ObjectiveWe tested the hypothesis that direct intramyocardial injection of bone marrow mononuclear cells in patients with non-ischemic dilated cardiomyopathy can improve left ventricular function and physical capacity.MethodsThirty non-ischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% were randomized at a 1:2 ratio into two groups, control and treated. The bone marrow mononuclear cells group received 1.06±108 bone marrow mononuclear cells through mini-thoracotomy. There was no intervention in the control group. Assessment was carried out through clinical evaluations as well as a 6-min walk test, nuclear magnectic resonance imaging and echocardiogram.ResultsThe bone marrow mononuclear cells group showed a trend toward left ventricular ejection fraction improvement, with magnectic resonance imaging - at 3 months, showing an increase from 27.80±6.86% to 30.13±9.06% (P=0.08) and returning to baseline at 9 months (28.78%, P=0.77). Magnectic resonance imaging showed no changes in left ventricular ejection fraction during follow-up of the control group (28.00±4.32%, 27.42±7.41%, and 29.57±4.50%). Echocardiogram showed left ventricular ejection fraction improved in the bone marrow mononuclear cells group at 3 months, 25.09±3.98 to 30.94±9.16 (P=0.01), and one year, 30.07±7.25% (P=0.001). The control group showed no change (26.1±4.4 vs 26.5±4.7 and 30.2±7.39%, P=0.25 and 0.10, respectively). Bone marrow mononuclear cells group showed improvement in New York Heart Association functional class, from 3.40±0.50 to 2.41±0.79 (P=0.002); patients in the control group showed no change (3.37±0.51 to 2.71±0.95; P=0.17). Six-minute walk test improved in the bone marrow mononuclear cells group (348.00±93.51m at baseline to 370.41±91.56m at 12 months, P=0.66) and there was a non-significant decline in the control group (361.25±90.78m to 330.00±123.42m after 12 months, P=0.66). Group comparisons were non-significant.ConclusionThe trend of intragroup functional and subjective improvement was not confirmed when compared to the control group. Direct intramyocardial application of bone marrow mononuclear cells in non-ischemic dilated cardiomyopathy was not associated with significant changes in left ventricular function. Differences observed within the bone marrow mononuclear cells group could be due to placebo effect or low statistical power.

Uninterrupted use of OAC in the perioperative of CIED surgery was associated with a reduced risk of bleeding. This strategy should be considered the preferred one in patients at moderate-to-high risk of thromboembolic events.

RBCCV Modificações no perfil do paciente submetido à operação de revascularização do miocárdio Changes in profile of patients submitted to coronary bypass graft surgery

objective: To compare the clinical and surgical profile between two groups of patients submitted to Myocardial Revascularization (MCR) surgery at the Instituto de Cardiologia of Rio Grande do Sul with a ten year interval, to observe its influence upon MCR hospital mortality and to verify the predictability of this result using the risk score. Methods:A retrospective cohort study involving 307 patients who underwent MCR surgery within a six month period during 1991/92 (INITIAL group, n=153) or 2001/02 (CURRENT group, n=154). Demographic characteristics, heart disease, comorbidities and surgical events were analyzed to compare the groups and to define the hospital mortality risk score (based on the Cleveland Clinic method). results:The CURRENT group was older, had more severe heart condition (functional class, incidence of heart failure and number of vessels with severe lesions) and a greater prevalence of comorbidities. The INITIAL group had a higher prevalence of nonelective surgery. Both groups had similar mean risk scores (2.8 + 3.1 for INITIAL and 2.2 + 2.5 for CURRENT) and hospital mortality rates (3.3% and 1.9% respectively). These figures are comparable to those for reported by Cleveland Clinic (for a risk score of 3 the predicted mortality range between 2.0 %; using a confidence level of 95% the predicted mortality is between 0 and 4.3%; and actual mortality confirmed by the study was 3.4%). conclusion:Patients currently submitted to MCR are older and in worse clinical condition (heart and systemic) than those operated on ten years ago; however, the risk scores and hospital mortality rates were slightly higher in the INITIAL group. The higher number of nonelective surgical interventions could have contributed to this. A risk score can be used to identify patients that require a higher level of care and to predict surgical outcomes.

Bone marrow mononuclear cells (BMMC) effects have been investigated in small series of nonischemic dilated cardiomyopathy (NIDC). Left ventricular myocardial contractility improvements occur, but doubt remains about their mechanism of action. We compared contractility changes in areas treated (free wall) and nontreated (septal wall) with BMMC, in selected patients who have showed significant ventricular improvement after free wall-only intramyocardial stem cells injection. From 15 patients with functional class III/IV (NYHA) and LVEF inferior to 35%, who received 9.6 ± 2.6 × 10(7) BMMC divided into 10 points over the left ventricular free wall, 7 (46.7%) showed LVEF relative improvement greater than 15%. Those patients were selected for further contractility study. BMMC were collected from iliac bone and isolated with Ficoll-Hypaque. Magnetic resonance imaging was used to measure the systolic thickening of the septal (nontreated) and free wall (treated) before injection and 3 months postoperatively. Mean systolic septal wall thickening increased from 0.46 to 1.23 mm (an absolute 0.77 ± 1.3 mm and relative 167.4% increase) and in the free wall from 1.13 to 1.87 mm (an absolute 0.74 ± 1.5 mm and relative increase of 65.5%). There was no difference in the rate of absolute or relative systolic thickening between the two walls (p = 0.866 and 1.0, respectively), when cells were injected only in the left ventricular free wall. BMMC transplantation in nonischemic dilated cardiomyopathy can improve ventricular function by an overall effect, even in areas that are not directly injected. This finding favors the existence of a diffuse mechanism of action, rather than a local effect, and should be reminded when the pathophysiology of stem cells is considered.