We present a case of a 34-year-old male with dilated cardiomyopathy in whom we performed a new surgical procedure; Le., ventricular volume reduction to improve function. This initial human experience was preceded by a series of ten sheep in which we demonstrated that by enlarging the left ventricle (LV), the ejection fraction was reduced, and by restoring normal diameter, the LV function returned to normal. (J Card Surg 7996;77:96-97)Over the last 45 years, we have observed that all animal hearts have the same muscle mass ratio (M = 4.18.R3. M = muscle mass; R = heart radius). Consequently, if any heart increases its diameter for any reason, the muscle mass has to increase to the cubic of each diameter increment in order to maintain normal left ventricular (LV) function. We performed experiments in sheep. By reducing the diameter of dilated LVs, their function improved. MATERIALS AND METHODSWe operated on a series of ten sheep, and obtained ejection fractions (EFs) preoperatively by cardiac catheterization and epicardial and transesophageal echocardiogram, where we could observe normal LV function (EF = 45%). On cardiopulmonary bypass (CPB), we divided the LV from the apex of the heart between the papillary muscles to the mitral valve annulus. A large pericardial patch was inserted to increase the ventricular diameter. None of the sheep came off bypass, and their EF fell down to 9%. Interestingly, the EF was low because the remaining normal heart muscle contractility was low when the diameter increased. CPB could be discontinued by removing the patch and returning the ventricle to previous normal measurements. The EF then returned to preoperative levels. CASE REPORTR.M., a 34-year-old male, was admitted August 1994 with heart failure New York Heart Association Class IV. There was peripheral edema and severe orthopnea. Cardiac catheterization ( Fig. 1) showed dilated cardiomyopathy with an EF of 17%.We proceeded with LV volume reduction by resecting a slice of LV between both papillary muscles, from the apex of the heart to the mitral annulus. The LV was repaired with a single 2-0 polypropylene suture. There were no problems weaning from bypass. RESULTSOne week postoperatively, we repeated the catheterization. The EF went up to 37% (Fig. 2). The patient had an uneventful postoperative course, and 2 months later, we repeated all of the laboratory data and the EF was 44%. Presently the patient is living a normal life.As of October 1995, we have performed the same operation on 154 patients.
RESUMO: A melhora clínica da função cardíaca pós aneurismectomia de ventrículo esquerdo elou cardiomioplastia com o músculo grande dorsal parece ser, ao menos parcialmente , devida ao remodelamento do ventrículo esquerdo. Através de pesquisa em nosso laboratório experimental com carneiros, demonstramos que o aumento do diâmetro do ventrículo é mais importante que a perda de massa muscular para a deterioração da função ventricular. Sabendo-se que em miocardiopatia dilatada não ocorre aumento de massa muscular, reduzimos o diâmetro do ventrículo para o normal, em uma série consecutiva de pacientes com esta lesão. No período de 1984 a 1995, foram operados com esta nova técnica, denominada, então, "Ventriculectomia Parcial", 103 pacientes portadores de miocardiopatias complexas e insuficiência cardíacacongestiva (NYHA IV). A operação é baseada na lei de Laplace (T =P .11.D) e consistiu na remoção de uma fatia de músculo da parede lateral do ventrículo esquerdo, iniciando-se na ponta deste , estendendo-se entre os músculos papilares e terminando próximo ao anel mitral. A cirurgia é realizada sob circulação extracorpórea normotérmica e não se utiliza cardioplegia. ~os os pacientes foram avaliados pré-operatoriamente com ecodopplercardiografia e ventriculografia digital, os quais revelaram fração de ejeção < 20%, confirmando estes pacientes como candidatos ao transplante cardíaco. A maioria era do sexo masculino (n=73) e a idade variou de 19 a 74 anos. As doenças foram : miocardite a virus (n=12); pós miocardioplastia (n=1) ; doença de Chagas (n=15); doença valvar (n=38) ; doença isquêmica (n=16) ; idiopática (n=21) . Óbitos hospitalares (ocorridos nos primeiros 30 dias da cirurgia) (n=13) : embolia pulmonar (n=4) ; insuficiência renal (n=5); sangramento (n=4). Óbitos tardios (ocorridos depois do 30 2 dia de cirurgia) (n=10) : arritmia (n=6) ; "insuficiência cardíaca" (n=2) ; causa desconhecida (n=2) ; 8 pacientes precisaram ser reoperados por sangramento. Não houve infecção e nenhum paciente precisou balão intra-aórtico. Todos saíram com nitroprussiato e 19 pacientes, com inotrópicos. A ventriculografia e a ecocardiografia pós-op mostraram melhora acentuada da FE (de 100% a 300%). Em conclusão, a nova técnrca "Ventriculectomia Parcial", com o objetivo de reduzir o diâmetro do ventrículo esquerdo, pode beneficiar pacientes em estágio final de cardiopatia dilatada. Este novo conceito pode, na nossa experiência, proporcionar ao paciente melhora clínica significativa e prolongamento de sua vida.
RESUMO : Foram estudados 101 pacientes submetidos a plástica da valva mitral em seis anos, com seguimento de 100%. Entre eles, 36 eram do sexo masculino e 65 do sexo feminino, com idade variando de dois a 62 anos (M = 28 ± 16,4). Desses, 57 (56,4%) foram submetidos apenas a abordagem valvar mitral. Os demais foram submetidos a procedimentos associados, como plástica tricúspide (9,9%), revascularização do miocárdio (4,0%), entre outros. Não foi registrado óbito imediato. O índice de mortalidade tardia foi de 2% (AVC hemorrágico após cinco anos e septicemia), no primeiro ano. As complicações não fatais foram representadas pela endocardite evidenciada em dois pacientes (2%), sendo tratados e curados, e um paciente com reestenose mitral pós-plástica por reagudização da doença reumática. O estudo atuarial revelou um índice de 79,0 ± 17,7% de sobrevida, um total de 76,3 ± 17,8% de pacientes livres de complicações, 80,0 ± 17,9% de reoperações, 100,0% livres de tromboembolismo. Os resultados ecodoplercardiográficos registraram que 89% dos pacientes evoluíram com ausência de insuficiência. Dos 11 % restantes, 7,4% apresentram insuficiência mitral discreta, 2,4% moderada e 2% importante. De acordo com a classificação da NYHA, os pacientes das classes III (83,8%) e IV (16,2%) passaram para as classes I (33,3%), II (60,6%), III (4,1%) e IV (2%). Os autores concluem que o anel de pericárdiO flexível conforma-se perfeitamente com o anel valvar, não produz hemólise e se endoteliza completamente a médio prazo. DESCRITORES: valva mitral, plastia; próteses valvulares cardíacas, biológicas, cirurgia.
IntroductionThe use of anti-retroviral therapy (ART) has dramatically reduced HIV-1 associated morbidity and mortality. However, HIV-1 infected individuals have increased rates of morbidity and mortality compared to the non-HIV-1 infected population and this appears to be related to end-organ diseases collectively referred to as Serious Non-AIDS Events (SNAEs). Circulating miRNAs are reported as promising biomarkers for a number of human disease conditions including those that constitute SNAEs. Our study sought to investigate the potential of selected miRNAs in predicting mortality in HIV-1 infected ART treated individuals.Materials and MethodsA set of miRNAs was chosen based on published associations with human disease conditions that constitute SNAEs. This case: control study compared 126 cases (individuals who died whilst on therapy), and 247 matched controls (individuals who remained alive). Cases and controls were ART treated participants of two pivotal HIV-1 trials. The relative abundance of each miRNA in serum was measured, by RTqPCR. Associations with mortality (all-cause, cardiovascular and malignancy) were assessed by logistic regression analysis. Correlations between miRNAs and CD4+ T cell count, hs-CRP, IL-6 and D-dimer were also assessed.ResultsNone of the selected miRNAs was associated with all-cause, cardiovascular or malignancy mortality. The levels of three miRNAs (miRs -21, -122 and -200a) correlated with IL-6 while miR-21 also correlated with D-dimer. Additionally, the abundance of miRs -31, -150 and -223, correlated with baseline CD4+ T cell count while the same three miRNAs plus miR-145 correlated with nadir CD4+ T cell count.DiscussionNo associations with mortality were found with any circulating miRNA studied. These results cast doubt onto the effectiveness of circulating miRNA as early predictors of mortality or the major underlying diseases that contribute to mortality in participants treated for HIV-1 infection.
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