|
33
|
Moreira LF. [Initial experience with partial left ventriculectomy as a treatment for end-stage heart failure]. Arq Bras Cardiol 1996; 66:223-4. [PMID: 8935688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
|
34
|
Abstract
BACKGROUND Dynamic cardiomyoplasty has been proposed in the treatment of severe cardiomyopathies. However, few reports to date have shown significant numbers of patients collected on a multicenter basis. METHODS From July 1987 to June 1994, dynamic cardiomyoplasty was performed in 112 patients in South America. The indications were dilated cardiomyopathy in 96 patients, Chagas' disease cardiomyopathy in 13, and ischemic cardiomyopathy in 3. Left latissimus dorsi muscle was used in all patients. RESULTS The thirty-day mortality rate was 8.1%, and patients were followed up for 22.1 +/- 18.6 months. Data of surviving patients show that 47.3% were in New York Heart Association functional class I, 45.6% in class II, and 7% in class III or IV 1 year after the operation. The 1-year survival was 78.4%; 2-year, 59.7%; and 5-year, 41.7%. The survival at 1 year was 86.1% for patients with dilated cardiomyopathy and 40% for those with Chagas' disease. At 5 years, these values were 49.8% and 9.5%, respectively. Long-term survival was also significantly affected by preoperative functional class and pulmonary vascular resistance. However, patients operated on in class III or intermittent class IV and without elevated pulmonary vascular resistance had survival rates of 91.5% at 1 year and 76.7% at 5 years of follow-up. CONCLUSIONS Cardiomyoplasty improves the functional status of patients with severe cardiomyopathies. Otherwise, long-term survival after this procedure is limited in patients with Chagas' disease and by patients' condition before the operation.
Collapse
Affiliation(s)
- L F Moreira
- Instituto do Coração da Universidade de São Paulo, Brazil
| | | | | | | |
Collapse
|
35
|
Moreira LF, Stolf NA. Dynamic cardiomyoplasty. Adv Card Surg 1996; 8:147-73. [PMID: 9111653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- L F Moreira
- Heart Institute, São Paulo University Medical School, Brazil
| | | |
Collapse
|
36
|
Bocchi EA, Guimarães GV, Moreira LF, Bacal F, de Moraes AV, Barreto AC, Wajngarten M, Bellotti G, Stolf N, Jatene A. Peak oxygen consumption and resting left ventricular ejection fraction changes after cardiomyoplasty at 6-month follow-up. Circulation 1995; 92:II216-22. [PMID: 7586412 DOI: 10.1161/01.cir.92.9.216] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The effects of cardiomyoplasty on cardiopulmonary exercise test characteristics are not fully known. METHODS AND RESULTS We determined in 19 patients who underwent cardiomyoplasty for treatment of refractory heart failure (New York Heart Association [NYHA] functional class III) before (pre) and at 6-month follow-up (post) maximum oxygen consumption (peak VO2), NYHA functional class, and resting left ventricular ejection fraction (LVEF) (MUGA). We analyzed the results according to pre peak VO2 < or > 14 mL/kg per minute and the correlation between the changes in absolute values of LVEF and peak VO2. Pre- and post-peak VO2 values were 15.9 +/- 4.4 and 18.6 +/- 6.4 mL/kg per minute, respectively (P = .059). In the subgroup with pre-peak VO2 < 14 mL/kg per minute, the peak VO2 increased from 11.1 +/- 1.9 to 16.4 +/- 6.2 mL/kg per minute (P = .02). The subgroup with peak VO2 > 14 mL/kg per minute showed pre- and post-peak VO2 of 19.2 +/- 2.6 and of 20.1 +/- 7 mL/kg per minute, respectively (P = .06). The pre-total exercise time of the entire group increased from 688.4 +/- 222.1 to 833.7 +/- 241.6 seconds (P < .04). For the subgroup with preoperative peak VO2 < 14 mL/kg per minute, exercise time improved from 585 +/- 76.9 to 825 +/- 186.3 seconds (P < .01). In the subgroup with preoperative VO2 > 14 mL/kg per minute, the preexercise and postexercise time was 763.6 +/- 264.4 and 840 +/- 282 seconds, respectively (P = .4). Pre-LVEF increased from 20.6 +/- 3.3% to 24.2 +/- 7.8% at 6 months of follow-up (P = .02). At 6 months of follow-up, 9 patients were in NYHA functional class I and 10 were in class II. There was no correlation between LVEF values and absolute values of peak VO2 before (r = .123, P = .6) and after (r = .27, P = .2) cardiomyoplasty. A weak correlation was observed between the changes in absolute values of peak VO2 and LVEF from the preoperative to the postoperative period (r = .48, P = .048). CONCLUSIONS Cardiomyoplasty is a useful method for improving NYHA functional class and LVEF in patients with heart failure. Peak VO2 < 14 mL/kg per minute before cardiomyoplasty may be a selection criterion with which to determine improved exercise capacity after surgery. The effects of cardiomyoplasty on LVEF appear to be partially associated with maximum exercise capacity changes.
Collapse
Affiliation(s)
- E A Bocchi
- Heart Institute, São Paulo (Brazil), University Medical School
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Kalil Filho R, Bocchi E, Rosemberg L, Bacal F, Moreira LF, Ferreira BM, Stolf NA, Magalhães AA, Bellotti G, Jatene A. [Evaluation of chronic morphological changes in the latissimus dorsi, after cardiomyoplasty, with magnetic resonance]. Arq Bras Cardiol 1995; 65:221-5. [PMID: 8579508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Long term clinical and hemodynamic benefits of dynamic cardiomyoplasty (DC) have been reported. However, no information is available about long-term morphological changes in the wrapped latissimus dorsi (LD) muscle in humans. METHODS The latissimus dorsi muscle flap was evaluated by magnetic resonance imaging (MRI) in 5 patients submitted to DC for treatment of severe dilated cardiomyopathy. All patients were studied from 24 to 52 months after the surgical procedure at the time of the cardiomyostimulator replacement. In the interim, LD was stimulated with burst of 6 pulses (burst duration 185 msec, burst freq 30Hz) synchronized to every cardiac contraction with a maximum of 100 LD contractions/min. Images were acquired on a GE Sigma 1.5 T system (TE = 25ms, TR = R- Rx2, slice thickness 8mm). RESULTS The thickness of was 7.6 +/- 0.8mm. In addition, the signal intensity of the LD was compared with that of thoracic skeletal muscle and was found to be increased (2.19 +/- 0.42). The signal intensity was similar to that of subcutaneous fat in those images. CONCLUSION Morphologic changes in the wrapped LD muscle consistent with fatty degeneration occur after DC and can be detected by MRI. Further studies will be necessary to demonstrate the clinical significance of such LD muscle flap changes.
Collapse
Affiliation(s)
- R Kalil Filho
- Instituto do Coração do Hospital das Clínicas-FMUSP, São Paulo
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Tanaka N, Kojima K, Muro M, Naomoto Y, Moreira LF, Orita K. Anti-proliferative and cytokinetic effects of tumor necrosis factor-alpha, interferon-alpha and 5-fluorouracil on a human tumor xenograft. Anticancer Res 1995; 15:1949-52. [PMID: 8572582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We have previously reported that interferon-alpha (IFN-alpha) and tumor necrosis factor-alpha (TNF-alpha) blocked the cell cycle progression of cancer cells at the S to G2 transition, causing a synergistic antitumor effect. In this study, the combined effects of both these cytokines and 5-fluorouracil (FUra) on tumor growth and cell cycle progression were investigated in a human colon cancer cell line, RPMI 4788, transplanted in CD-1 nude mice. Daily administration of IFN-alpha and TNF-alpha for 21 days markedly suppressed the tumor growth and induced cytokinetic alterations in which S phase cells were increased and cells in G2/M phase were decreased. FUra added to these cytokines further suppressed tumor development but did not affect the cytokinetics further. Combination of FUra and cytokines in a low dose, either of which alone had no effect, suppressed the tumor growth. These findings demonstrate that IFN-alpha, TNF-alpha and FUra have a distinct antitumor effect in combination.
Collapse
Affiliation(s)
- N Tanaka
- First Department of Surgery, Okayama University Medical School, Japan
| | | | | | | | | | | |
Collapse
|
39
|
Moreira LF, Kamikawa Y, Naomoto Y, Haisa M, Orita K. Endoscopic mucosal resection for superficial carcinoma and high-grade dysplasia of the esophagus. Surg Laparosc Endosc Percutan Tech 1995; 5:171-5. [PMID: 7543336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Endoscopic mucosal resection (EMR) is a recently introduced therapeutic method based on the principles of the strip biopsy for resection of flat lesions of the gastrointestinal tract. Eleven asymptomatic patients (nine men, two women) with superficial carcinoma or high-grade dysplasia of the intrathoracic esophagus were treated by EMR during a 6-month period. The patients' mean age was 64 years (range, 49-78). The site of the lesions was the middle third of the esophagus in eight, upper third in two, and lower third in one patient. All patients in this series had a flat (II) type of superficial cancer. The procedure was carried out in all 11 patients without complication. Histopathological examination of the specimens revealed squamous cell carcinoma in nine patients. The remaining two patients were confirmed to have dysplasia only. Free margins measured greater than 5 mm in all cases. No recurrence was detected in a mean follow-up of 8 (5-10) months. For superficial flat lesions, EMR proved to be a safe and curative procedure that provided good quality of life following resection. However, larger trials are needed to confirm these results. Applying EMR to esophageal dysplasia could decrease the incidence of esophageal cancer.
Collapse
Affiliation(s)
- L F Moreira
- First Department of Surgery, Okayama University Medical School, Japan
| | | | | | | | | |
Collapse
|
40
|
Abstract
Dynamic cardiomyoplasty has been performed to reinforce the myocardium in the treatment of patients with severe cardiomyopathies. At the Heart Institute of São Paulo University Medical School, 36 patients were submitted to cardiomyoplasty between May 1988 and December 1993. The indications were idiopathic dilated cardiomyopathy in 31, ischemic cardiomyopathy in 3, and Chagas' disease cardiomyopathy in 2 patients. Twenty-eight patients were categorized in New York Heart Association (NYHA) Class III and 8 in Class IV despite the use of maximal medical therapy. There were no hospital deaths, and patients were followed up from 2 to 70 months (mean, 24 months). Besides the improvement of NYHA functional class from 3.2 +/- 0.6 to 1.6 +/- 0.9 at 6 months of follow-up, patients also presented significant changes in the left ventricular systolic and diastolic functions. Nevertheless, 16 patients died, and 2 patients were submitted to heart transplantation during late follow-up. Actuarial survival rates were 82.3% at 1 year, 61.5% at 2 years, and 38.8% at 5 years of follow-up. Otherwise, the analysis of factors influencing the outcome showed that long-term survival was significantly affected by preoperative functional class and by pulmonary vascular resistance. The 26 patients operated in NYHA functional Class III and with pulmonary vascular resistance below 4 Wood units presented survival rates of 72.7% at 2 years and of 63% at 5 years of follow-up. In conclusion dynamic cardiomyoplasty improves functional class and left ventricular function in patients with severe cardiomyopathies. However, the long-term survival after this surgical procedure may be limited by the patients' condition before the operation.
Collapse
Affiliation(s)
- L F Moreira
- Heart Institute of São Paulo, University Medical School, Brazil
| | | | | | | | | | | |
Collapse
|
41
|
Moreira LF, Naomoto Y, Hamada M, Kamikawa Y, Orita K. Assessment of apoptosis in oesophageal carcinoma preoperatively treated by chemotherapy and radiotherapy. Anticancer Res 1995; 15:639-44. [PMID: 7539243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Apoptosis, programmed cell death, was immunohistochemically determined in 55 samples of oesophageal squamous cell carcinoma using the BM1 Mab. Sections from patients not treated (group 1, n = 12) or preoperatively treated by chemotherapy (group 2, n = 11), radiation (group 3, n = 13) or both (group 4, n = 8), and 11 additional cases of high-grade dysplasia or early cancer were examined. Most of the apoptotic cells were BM1-positive and checked by TUNEL proved to be nick end positive. They accounted for 7 (11%), 19 (29%), 21 (32%) and 26 (38%) cells per field in those 4 groups respectively. Chemotherapy and/or radiation significantly increased the number of apoptotic cells as compared to controls (p = 0.029 and p = 0.029, respectively). To assess the implications of the oncogene expression in the apoptotic pathway, additional section stained with bcl2 and p53 were negative for bcl2 and were positive for p53 in 16 samples (37%). Overall, positive cases for p53 mutation showed a significantly decreased incidence of apoptotic cells (p = 0.03). These results suggest that in situ assessment of apoptotic response better correlates to the apoptosis induced by radiation than that by chemotherapy, that abnormalities of the p53 protein decrease the apoptotic response in oesophageal carcinoma, and that immunohistochemical analysis of p53 protein helps to determine the sensitivity to these anticancer agents.
Collapse
Affiliation(s)
- L F Moreira
- First Department of Surgery, Okayama University Medical School, Japan
| | | | | | | | | |
Collapse
|
42
|
Moreira LF, Stolf NA, Bocchi EA, Bacal F, Pêgo-Fernandes PM, Abensur H, Meneghetti JC, Jatene AD. Clinical and left ventricular function outcomes up to five years after dynamic cardiomyoplasty. J Thorac Cardiovasc Surg 1995; 109:353-62; discussion 362-3. [PMID: 7853887 DOI: 10.1016/s0022-5223(95)70397-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Improvement in congestive heart failure and left ventricular function after dynamic cardiomyoplasty has been reported in patients with severe cardiomyopathies, but the long-term effects of this procedure remain unclear. In this investigation 31 patients undergoing cardiomyoplasty for treatment of idiopathic dilated cardiomyopathy were annually investigated with radionuclide scintigraphy, Doppler echocardiography, and right-sided heart catheterization. They were in New York Heart Association functional class III or IV before the operation. No hospital deaths occurred, but one patient with progressive heart failure required urgent heart transplantation 42 days after cardiomyoplasty. The other patients were followed up from 6 to 70 months (mean 25.6 months) and 12 patients died at late follow-up. Actuarial survivals were 86% at 1 year, 61.4% at 2 years, and 42.5% at 3 to 5 years of follow-up. Multivariate analysis of factors influencing outcome showed that long-term survival was significantly affected by preoperative functional class and pulmonary vascular resistance. Functional class improved from 3.2 +/- 0.4 to 1.7 +/- 0.7 in the surviving patients (p < 0.01). Furthermore, left ventricular ejection fraction improved from 19.8% +/- 3% to 23.9% +/- 7.2% (p < 0.01), and significant changes in stroke index, arterial pressure, pulmonary wedge pressure, and left ventricular stroke work index were also found at 6 months of follow-up. In the late postoperative period, the left ventricular ejection fraction tended to decrease and returned to preoperative levels at 5 years, whereas hemodynamic variables did not change significantly. Thus, despite the tendency of the left ventricular ejection fraction to decrease at late follow-up, the long-term course of these patients seems to be characterized by the maintenance of hemodynamic improvement. However, long-term survival after cardiomyoplasty is limited by the severity of the patient's condition before the operation.
Collapse
Affiliation(s)
- L F Moreira
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo, Brazil
| | | | | | | | | | | | | | | |
Collapse
|
43
|
Abstract
It has been demonstrated that respiratory resistance and elastance increase whilst the abdomen remains open during longitudinal laparotomy. We wished to determine whether changes also occur after abdominal closure in the same animal preparation. In 10 sedated, anaesthetized paralysed, and mechanically-ventilated rats (309 +/- 33 (SD) g), resistances and elastances of the respiratory system, lung, and chest wall were measured both before longitudinal laparotomy and directly after abdominal closure. Furthermore, the resistances were also split into their initial and difference components, the former reflecting the Newtonian resistances and the latter representing the viscoelastic/inhomogeneous pressure dissipations in the system. For this purpose, the end inflation occlusion during constant inspiratory flow method was used. After laparotomy, no statistically significant changes were found in elastances and resistances of the respiratory system, lungs and chest wall (paired Student's t-test, significance level = 5%). It can be concluded that after midline xiphipubic laparotomy accompanied by bilateral ventro-dorsal infracostal incision, respiratory resistances and elastances were not different from those found in the control condition.
Collapse
Affiliation(s)
- L F Moreira
- Instituto de Biofisica Carlos Chagas Filho, UFRJ, Ilha do Fundão, Rio de Janeiro, Brazil
| | | | | | | | | |
Collapse
|
44
|
Erdman S, Strasberg B, Invernizzi C, Fiandra O, Moreira LF, Stolf NA. Cardiomyoplasty review: physiological principles and characteristics of electrically stimulated skeletal muscle. II. A therapeutic option. J Cardiovasc Surg (Torino) 1994; 35:153-9. [PMID: 7775531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Chronic heart failure continues unsolved as ever despite recent advances in cardiac surgery and pharmacological new armamentarium and remains a significant cause of death, regardless of etiology. Cardiomyoplasty (CMP), a new form of biomechanical ventricular support, has given new life to the field of mechanical circulatory support, providing a "bridge" to transplantation and serving as a possible alternative to surgical treatment. The geographic distribution of world experience in 401 patients shows that 80% were centralized in Europe (50%) and South America (30%). This review of the data analysis, documented improved changes in patients clinical status, further clarifies and appropriate patients population indications for DCMP as well as that more than 80% survival probability for NYHA class II & III and an early procedure related mortality of 8 to 10%.
Collapse
Affiliation(s)
- S Erdman
- Department of Cardio-Thoracic Surgery, Beilinson Medical Center, Petah Tiqva Israel
| | | | | | | | | | | |
Collapse
|
45
|
Hamazaki K, Sato S, Yunoki M, Noda T, Moreira LF, Mimura H, Orita K. Kupffer cell function in chronic liver injury and after partial hepatectomy. Res Exp Med (Berl) 1994; 194:237-46. [PMID: 7800933 DOI: 10.1007/bf02576385] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The reticuloendothelial system (RES) plays an important role in the biological defense system. In the liver, Kupffer cells are the main constituent of the RES, and when their function is impaired postoperative complications may more often occur. By using 99mTc-labeled human serum albumin millimicrospheres (99mTc-HSA-MM) combined with assessment of single photon emission computed tomography (SPECT), we have attempted to determine the function of Kupffer cells independently of the hepatic blood flow. First, Kupffer cell function in rats with chronic liver injury caused by CCl4 was studied. The hepatic uptake rate in chronic liver injury was decreased, and a reduced phagocytic activity of the Kupffer cells was noted. The parameter concerning Kupffer cell degradation, the excretion rate (k), was markedly decreased in the early period of chronic liver injury. Changes in Kupffer cell function after 30% and 70% hepatectomy were also studied. After 30% hepatectomy, the excretion rate was decreased on the first postoperative day (POD), and it was increased beyond that found after sham operation on the 3rd POD. In contrast, slower recovery of uptake rate was demonstrated. After 70% hepatectomy, both uptake and excretion rates were markedly reduced, and recovery was prolonged beyond the 5th POD. The hepatic uptake was not parallel with the excretion rate in either experiment. These results suggest that the method that measures the hepatic excretion rate may provide a better assessment of Kupffer cell function than the current uptake measurement with radiolabeled colloid.
Collapse
Affiliation(s)
- K Hamazaki
- First Department of Surgery, Okayama University Medical School, Japan
| | | | | | | | | | | | | |
Collapse
|
46
|
Tanaka N, Ohoida J, Matuno T, Gouchim A, Iwagaki H, Moreira LF, Orita K. Response of adenosquamous carcinoma of the pancreas to interferon-alpha, tumor necrosis factor-alpha and 5-fluorouracil combined treatment. Anticancer Res 1994; 14:2739-42. [PMID: 7872711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A 48-year-old woman with a nonresectable pancreatic tumor received combination chemotherapy with cytokines (IFN-a plus TNF-a) and 5-FU. Since partial response was confirmed after seven months, she underwent re-exploration, and received a pancreatico-duodenectomy. Histologically, the tumor was an adenosquamous carcinoma of the pancreas. She recovered uneventfully. However, the tumor rapidly recurred, and she died five months after surgery. Despite the poor result, the survival of the patient with advanced pancreatic cancer for twelve months after the staring of the treatment suggests that combined chemotherapy with cytokines and 5-FU may be a therapeutic modality for advanced pancreatic cancer.
Collapse
Affiliation(s)
- N Tanaka
- First Department of Surgery, Okayama University Medical School, Japan
| | | | | | | | | | | | | |
Collapse
|
47
|
Bocchi EA, Moreira LF, de Moraes AV, Bacal F, Sosa E, Stolf NA, Bellotti G, Jatene AD, Pilleggi F. Arrhythmias and sudden death after dynamic cardiomyoplasty. Circulation 1994; 90:II107-11. [PMID: 7955235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The main causes of death in patients with severe cardiomyopathy are progressive heart failure and sudden death. The influence of cardiomyoplasty on the incidence of sudden death and arrhythmias in patients with cardiomyopathy remains unclear. The aim of this study was to investigate the occurrence of arrhythmias and sudden death after cardiomyoplasty. METHODS AND RESULTS We studied 32 patients (26 male, 6 female; mean age, 48 +/- 12 years) who submitted to cardiomyoplasty for treatment of heart failure in New York Heart Association (NYHA) class III (n = 24) or class IV (n = 8). The etiology was idiopathic dilated cardiomyopathy in 27 patients, ischemic heart disease in 3 patients, and Chagas' heart disease in 2 patients. Patients were routinely studied before and every 6 months after cardiomyoplasty by means of radioisotopic angiography and 24-hour Holter monitor recordings. There were no operative or immediate postoperative deaths. During the postoperative period, 5 patients presented with acute atrial fibrillation and 1 had an episode of sustained ventricular tachycardia. All episodes were successfully treated with intravenous antiarrhythmic drugs or cardioversion. During follow-up (from 2 to 66 months), 15 patients died from sudden death (n = 5) or progressive heart failure (n = 10). Survival rates at 1, 2, and 4 years were 79.9 +/- 7%, 62.5 +/- 9.7% and 35 +/- 12.1%, respectively. At 6-month follow-up, NYHA functional class improved from 3.2 +/- 0.4 to 1.7 +/- 0.6 (P = .001) and left ventricular ejection fraction increased from 19.8 +/- 3.3% to 24 +/- 8.2% (P = .004). The mean values per day of premature ventricular complexes (PVCs) and episodes of nonsustained ventricular tachycardia (NSVT) did not change statistically. The mean number of PVCs per 24 hours before and at 6, 12, 24, 36, and 48 months after surgery were 126 +/- 44, 96 +/- 33, 90 +/- 29, 81 +/- 35, 71 +/- 35, and 59 +/- 48. The mean number of episodes of NSVT per 24 hours before and at 6, 12, 24, 36, and 48 months after surgery were 3.3 +/- 1.3, 1.9 +/- 0.5, 1.3 +/- 0.5, 1 +/- 0.5, 1.5 +/- 1.1, and 0.6 +/- 0.5, respectively. With respect to analysis of the idiopathic dilated cardiomyopathy subgroup, there also were no significant differences in the incidences of pre- and postoperative arrhythmias. CONCLUSIONS Despite NYHA functional class and left ventricular function improvements observed after cardiomyoplasty, the incidence of arrhythmias did not change, and sudden death was an important finding mainly in late follow-up. The problem of sudden death after cardiomyoplasty, the mechanism that produces it, and the means to prevent it remain critical areas for future research.
Collapse
MESH Headings
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/etiology
- Cardiomyopathy, Dilated/diagnosis
- Cardiomyopathy, Dilated/epidemiology
- Cardiomyopathy, Dilated/surgery
- Cardiomyoplasty
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Electrocardiography, Ambulatory
- Female
- Follow-Up Studies
- Humans
- Incidence
- Male
- Middle Aged
- Survival Analysis
- Survival Rate
- Time Factors
Collapse
Affiliation(s)
- E A Bocchi
- Heart Institute, São Paulo University, Brazil
| | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Kalil-Filho R, Bocchi E, Weiss RG, Rosemberg L, Bacal F, Moreira LF, Stolf NA, Magalhães AA, Bellotti G, Jatene A. Magnetic resonance imaging evaluation of chronic changes in latissimus dorsi cardiomyoplasty. Circulation 1994; 90:II102-6. [PMID: 7955234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Long-term clinical and hemodynamic benefits of dynamic cardiomyoplasty (DC) have been reported. However, no information is available about long-term morphological changes in the wrapped latissimus dorsi (LD) muscle in humans. METHODS AND RESULTS The LD muscle flap was evaluated by magnetic resonance imaging (MRI) in 13 patients submitted to dynamic cardiomyoplasty for treatment of severe dilated cardiomyopathy. Eight patients were studied 15 days after the surgery (group 1) and 5 patients were studied from 24 to 52 months after the surgical procedure at the time of the cardiomyostimulator replacement (group 2). In the interim, LD was stimulated with burst of 6 pulses (duration, 185 milliseconds; burst frequency, 30 Hz) synchronized to every cardiac contraction, with a maximum of 100 LD contractions per minute. Images were acquired on a GE Sigma 1.5-T system (echo time, 25 milliseconds; repetition time, R-R x 2; slice thickness, 8 mm). The thickness of the LD decreased from 19.6 +/- 7.3 mm for group 1 to 7.6 +/- 0.8 mm for group 2 (P < .01). In addition, the signal intensity of the LD was compared with that of thoracic skeletal muscle and was found to be significantly increased in group 2 (2.19 +/- 0.42) compared with group 1 (1.04 +/- 0.07, P < .001). The signal intensity for group 2 on the T1-weighted images was similar to that of subcutaneous fat in those images. CONCLUSIONS Morphological changes in the wrapped LD muscle consistent with fatty degeneration occur after DC and can be detected by MRI. Further studies will be necessary to demonstrate the clinical significance of such LD muscle flap changes.
Collapse
|
49
|
Moreira LF, Stolf NA, Bocchi EA, Bacal F, Pêgo-Fernandes PM, Jatene AD. [Cardiomyoplasty perspectives in the treatment of heart failure]. Arq Bras Cardiol 1994; 63:261-6. [PMID: 7779003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- L F Moreira
- Instituto do Coração do Hospital das Clínicas, FMUSP, São Paulo
| | | | | | | | | | | |
Collapse
|
50
|
Pêgo-Fernandes PM, Stolf NA, Leirner AA, Moreira LF, Jatene AD. [Mechanical circulatory support as a bridge to cardiac transplantation]. Arq Bras Cardiol 1994; 63:255-9. [PMID: 7779002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
|