apr. / jun. 2007 - vol. 2 - number 2

Transcrição

APR. / JUN. 2007 - VOL. 2 - NUMBER 2
CARDIOVASCULAR
SCIENCES FORUM
CARDIOVASC SCI FORUM Apr. / Jun. 2007 Vol. 2/ NUMBER 2
EDITORIAL COORDINATION
Otoni M. Gomes (Brazil),
Pascal Dohmen (Germany),
Alfredo I. Fiorelli (Brazil),
José Carlos Dorsa V. Pontes (Brazil).
ASSOCIATED EDITORS
Antônio S. Martins (Brazil),
Carlos Henrique Marques Santos (Brazil),
Danton R. Rocha - Loures (Brasil),
Domingo M. Braile (Brazil),
Domingos Sávio Souza (Sweden),
Elias Kallás (Brazil),
Michael Dashwood (England),
Ricardo Gelpi (Argentina),
Tomas A. Salerno (USA).
Sponsored by: Fundação Cardiovascular São Francisco de Assis - ServCor (MG - Brazil)
Fundação Cardiovascular S. Francisco de Assis / ServCor - Truth is Jesus . St John 14.6
President: Elaine Maria Gomes (OAB)
Scientific Coordination: Otoni M. Gomes
Clinic Director: Eros Silva Gomes
Events Administration: Elton S. Gomes
International Scientific Board
Alberto J. Crottogini (Argentina)
Borut Gersak (Slovenia)
Celina Morales (Argentina)
Daniel Bia (Uruguay)
Domingos S. R. Souza (Sweden)
Eduardo Armentano (Uruguay)
Eduardo R. Migliaro (Uruguay)
Grant Pierce (Canada)
Horacio Cingolani (Argentina)
Ivan Knezevic (Slovenia)
Kisham Narine (Germany)
Kushagra Kataryia (EE.UU)
Manoel Rodrigues (Argentina)
Martin Donato (Argentina)
Martin Villa-Petroff (Argentina)
Michael Dashwood (England)
Naranjan S. Dhalla (Canadá)
Patrícia M. Laguens (Argentina)
Pawan K. Singal (Canadá)
Ricardo Gelpi (Argentina)
Ruben P. Laguens (Argentina)
Tofy Mussivand (Canadá)
Tomas A. Salerno (EE.UU)
Verônica D’Annunzio (Argentina)
Scientific Co-sponsorship by: South American Section of the International Academy of Cardiovascular Sciences
(IACS - SAS), Department of Cardiorespiratory Physiology and Experimental Cardiology of the Brazilian Society
of Cardiology, Department of Experimental Research of the Brazilian Society of Cardiovascular Surgery (DEPEX
- SBCCV), SBCCV Department of Extracorporeal Circulation and Mechanical Assisted Circulation (DECAM SBCCV), SBCCV Departament of Cardiology (SBCCV - DECARDIO, SBCEC - Brazilian Society of Extracorporeal
Circulation.
1
CARDIOVASCULAR SCIENCES FORUM
CARDIOVASCULAR
SCIENCES FORUM
CARDIOVASC SCI FORUM Apr. / Jun. 2007
SCIENTIFIC BOARD - BRAZIL
Adalberto Camim (SP)
Aguinaldo Coelho Silva (MG)
Alan Tonassi Paschoal (RJ)
Alcino Lázaro da Silva (MG)
Alexandre Ciappina Hueb (SP)
Alexandre Kallás (MG)
Antônio A. Ramalho Mota (MG)
Antônio de Pádua Jazbik (RJ)
Antônio S. Martins (SP)
Bruno Botelho Pinheiro (GO)
Carlos Alberto M. Barrozo (RJ)
Carlos Henrique V. Andrade (MG)
Cláudio Pitanga M. Silva (RJ)
Cristina Kallás Hueb (SP)
Danton R. Rocha - Loures (PR)
Domingos J. Moraes (RJ)
Eduardo Keller Saadi (RS)
Elmiro Santos Resende (MG)
Eduardo Sérgio Bastos (RS)
Eros Silva Gomes (MG)
Evandro César V. Osterne (DF)
Fábio B. Jatene (SP)
Francisco Diniz Affonso Costa (PR)
Francisco Gregory Jr. (PR)
Geraldo Martins Ramalho (RJ)
Geraldo Paulino S. Filho (GO)
Gilberto V. Barbosa (RS)
Gladyston Luiz Lima Souto (RJ)
Guaracy F. Teixeira Filho (RS)
Hélio Antônio Fabri (MG)
Hélio P. Magalhães (SP)
Henrique Murad (RJ)
João Bosco Dupin (MG)
João Carlos Ferreira Leal (SP)
João Jackson Duarte (MS)
Jorge Ilha Guimarães (RJ)
José Biscegli (SP)
José Dôndice Filho (MG)
José Francisco Biscegli (SP)
José Maria F. Memória (CE)
José Teles de Mendonça (SE)
Liberato S. Siqueira Souza (MG)
Luiz Antonio Brasil (GO)
Luiz Boro Puig (SP)
Luis Carlos Vieira Matos (DF)
Luiz Fernando Kubrusly (PR)
Luiz Ricardo Goulart (MG)
Marcelo Sávio Martins (RJ)
Marcio Vinicius L. Barros (MG)
Marcílio Faraj (MG)
Mario Coli J. Moraes (RJ)
Mario Oswaldo V. Peredo (MG)
Melchior Luiz Lima (ES)
Messias Antônio Araújo (MG)
Miguel Angel Maluf (SP)
Mônica M. Magalhães (ES)
Neimar Gardenal (MS)
Noedir A. G. Stolf (SP)
Oswaldo Sampaio Neto (DF)
Pablo Maria A. Pomeratzeff (SP)
Paulo Antônio M. Motta (DF)
Paulo de Lara Lavítola (SP)
Paulo Rodrigues da Silva (RJ)
Pedro Rocha Paniagua (DF)
Rafael Haddad (GO)
Ronald Sousa Peixoto (RJ)
Rika Kakuda (SE)
Roberto Hugo Costa Lins (RJ)
Ronaldo Abreu (MG)
Ronaldo D. Fontes (SP)
Ronaldo M. Bueno (SP)
Rubio Bombonato (SC)
Rui Manuel S.S. A. Almeida (PR)
Sérgio Luis da Silva (RJ)
Sérgio Nunes Pereira (RS)
Sinara Silva Cotrim (MG)
Tânia Maria A. Rodrigues (SE)
Victor Murad (ES)
Walter José Gomes (SP)
EDICOR Ltda.
“Truth is Jesus the Word of God”
John 1.1; 14.6; 17.17
2
CARDIOVASCULAR
SCIENCES FORUM
EDITORIAL SECRETARY
Fundação Cardiovascular São Francisco de Assis
R. José do Patrocínio, 522 - Santa Mônica,
Belo Horizonte / MG - Brazil
CEP: 31.525-160 - Tel./ Fax: (55) 31 3439.3004
e-mail: [email protected]
Site: www.servcor.com/cvsf
DATA PROCESSING CENTER
Coordination:
Elton Silva Gomes
Cover:
Elton Silva Gomes, Joselito Pacheco Barbosa
Tiping:
Maristela de Cássia Santos Xavier
Lay-out:
Elton S. Gomes
ADVERTISING
Advertising inquiries should be addressed to
ServCor - Division of Events,
R. José do Patrocínio, 522 - Santa Mônica
Belo Horizonte / MG - Brazil - CEP: 31.525-160
Tel./ Fax: (55) 31 31 3439.3004
[email protected]
Copyrights:
EDICOR Ltda.
“Truth is Jesus the Word of God”
John 1.1; 14.6; 17.17
Home Page: www.servcor.com
3
Cardiovasc Sci Forum Apr. /Jul. 2007 Vol. 2 / Number 2
CONTENTS
EDITORIAL
Page 5
Celular Therapy in Cardiology
(English)
Danton Richlin Rocha-Loures
ORIGINAL ARTICLE
Page 7
Page 13
In Vitro Platelet Activation in Platelet Concentrates after
Leucocyte-Depletion by Filtration Helge Schoenfeld, Aristomenis Exadaktylos, Manfred Muhm, Claudia Spies,
Hartmut Radtke, Pascal M. Dohmen
Post-Conditioning:Preliminary Results of this New Option
in the Treatment of Mesenteric Ischemia and Reperfusion.
(English)
(English/ Portuguese)
Carlos Henrique M. Santos, Otoni M. Gomes, José Carlos Dorsa V. Pontes,
Luciana N. O. Miiji, Marco Aurélio Bispo
SPECIAL ARTICLE
Page 25
The Isolated Perfused Heart According to Langendorff
(History and presence) Modifications and Aplications
H.J. Döring
(English)
CASE REPORT
Page 39
Pappilary Fibroelastoma: A Case Report
(English / Portuguese)
José Oscar R. Brito, Mariana B. Tostelly, Clara Weksler,
Ivan Antonio M. Paula, Flávio Gouveia, Odilon N. Barbosa
Page 45
INSTRUCTIONS FOR AUTHORS
Page 47
UPCOMING MEETINGS
INTENSICÁRDIO III
III BRAZILIAN CONGRESS OF INTENSIVE CARDIOLOGY
XVI FORUM DA SOCIEDADE CENTRO-OESTE DE CIRURGIA CARDIOVASCULAR
XVI FORUM OF THE CENTRO-OESTE SOCIETY OF CARDIOVASCULAR SURGERY
LXII CONGRESSO BRASILEIRO DE CARDIOLOGIA
LXII BRAZILIAN CONGRESS OF CARDIOLOGY
FORUM CIENTÍFICO XVII
SCIENTIFIC FORUM XVII
INTERNATIONAL CONGRESS OF CARDIOVASCULAR SCIENCIES
XXXV CONGRESSO BRASILEIRO DE CIRURGIA CARDIOVASCULAR 2008
XXXV BRAZILIAN CONGRESS OF CARDIOVASCULAR SURGERY 2008
CONGRESSO BRASILEIRO DE CARDIOLOGIA DA FAMÍLIA
BRAZILIAN CONGRESS ON CARDIOLOGY FOR THE FAMILY
SAÚDE SHOW - PLANETA PLUG
4
EDITORIAL
Celular Therapy in Cardiology
Danton R. Rocha Loures
With the birth of Dolly, in 1996, it was
proved that from a single nucleous cell it is possible
to form a multicelular organism with more than
200 types of different cells. The human body is
composed of more than 750 trilions of cells.
The basis of cell knowledge were developed
from studies of the anatomist and physiologist
Theodoro Scchwann in 1839. It was not until the
beginning of the 20 th century that Hans Spermann
and Jacques Loeb, both embryologists when they
began to unravel the secrets of cell division with
experiments in frogs embryos.
In 1998, James Thompson, at University
of Wisconsin and John Geahart at John Hopkins,
isolated the first embryonic and germinative human
cells, derived from reproductive primordial human
embryos cells.
These cells, also called stem cells, are
divided into two types: Embrionic Stem Cells and
Adult Stem Cells.
The embryonic stem cells have the
capacity to generate any cell in the human body
but the placenta. The adult stem cells according to
Christopher Bjorson and cols, from the University
of Washington, have a weaker and short capacity to
generate cells when compare with the embryonic
5
stem cells.
Experimental studies have shown that
embryonic stem cells, as a pluripotent cell, have
the ability “in vitro” to transform itself in any
tissue and organ.
The potential for therapeutics of these cells
is fantastic, but ethical, religious matters and also
the unknown mechanism of multiplication and
differentiation of these cells with the possibility of
developing tumors, have raised more interest on
adult stem cells.
In 1998, Giullina Ferari and cols, from the
Instituto San Rafaelle- Tellethon, have shown the
first report on adult stem cells, and have estabished
that these cells can be found at the bone marrow
and they have the ability to originate scheletal
muscle cells that these cells can migrate from the
bone marrow to the injured muscle.
In recent studies, it was shown that adult
stem cells can also be found in the skin, nervous
system, dental tissue, intestine and many other
organs of human body.
The myocites do not have the ability to
multiply “in vitro”. Apparently there is a resistance to restart the cellular cicle. That is the main reason
to look for a scheletal muscle precursor, the
Autologus Myoblast.
Menasche and cols, in France, were the
first to apply Myoblast in the heart. Five months
after the cell transplantation, there was metabolic
activity and contractility in a previous akinetic
area, increase ejection fraction and improvement
in functional class.
In this same French Group, Scorsin and
cols, latter observed the absence of “gap junctions”
in the membranes of scheletal cells, indicating
loss in the eletromechanical coupling.
Paradoxaly, Chiu and cols, have transplanted
myoblasts in a Acute Myocardial Infarction ( AMI )
after cryoinjury in dogs and the histological analysis
showed muscle tissue identical to the myocardial
and its structures.
Latter publications, like Orlic and Cols,
also in a experimental model of AMI have shown
by immunohytochemical studies, the presence of
49 % of smoth muscle cells and improvement up
to 30 % in ejection fraction, after injection of 2 x
10 5 adult stem cell .
Recently, Piero Anversa has experimentally
demonstrated the capacity of adult stem cells to
differentiate in vascular cells and cells with the
same histological behavior of myocites.
Insner, Asahara and Kocher also have shown
that adult stem cells, mobilized with Granulocyte
Stimulating Colony Factor or cultured, when
injected intravenously in atymic rats after AMI,
promoting a reduction in 30 % in the necrotic
area.
Despite the worldwide interest in the
therapeutic use of adult stem cell into the heart,
there are endless unanswered questions like which
is the best type of stem cell, what is the best route,
how long it will last the therapeutic effect, how
many repetitions of the procedure is possible and
last but not least the legislation about the use of
Human Embryonic Stem Cells, concerning ethical,
religious and therapeutic matters.
Most of these questions shall be answered
in a near future. In Brazil, with the support
from the National Health Department, under the
coordination of Campos de Carvalho, from the
Hospital Laranjeiras do Rio de Janeiro, it has been
developed a multicenter, ramdomized trial with
adult stem cells injection as therapy for Cardiac
Failure, involving 1200 patients divided in 4
groups ( 300 patients each ) respectively in dilated
and ischemic cardiomyopathy, AMI and Chagas
disease.
6
ORIGINAL ARTICLE
In vitro Platelet Activation in Platelet
Concentrates after Leucocyte-Depletion by
Filtration
Short running head: “Activation in filtered platelet concentrates”
Helge Schoenfeld, MD 1, Aristomenis Exadaktylos, MD 2, Manfred Muhm, MD, PhD 3, Claudia
Spies, MD, PhD 1, Hartmut Radtke, MD, PhD 4, Pascal M. Dohmen MD, PhD 5
Abstract: The transfusion of platelet
concentrates is a common therapeutic strategy in
patients undergoing cardiac surgery. The use of
single-donor apheresis platelet concentrates and
filtration of platelet concentrates are standard
procedures to prevent initial or recurrent
transfusion reactions like alloimmunization
in thrombocytopenic patients. We determined
the spontaneous and induced activation of
platelets before and after leucocyte-depletion
by filtration in 20 consecutive single-donor
apheresis platelet concentrates. The filtration
was done within two hours after production of
platelet concentrates. Spontaneous, adenosine
diphosphate-induced and collagen-induced CD62expression were determined by flow cytometry
via CD62-expression on platelet membrane
surface. Furthermore, adenosine diphosphate- and
collagen-induced aggregation were measured by
aggregometry. Before filtration, 5.8% of platelets
in single-donor apheresis platelet concentrates
were activated spontaneously. Filtration led
to a mild but significant increase (p<0.001)
of spontaneous activation of platelets (8.4%).
Measured cytometrically, filtration resulted
in a significantly increased collagen-induced
7
aggregability of platelets, whereas adenosine
diphosphate-induction was unaffected. On
aggregometer, adenosine diphosphate -induction
resulted in a slightly but significantly decreased
aggregation response after filtration (77% vs.
69%, p=0.03). We could not show differences in
collagen-induced aggregation before and after
filtration. In conclusion, due to our in vitro data
we suggest that filtration has only a small impact
on the clinically relevant functional integrity of
single-donor apheresis platelet concentrates.
Key words: platelet concentrates, thrombocytopenia, filtration, activation,
aggregation, CD62-expression, ADP, collagen.
Department of Anesthesiology and Intensive Care Medicine, Charité
– Universitaetsmedizin Berlin, Germany
2
Departments of Anesthesiology and Emergency Medicine, University
Hospital of Bern, Inselspital, Switzerland
3
Department of Anesthesiology and Intensive Care Medicine, St. Vincent Hospital, Vienna, Austria
4
Institute of Transfusion Medicine, Charité – Universitaetsmedizin Berlin, Germany
5
Department of Cardiovascular Surgery, Charité – Universitaetsmedizin
1
Berlin, Germany
Address for correspondence:Helge Schoenfeld, MD. Department of Anesthesiology and Intensive Care Medicine,
Charité
Universitaetsmedizin Berlin, Campus Charité Mitte,
Charitéplatz 1, 10117 Berlin, Germany
Phone: 0049-30-450 531012 / FAX: 0049-30-450 531911
E-mail: [email protected]
Introduction
The use of platelet concentrates (PCs) during and after cardiac surgery is a common therapeutic strategy since patients scheduled for coronary artery bypass grafting often take antiplatelet
drugs like aspirin, tirofiban and clopidogrel still
before emergency cardiac surgery (1). Moreover,
extracorporeal circulation during heart surgery
may lead to activation of platelets (2-4) and a need
for platelet transfusion. The transfusion of single-donor apheresis platelet concentrates (SDPs)
with lower levels of leucocyte contamination and
prestorage leucocyte-depletion in PCs by filtration
are standard procedures and represent strategies
that have been proposed to prevent initial or recurrent transfusion reactions like human leucocyte
antigene (HLA)-alloimmunization in thrombocytopenic patients (5-7).
Recent studies showed that manipulation
on SDPs may lead to activation and an impaired
in vitro aggregation response. In vitro, platelet
aggregation in response to adenosine diphosphate
(ADP) was reduced after prolonged storage.
Collagen is a stronger activator capable of
aggregating partially damaged platelets (8,9). It
has been suggested that spontaneously activated
platelets cause a diminished increase in post
transfusion platelet numbers (10). A number of in
vitro studies examined the functional integrity of
platelets in single donor and random donor platelet
concentrates before and after filtration. Some
authors found no significantly altered aggregation
response of platelets after filtration (11,12). On
the other hand, a significantly increased activation
of filtered platelets was described (13). In vivo,
studies of platelet recovery and bleeding times
after transfusion of filtered platelets showed an
effective function of platelets (14).
However, only platelets that show
activation after physiological stimulation are
useful. The purpose of our study was to determine
the spontaneous and induced activation of freshly
produced SDPs by flow cytometry and induced
platelet aggregation with ADP and collagen before
and after leucocyte-depletion by filtration. These
tests are surrogate measures to evaluate platelet
hemostatic function.
Materials and Methods
We obtained 20 consecutive SDPs
from normal volunteer donors by automated
plateletpheresis (MCS 3p, Haemonetics, Munich,
Germany). Each donor was screened according to
the German guidelines (i.e. they were free from
relevant infectious, hepatic, renal, cardiovascular
or malignant diseases) (15). The donors had no
antiplatelet drug ingestion, such as aspirin, tirofiban,
or clopidogrel, or nonsteroidal antiinflammatory
drugs, in the previous 10 days and no alcohol
ingestion in the previous 24 hours. Every donor
signed a consent that at the time of blood donation
the donor is waiving rights concerning the donated
unit of blood. No changes to our clinical routine
management of either donor or recipient were
made. The volume of PCs was 220-250 ml. All
PCs were leucocyte-depleted within two hours
after its production by filtration (LRF6/10-filter,
Pall, Dreieich, Germany) and stored at 22° C with
constant agitation. Before and immediately after
the filtration we took 3 ml to 5 ml of each unit
under sterile conditions using a sterile docking
system (TSCD, Terumo Eirpoe, Leuven, Belgium).
All our measurements were done within 2 hours
after filtration.
The in vitro studies were performed
before and after platelet filtration procedure. The
mean platelet volume (MPV) and platelet counts
of the PCs were determined electronically (H1
8
Technicon, Tarrytown, NY, USA). For platelet
aggregation studies, platelet samples were diluted
with autologous plasma to a concentration of
250 x 109/l. Aggregation response to ADP with a
working concentration of 18 µM, or collagen with a
working concentration of 1.9 mg/ml was recorded
on an aggregometer (Platelet Aggregation Profiler4, MÖLAB, Hilden, Germany). Aggregation
response was defined as the maximum change in
light transmittance after induction and expressed
as percent of platelet poor plasma. A higher
light transmittance reflects a stronger platelet
aggregation.
Spontaneous as well as ADP- and collagen-induced
platelet CD62 (Becton Dickinson, Heidelberg,
Germany) -expression on platelet membrane
surface were analyzed by flow cytometry (FACscan,
Becton Dickinson, Heidelberg, Germany) as
described previously (8).
Statistical analysis was performed using
Student`s paired t-test. Data are given as mean ±
standard deviation. A difference was considered
significant when p<0.05.
Results
The platelet counts of SDPs were
significantly decreased (p<0.001) after the filtration
procedure (Table 1). There was no difference in
MPV of platelets before and after filtration.
After filtration, platelets showed a significant
(p<0.03) loss in ADP-induced aggregability in
aggregometry (Table 2). In contrast, there was
no difference between freshly obtained filtered
and unfiltered platelets in collagen-induced
aggregation.
Filtration of SDPs resulted in a statistically
significant increase of spontaneously activated
platelets (p<0.001) as evaluated by CD62expression in flow cytometry. ADP-induced
activation demonstrated no difference between
filtered and unfiltered platelets. Collagen-induction
resulted in a significant higher activation response
after filtration procedure (p=0.01) (Table 3).
Tables
Table 1. Mean platelet volume and platelet count
MPV [fl]
Before filtration
After filtration
p value
7.0 ± 0.6
7.0 ± 0.7
0.91
Platelet count [x 109/l]
1.370 ± 167
1.296 ± 160
Mean +- standard deviation, MPV indicates mean platelet volume
< 0.001
Table 2. Aggregation response in aggregometry induced by adenosine diphosphate and collagen
Before filtration
After filtration
p value
ADP-induced [%]
77 ± 19
69 ± 23
0.03
Collagen-induced [%]
98 ± 5
96 ± 10
0.49
Mean +- standard deviation, ADP indicates adenosine diphosphate
9
Table 3. Spontaneous, adenosine diphosphate- and collagen-induced activation of platelets
CD62 expression on membrane surface
Before filtration
After filtration
p value
Spontaneous activation [%]
5.8 ± 2.4
8.4 ± 3.0
<0.001
ADP-induced activation [%]
82.3 ± 5.2
81.9 ± 4.1
0.61
80.1 ± 10.0
0.01
Collagen-induced activation [%]
77.4 ± 10.6
Mean +- standard deviation; ADP indicates adenosine diphosphate
Discussion
We studied the functional integrity of
freshly produced, leucocyte-depleted SDPs by
filtration in vitro. In this study, single donor platelets
were filtered immediately after its production.
It could be shown that the use of prestorage
leucocyte-depletion of blood products reduced
the platelet alloimmunization and refractoriness
(16). A number of highly efficient filters have been
developed which are capable of relatively reliable,
3–4 log reduction in leucocyte contamination of
platelets obtained either by apheresis or prepared
as platelet concentrates. A ‘target level’ of less than
5 x 106 leucocytes per transfusion has generally
been stated, although there are virtually no data
about how many leucocytes suffice to serve as an
immunologic stimulus. Leucocyte filtration is not
without its problems, however. The filters can be
associated with appreciable loss of platelets (up
to 25–35% and sometimes greater when fresh
apheresis platelets are filtered) and sometimes
‘fail’ and permit excessive numbers of leucocytes
to be transfused (17,18). Previous studies testing
integrity, function, activation and aggregation of
leucocyte-depleted platelets differed by the type of
depletion procedures, automated and manual, and
filters used (5-7,11-13,19,20).
In our study, the process of leucocytedepletion by filtration did not significantly
influence the MPV. Weisbach et al. demonstrated
also no alterations of MPV after filtration of PCs
(19). Previous in vitro studies could not show
significant differences of the morphology score of
platelets before and after filtration (20). In contrast,
MPV was increased in activated platelets (21,22).
The loss of platelets by filtration we measured
was also described by previous studies (14,19,23).
The platelet loss is technically not avoidable but
clinically not relevant.
Our aggregation tests indicated that
filtered platelets have a significant lesser extent of
aggregation when exposed to ADP. These results
are contrast to findings of other studies, which could
not show decreased ADP-induced aggregation
responses in filtered platelets (11,12,20,24). Our
findings that collagen-induced aggregation did
not differ between filtered and unfiltered platelets
confirm previous findings (20,24,25), whereas
Weisbach et al. showed an increased collageninduced aggregation response after filtration. The
author explained their findings with a preferred
removal of platelets that were activated during
cytapheresis in filters (19). Additionally, Holme
et al. examined the ristocetin-induced aggregation
response of PCs and could not show significant
differences before and after filtration of PCs (26).
We tested the in vitro function of unfiltered
and filtered platelets using a flow cytometer.
Initially, we could show that the spontaneous
CD62-expression on the membrane surface was
significantly increased in filtered platelets. It is
10
commonly accepted that platelet activation is
associated with secretion of alpha granule and
expression of CD62 (P-selectin, GMP-140) on the
platelet surface (27,28). Other studies found no
significant differences in CD62-expression after
filtration (14,20). Weisbach et al. could show that
platelets of freshly produced PCs had morphological
signs of activation, like degranulation, using an
electron microscope (25). But these characteristics
were identical, before and after filtration (25).
In the present study, we found no difference
between ADP-induced activation before and after
filtration. The filtered platelets showed a significant
increased activation response after collagen
stimulation. We could show in our recent studies
that strongly stressed platelets partially with
diminished ADP-induced aggregability offer no
significant changes in collagen-induced activation
after volume-reduction or cryopreservation of
PCs (9,29) or even have an increased collageninduced aggregability after washing of PCs (8).
Our results are similar to findings of Walkowiak
et al. (30). They examined washed platelets and
showed an increased expression of CD62 after
thrombin stimulation whereas stimulation with
ADP exhibited resistance to ADP in washed
platelets. The findings suggest that collagen and
thrombin are strong platelet agonists being able to
overcome platelet desensitization resulting from
the induced platelet stimulation. ADP, a much
weaker agonist, failed to produce the same degree
of alpha-degranulation.
In summary, filtration of PCs is a standard
procedure to reduce the leucocyte count in PCs
and represents a strategy that has been proposed to
prevent initial or recurrent transfusion reactions.
Filtration was associated with significantly
increased spontaneous platelet activation. The in
vitro function measured by ADP- and collagen11
induced activation was preserved. In vivo, filtered
platelets showed a normal survival and an effective
reduction of the bleeding times (14). In conclusion,
due to our in vitro data we suggest that filtration
has only a small impact on the clinically relevant
functional integrity of SDPs.
Bibliographics References
1.
American Society of Anesthesiologists Task Force on
Perioperative zansfusion and Adjuvant Therapies.
Practice guidelines for perioperative blood transfusion
and adjuvant therapies: an updated report by the
American Society of Anesthesiologists Task Force on
Perioperative Blood Transfusion and Adjuvant Therapies.
Anesthesiology 2006; 105: 198-208.
2.
Borgdorff P, Tangelder GJ. Pump-induced platelet
aggregation with subsequent hypotension: Its mechanism
and prevention with clopidogrel. J Thorac Cardiovasc
Surg 2006; 131: 813-821.
3.
Izuha H, Hattori M, Igari T, Wakamatsu D, Watanabe
M, Yokoyama H. Changes in platelet aggregation
during cardiopulmonary bypass: comparison of poly2-methoxyethylacrylate and heparin as a circuit coating
material. J Artif Organs 2005; 8: 41-46.
4.
Guay J, Ruest P, Lortie L. Cardiopulmonary bypass induces significant platelet activation in children undergoing
open-heart surgery. Eur J Anaesthesiol 2004; 21: 953-956.
5.
Andreu G, Dewailly J, Laberre C, Quarre MC, Bidet ML,
Tardivel R, Devers L, Lam Y, Soreau E, Boccaccio C,
Piard N, Bidet JM, Genetet B, Fauchet A. Prevention of
HLA immunization with leukocyte-poor packed red cells
and platelet concentrates obtained by filtration. Blood
1988; 72: 964-969.
6.
Muylle L. The role of cytokines in blood transfusion
reactions. Blood Rev 1995; 9: 73-83
7.
Wadhwa M, Seghatchian MJ, Dilger P, Sands D, Krailadisiri
P, Contreras M, Thorpe R. Cytokines in WBC-reduced
apheresis PCs during storage: a comparison of two WBCreduction methods. Transfusion 2000; 40: 1118-1126.
8.
Schoenfeld H, Muhm M, Doepfmer U Exadaktylos A,
Radtke H. Platelet activity in washed platelet concentrates.
Anesth Analg 2004; 99:17-20.
9.
Schoenfeld H, Muhm M, Doepfmer UR Kox WJ, Spies
C, Radtke H. The functional integrity of platelets in
volume-reduced platelet concentrates. Anesth Analg
2005; 100:78-81.
10. Rinder HM, Snyder EL. Activation of platelet concentrate
during preparation and storage. Blood Cells 1992; 18:
445-456.
21. Fijnheer R, Pietersz RN, de Korte D, Roos D. Monitoring
of platelet morphology during storage of platelet
concentrates. Transfusion 1989; 29: 36-40.
11.
Bertolini F, Rebulla P, Marangoni F, Sirchia G. Platelet
concentrates stored in synthetic medium after filtration.
Vox Sang 1992; 62: 82-86.
22.
12.
Sweeney JD, Holme S, Stromberg RR, Heaton WA. In
vitro and in vivo effects of prestorage filtration of apheresis platelets. Transfusion 1995; 35: 125-130.
13. Devine DV, Bradley AJ, Maurer E, Levin E, Chahal S,
Serrano K, Gyongyossy-Issa MI. Effects of prestorage
white cell reduction on platelet aggregate formation
and the activation state of platelets and plasma enzyme
systems. Transfusion 1999; 39: 724-734.
14.
Van Marwijk Kooy M, van Prooijen HC, Borghuis L, Moes
M, Akkerman JW. Filtration. A method to prepare white
cell-poor platelet concentrates with optimal preservation
of platelet viability. Transfusion 1990; 30:34-38.
15. Bundesärztekammer. Guidelines for production of
blood and blood components and use of blood
products. Bundesgesundheitsbl Gesundheitsforsch
Gesundheitsschutz 2000; 43: 555-589.
16.
Seftel MD, Growe GH, Petraszko T, Benny WB, Le A,
Lee CY, Spinelli JJ, Sutherland HJ, Tsang P, Hogge DE.
Universal prestorage leukoreduction in Canada decreases
platelet alloimmunization and refractoriness. Blood 2004;
103: 333-339.
17. Schiffer CA. Diagnosis and management of refractoriness
to platelet transfusion. Blood Rev 2001; 15: 175-180.
18. Kao KJ, Mickel M, Braine HG, Davis K, Enright H,
Gernsheimer T, Gillespie MJ, Kickler TS, Lee EJ,
McCullough JJ, et al. White cell reduction in platelet
concentrates and packed red cells by filtration: a
multicenter clinical trial. The Trap Study Group.
Transfusion 1995; 35: 13-19.
19. Weisbach V, Putzo A, Zingsem J, Riewald M, Zimmermann
R, Eckstein R, Riess H. Leukocyte depletion and storage
of single-donor platelet concentrates. Vox Sang 1997; 72:
20-25.
20.
Boomgaard MN, Joustra-Dijkhuis AM, Gouwerok CW,
Steneker I, Reesink HW, Loos JA, Pietersz RN, de Korte
D. In vitro evaluation of platelet concentrates, prepared
from pooled buffy coats, stored for 8 days after filtration.
Transfusion 1994; 34: 311-316.
Jagroop IA, Clatworthy I, Lewin J Mikhailidis DP.
Shape change in human platelets: measurements with
channelyzer and visualisation by electron microscopy.
Platelets 2000; 11: 28-32.
23. Snyder EL, DePalma L, Napychank P. Use of polyester
filters for the preparation of leukocyte-poor platelet
concentrates. Vox Sang 1988; 54: 21-23.
24.
Bock M, Heim MU, Weindler R, Bilas A, Greither L, Salat
C, Mempel W. White cell depletion of single-donor platelet preparations by a new adsorption filter. Transfusion
1991; 31: 333-334.
25. Weisbach V, Riess H, Gindi N, Zeiler T, Riewald M,
Zingsem J, Eckstein R. Changes in thrombocytapheresis
concentrations caused by leukocyte depletion with
polyester filters. Infusionsther Transfusionsmed 1992;
19: 146-148.
26. Holme S, Snyder E, Heaton A, Keegan T, Napychank P.
In vitro and in vivo evaluation of cotton wool filtration
of platelet concentrates obtained by automated and manual apheresis. Transfusion 1992; 32: 328-333.
27. McEver RP, Martin MN. A monoclonal antibody to a
membrane glycoprotein binds only to activated platelets.
J Biol Chem 1984; 259: 9799-9804.
28.
George JN, Pickett EB, Saucerman S, McEver RP, Kunicki TJ, Kieffer N, Newman PJ. Platelet surface glycoproteins. Studies on resting and activated platelets and
platelet membrane microparticles in normal subjects, and
observations in patients during adult respiratory distress
syndrome and cardiac surgery. J Clin Invest 1986; 78:
340-348.
29.
Schoenfeld H, Griffin M, Muhm M, Doepfmer UR,
Von Heymann C, Goktas O, Exadaktylos A, Radtke
H. Cryopreservation of platelets at the end of their
conventional shelf life leads to severely impaired in vitro
function. Cardiovasc J S Afr 2006; 17: 125-129.
30. Walkowiak B, Kralisz U, Michalec L Majewska E, Koziolkiewicz W, Ligocka A, Cierniewski CS. Comparison of
platelet aggregability and P-selectin surface expression on
platelets isolated by different methods. Thromb Res 2000;
99: 495-502.
12
Post-Conditioning:Preliminary Results of this
New Option in the Treatment of Mesenteric
Ischemia and Reperfusion.
Carlos Henrique Marques dos Santos, Otoni Moreira Gomes,
José Carlos Dorsa Vieira Pontes, Luciana Nakao Odashiro Miiji,
Marco Aurélio Bispo
Abstract: Preconditioning has the capacity of
minimizing lesions for ischemia and reperfusion
process.
Postconditioning
was
described
presenting similar results in myocardic and spinal
cord ischemia and reperfusion, but there are no
utilization reports of this method in mesenteric
ischemia. Objective: Evaluate the preconditioning
and postconditioning capacity to decrease
intestinal mucosa lesions in rats submitted to
mesenteric ischemia and reperfusion process.
Method: Nine rats were studied: Group A, 3 rats
submitted to mesenteric ischemia (30 minutes)
and reperfusion (60 minutes); Group B (3 rats),
mesenteric ischemia and reperfusion preceded by
the preconditioning for three cycles of ischemia
and reperfusion by two minutes duration; Group C
(3 rats), mesenteric ischemia and reperfusion and,
preceding the beginning of reperfusion, it were
submitted to postconditioning for three reperfusion
and ischemia cycles by two minutes duration.
At least, a segment of ileum was parched for
histological analysis. We evaluated the results by
CHIU’s Score(14). Results: According to CHIU’s
Score(14) the results were: In the group A, 3,3;
Groups B and C, 1. Conclusion: These preliminary
results appear for a possible equivalence in the
13
capacity between PrC and PoC of minimizing the
mesenteric ischemia and reperfusion lesions in
rats, having need of evaluation of larger number
of animals for its proof.
Descriptors: post-conditioning, ischemic preconditioning,
physiopathology, ischemia, reperfusion, mesenteric arteries
Mato Grosso do Sul Federal University, Department of
Surgical Clinic and Cardiovascular Foundation São Francisco de Assis, Belo Horizonte-MG.
Rua Aluízio de Azevedo, 606 - Jardim São Bento - Campo
Grande - Mato Grosso do Sul - Brazil – CEP: 79004050.
E-mail: [email protected]
Introduction
In 1986 two publications brought a great
advance for ischemia and reperfusion syndrome
treatment. The first of them were Parks and Granger
(1), demonstrating that reperfusion is more harmful
than ischemia separately, fact until then unknown,
promoting a great change in the valid concepts
and giving beginning the countless studies that
came to elucidate ischemia and reperfusion
physiopathology. The second great importance
publication was the one of Murry, Jennings and
Reimer (2) that brought the concept from the
pre-conditioning (PrC) like form of minimizing
ischemia and reperfusion lesions. These authors
also described the occlusion coronary short
periods beneficial effect followed by reperfusion
short periods, before if initiate ischemia phase
properly told, observing reduction in the ischemic
miocardic lesion in dogs. This protective effect
also has described been more recently in other
organs like intestines, kidneys, liver, brain, spinal
cord, retina and skeletal muscle (3).
However, there are situations in which ischemia is identified already when the lesions are installed,
not existing opportunity for use of the pre-conditioning.
In 2003, Zhao, Corvera, Halkos et al.(4)
They presented the concept of the post-conditioning
(PoC), that consists in the accomplishment of one
or more short cycles of reperfusion followed by one
or more short cycles of ischemia, immediately after
the ischemia phase and before if give by permanent
reperfusion. These authors demonstrated that PrC
was as effective as PoC in the reperfusion lesions
prevention.
This study carried to other publications that
of similar form have been demonstrating PoC’s
capacity of preventing the ischemia and reperfusion
lesions, as much as PrC (5).
Shorts and repeated reperfusion periods held
in PoC are related to malondhyaldeide low levels,
suggesting production of lipidic peroxidation and
reduction attenuation of super oxide anions (4). PoC
can limit the oxygen offer, that acts like production
substratum of Reactive oxygen species (ROS), and, this
way, attenuate the cellular lesion of reperfusion. Thus, a
decrease in ROS’s Production can reduce the endothelial
activation and the adhesion of polymorphonuclear.
Moreover, PoC also can act of mechanical
form during reperfusion. The pressure increase
in the vase wall that occurs of abrupt way in the
reperfusion can cause tissue damage and edema
by the endothelial stretching and increase of the
liquid overfilling for the tissue parenchyma (6). A
pressure gradual restoration on the endothelium in
the reperfusion reduces the microvascular offense,
the infarct size and the tissue edema(7). PoC can
act in the modulation of the hydrodynamic forces
during reperfusion and thus decrease the edema
and the tissue damage.
Among the several performance possible
forms of PoC in the protection against the tissue
lesions by ischemia and reperfusion are the oxidative
stress reduction and of neutrophils accumulation, the
endothelial dysfunction and the apoptosis attenuation
and of the calcium mitochondrial accumulation(8). In
PoC still occurs the activation of the potassium-ATP
mitochondrial channels, inhibiting the permeability
mitochondrial increase, and, consequently, preventing
the peroxide production and glutathione decrease(9).
Sun, Wang, Kerendi et al.(10) also believe
that the protection offered by PoC is due to the
decrease of ROS production, of the peroxidation
lipidic reduction and of the intracellular and
mitochondrial accumulation of the calcium. These
authors demonstrated that in vitro, even in the
absence of inflammatory cells, occurs production
increase of ROS during reoxigenation and that this
production is smaller when it accomplishes PoC.
Staat, Rioufol, Piot et al.(11) already
demonstrated PoC’s beneficial effects in human
beings, accomplishing intermittent reperfusion
during angioplasty in patients with acute infarct of
miocardium, having observed miocardic offense
reduction. Also Loukogeorgakis, Panagiotidou,
Yellon et al.(12) accomplished experimental study
in human beings in which they provoked transitory
ischemia in the superior member followed by
reperfusion, observing PoC’s protective effect.
These authors also demonstrated that the reperfusion first
moments are fundamental for the endothelial protection.
In the miocardic ischemia and reperfusion is
14
already very established that the protection offered
by PoC is not accidental, result of an unique study, or
exclusive of an experimental model or species animal,
once it has been being demonstrated its effectiveness
in cardiomyocites isolated, isolated hearts, in hearts in
situ of mice, mice, rabbits, pigs and dogs(5). Cardiac
ischemia and of the spinal cord(13) were already
cared for effective form by this method.
This way, it seems very promising PoC’s
use in the lesions treatment for ischemia and
reperfusion, mostly in that clinical situations
in which ischemia is already installed when of
the diagnosis, not existing opportunity of PrC.
Considering that still there are no studies analyzing
PoC’s effects in the intestinal ischemia and
reperfusion, the goal of this study is to present the
preliminary results of an experimental study in rats
submitted at mesenteric ischemia and reperfusion.
Objective
The objective of this study is to avaliate
the preliminary results of an experimental study
analyzing comparatively the PrC and PoC in rats
submitted at mesenteric ischemia and reperfusion.
Materials and Methods
The study had previous approval of the
Committee of Ethics in Animal Experimentation of
the of the Mato Grosso do Sul Federal University.
Nine rats were studied (Rattus norvegicus
albinus, Rodentia, Mammalia), of the lineage
Wistar, males, adults, with weight varying from
270 to 350 grams, with average of 305 grams,
coming of the Bioterium of the Mato Grosso do
Sul Federal University.
The animals were distributed in the
following groups (figure 1):
- A) Ischemia and Reperfusion: three rats
submitted at intestinal ischemia during 30 minutes
by occlusion of the mesenteric cranial artery
following by reperfusion of 60 minutes. - B) Preconditioning: three rats submitted
to the ischemia procedure during 30 minutes by
occlusion of the mesenteric cranial artery and
reperfusion during 60 minutes. The ischemia
phase was preceded by three ischemia cycles (two
minutes each) inserted with three reperfusion
cycles (two minutes each). - C) Post-conditioning: three rats submitted
to the ischemia procedure during 30 minutes by
occlusion of the mesenteric cranial artery and
reperfusion during 60 minutes. Between the
ischemia and the reperfusion three reperfusion
cycles were accomplished (two minutes each)
inserted with three ischemia cycles (two minutes
each).
Figure 1. Schematic demonstration of the ischemia and
reperfusion periods and in the
groups A, B and C (the numbers correspond at the time in
minutes).
15
The animals were anesthetized with intraperitoneal injection of solution of 2:1 of Cetamin®
50mg/ml, and Xilazin® 20mg/ml, respectively, in
the dose of (0,1ml/100g).
It was done medium longitudinal laparotomy of approximately four centimeters, identification and dissection of the cranial mesenteric
artery, witch was occluded by vascular clamp by
different periods in agreement with the belonging
group (illustration 1). Completed the experiment,
it was taken out a segment of approximately one
centimeter of the ileum, five centimeters proximal
to the cecum and put in formaldehyde solution to
10% for subsequent histological analysis. The animals were submitted the euthanasia by anesthetic
plan increased.
The laminas were prepared by HE and
analyzed to the optical microscopy and they were
classified in agreement with the degree of tissue
lesion according to CHIU’s Score(14): - 0: mucous membrane without alterations. - 1: vilosithys well constituted, without cellular break or lawsuit, however, with formation of
the Grunhagen space. - 2: presence of cellular break, formation of
the Grunhagen space and spacing increased
among the vilosithys. - 3: destruction of the free portion of the
vilosithys, presence of capillary extensive and
inflammatory cells.
- 4: structural destruction of the vilosithys,
just having sketch of some, formed by
inflammatory cells and necrotic material, with
hemorrhage and basal glandular ulceration. - 5: destruction of every mucous tunic, no more
being observed any glandular structure, but
just amorphous material deposited on the
screen submucosa.
Results
They were found the following results
(Graphic 1): in the group A two animals with lesion
degree 3 and one with lesion degree 4 (average
3,3); in the groups B and C all the animals had
lesion degree 1 (average 1).
Graphic 1. Graphic comparative of the histological analysis of the degrees of lesion of the intestinal mucous membranes
of the rats of the groups A, B and C according to the CHIU’s Score(14).
16
Discussion
Along the last 20 years many forms
of treatments for the mesenteric ischemia and
reperfusion have been tested without great
success(15,16). With the coming of PrC a lot was
advanced in the treatment of the ischemia and
reperfusion syndrome, however, specifically in
relation to the mesenteric ischemia and reperfusion,
its use is harmed by the fact of in the great majority
of the cases the ischemia already to be installed
in the moment of the diagnosis(17). This is the
primordial factor to evaluate the effectiveness of
PoC, because, confirmed its effectiveness also in
the mesenteric ischemia, its clinical applicability
could be very important. In spite of that, no
there are still studies evaluating its action in the
mesenteric ischemia and reperfusion.
Zhao et al.(4) were the first ones to tell
the similarity of the results of PrC and PoC in the
prevention of the current lesions of the ischemia and
reperfusion process. The study was accomplished
in dogs, taking place occlusion of the left anterior
descending artery by 60 minutes and reperfusion
by three hours. PrC was made by an ischemia cycle
with duration of five minutes and reperfusion by
ten minutes. PoC consisted of three reperfusion
and ischemia cycles with duration of 30 seconds
each. The infarct area was similar in the PrC and
PoC groups and significantly smaller than in the
control group.
Most of the studies that analyzed the effects
of PoC was accomplished in the miocardic ischemia
and reperfusion. Donato, D’Annunzio, Sabán et
al.(19) compared PrC and PoC in isolated hearts of
rabbits, accomplishing ischemia and reperfusion by
30 minutes. PrC was accomplished by an ischemia
and reperfusion cycle of five minutes each, and,
PoC by two reperfusion and ischemia cycles of 30
seconds each. They concluded that PoC reduces the
17
size of the infarct in the same magnitude that PrC,
without modifying the dysfunction ventricular.
These results were obtained also by
Darling, Jiang, Maynard et al.(20) in experimental
study evaluating infarct in rabbit’s hearts. PoC was
capable to minimize the infarct area in comparison
with the control group, taking place four reperfusion
and ischemia cycles with duration of 30 seconds
before feeling the reperfusion phase.
Tang, Sato, Tiwari et al.(21) demonstrated
that PoC is as effective as PrC in the prevention
of the current lesions of the coronary ischemia
and reperfusion process in rats, since the time of
ischemia doesn’t pass 45 minutes. After this period,
according to these authors, PrC presents better
results as for the decrease of the infarct area.
The mechanism of protection by PoC in the
ischemia and reperfusion process isn’t still totally
clear, but its exist evidences that PoC can be related
to a significant decrease in the malondialdheyde
levels and related to the lipidic peroxidation
products. These observations suggest a decrease in
the ROS production and smaller offense mediated
by oxidizers with PoC(4).
In this study average of cellular lesion
3,3 score was observed in the control group, in
contrast with average 1 score in the PrC and PoC
groups, suggesting a possible equivalence among
both techniques against the mesenteric ischemia
and reperfusion lesion, although with number still
reduced of animals. These results appear for the
better evaluation need in these studies for real
proof of the effectiveness of PoC in the mesenteric
ischemia and reperfusion.
Conclusion
These preliminary results appear for a
possible equivalence in the capacity between PrC
and PoC of minimizing the mesenteric ischemia
and reperfusion lesions in rats, having need of
evaluation of larger number of animals for its
proof.
Physiol Heart Circ Physiol 2005; 288: 1900-1908.
11. Staat P, Rioufol G, Piot C, Cottin Y, Cung TT, L’Huillier I,
Aupetit JF, Bonnefoy E, Finet G, Andre-Fouet X, Ovize
M. Postconditioning the human heart. Circulation 2005;
112: 2143-2148.
12. Loukogeorgakis SP, Panagiotidou AT, Yellon DM, Deanfield JE, McAllister RJ. Postconditioning protects against
endothelial ischemia-reperfusion injury in the human forearm. Circulation 2006; 113: 1015-1019.
1.
Parks DA, Granger DN. Contributions of ischemia and reperfusion to mucosal lesion formation. Am J Physiol 1986;
250: 749-753.
2.
Murry CE, Jennings RB, Reimer KA. Preconditioning
with ischemia: a delay of lethal cell injury in ischemic
myocardium. Circulation 1986; 74:1124-1136.
3.
Hotter G, Closa D, Prados M, Fernandez-Cruz L, Prats
N, Gelpi E, Roselló-Catafau J. Intestinal preconditioning
is mediated by a transient increase in nitric oxide. Biochem
Biophys Res Commun 1996; 222(1):27-32.
4.
Zhao ZQ, Corvera JS, Halkos ME, Kerendi F, Wang NP,
Guyton RA, Vinten-Johansen J. Inhibition of myocardial
injury by ischemic postconditioning during reperfusion:
comparison with ischemic preconditioning. Am J Physiol
Heart Circ Physiol 2003; 285:579-588.
5.
Schipke JD, Halkos ME, Kerendi F, Gams E, VintenJohansen J. Postconditioning: a brief review. Arch Med Sci
2006; 2: 137-145.
6.
Halldorsson AO, Kronon MT, Allen BS, Rahman S, Wang
T. Lowering reperfusion pressure reduces the injury after
pulmonary ischemia. Ann Thorac Surg 2000; 69: 198-204.
17.
7.
Sato H, Jordan JE, Zhao ZQ, Sarvotham SS, VintenJohansen J. Gradual reperfusion reduces infarct size
and endothelial injury but augments neutrophil
accumulation. Ann Thorac Surg 1997; 64: 1099-1107.
8.
Kerendi F, Kin H, Halkos ME, Jiang R, Zatta AJ, Zhao
ZQ, GuytON RA, Vinten-Johansen J. Remote postconditioning. Brief renal ischemia and reperfusion applied
before coronary artery reperfusion reduces myocardial infarct size via endogenous activation of adenosine receptors. Basic Res Cardiol 2005; 100: 404-412.
18. Zhao ZQ, Corvera JS, Halkos ME, Kerendi F, Wang NP,
9.
Couvreur N, Lucats L, Tissier R, Bize A, Berdeaux A,
Ghaleh B. Differential effects of postconditioning on
myocardial stunning and infarction: a study in conscious
dogs and anesthetized rabbits. Am J Physiol Heart Circ
Physiol 2006; 291: 1345-1350.
10.
Sun HY, Wang NP, Kerendi F, Halkos M, KIN H,
Guyton RA, Vinten-Johansen J, ZHAO ZQ. Hypoxic
postconditioning reduces cardiomyocyte loss by inhibiting
ROS generation and intracellular Ca2+ overload. Am J
13. Huang H, Zhang L, Wang Y, Yao J, Weng H, Wu H, Chen
Z, LIU J. Effect of ischemic post-conditioning on spinal
cord ischemic-reperfusion injury in rabbits. Can J Anaesth 2007; 54: 42-48.
14. Chiu CJ, McArdle AH, Brown R, Scott HJ, Gurd FN.
Intestinal Mucosal Lesion in Low-Flow States. Arch Surg
1970; 101: 478-483.
15. Santos CHM, Gomes OM, Pontes JCDV, Miiji LNO, Higa
EI. Uso do propofol (2,6 diisopropilfenol) como inibidor
da lesão tecidual na isquemia e reperfusão mesentérica.
Estudo experimental em ratos. Acta Cir Bras 2003; 18(4):
347-354.
16. Santos CHM, Gomes OM, Pontes JCDV. Terapêutica
medicamentosa na isquemia e reperfusão mesentérica:
revisão da literatura. Rev Bras Coloproctol 2006; 26(1):
28-33.
Santos CHM. Evolution and Challenges in the Phisiopatology of the Ischemia and Reperfusion. Cardiovasc Sciences Forum 2006; 1(3): 6-8.
19. Donato M, D’Annunzio V, Sabán M, Flor L, Gelpi RJ.
Poscondicionamiento: un nuevo mecanismo protector.
Su comparación con el precondicionamiento en el infarto
experimental. Rev Arg Cardiol 2004; 72(4): 258-262.
20. Darling CE, Jiang R, Maynard M, Whittaker P, Vinten-Johansen J, Przyklenk K. “Postconditioning” via Stuttering
Reperfusion Limits Myocardial Infarct Size in Rabbit
Hearts: Role of ERK 1/2. Am J Physiol Heart Circ Physiol 2005; 289: 618-626.
21. Tang XL, Sato H, Tiwari S, Dawn B, Bi Q, LI Q, Shirk
G, Bolli R. Cardioprotection by postconditioning in
conscious rats is limited to coronary occlusions < 45 min.
Am J Physiol Heart Circ Physiol 2006; 291: 2308-2317.
18
Pós-Condicionamento Isquêmico: Resultados
Preliminares desta Nova Opção no Tratamento da
Síndrome de Isquemia e Reperfusão Mesentérica
Carlos Henrique M. Santos, Otoni M. Gomes, José Carlos
Dorsa V. Pontes, Luciana N. O. Miiji, Marco Aurélio Bispo
Post-Conditioning:Preliminary Results of this New Option in the
Treatment of Mesenteric Ischemia and Reperfusion.
Carlos Henrique M. Santos, Otoni M. Gomes, José Carlos Dorsa V. Pontes,
Luciana N. O. Miiji, Marco Aurélio Bispo
ABSTRACT: Preconditioning has the capacity of
minimizing lesions for ischemia and reperfusion process. Postconditioning was described presenting similar results in myocardic and spinal cord ischemia and
reperfusion, but there are no utilization reports of this
method in mesenteric ischemia. Objective: Evaluate
the preconditioning and postconditioning capacity to
decrease intestinal mucosa lesions in rats submitted to
mesenteric ischemia and reperfusion process.Method: Nine rats were studied: Group A, 3 rats submitted
to mesenteric ischemia (30 minutes) and reperfusion
(60 minutes); Group B (3 rats), mesenteric ischemia
and reperfusion preceded by the preconditioning for
three cycles of ischemia and reperfusion by two minutes duration; Group C (3 rats), mesenteric ischemia
and reperfusion and, preceding the beginning of reperfusion, it were submitted to postconditioning for three
reperfusion and ischemia cycles by two minutes duration. At least, a segment of ileum was parched for histological analysis. We evaluated the results by CHIU’s
Score (14). Results: According to CHIU’s Score (14)
the results were: In the group A, 3,3; Groups B and C,
1. Conclusion: These preliminary results appear for
a possible equivalence in the capacity between PrC
and PoC of minimizing the mesenteric ischemia and
reperfusion lesions in rats, having need of evaluation
19
of larger number of animals for its proof.
DESCRITORES: pós-condicionamento isquêmico, pré-condicionamento isquêmico, fisiopatologia, isquemia, reperfusão, artérias mesentéricas.
Universidade Federal de Mato Grosso do Sul
– Departamento de Clínica Cirúrgica e Fundação
Cardiovascular São Francisco de Assis. Rua
Aluízio de Azevedo, 606 – Jardim São Bento
– Campo Grande – Mato Grosso do Sul – Brasil
– CEP: 79004050. E-mail: chmarques@terra.
com.br
Introdução
Em 1986 duas publicações trouxeram um
grande avanço para o tratamento da síndrome de isquemia e reperfusão. A primeira delas foi a de Parks
& Granger(1), demonstrando que a reperfusão é mais
lesiva do que a isquemia isoladamente, fato até então desconhecido, promovendo uma grande mudança
nos conceitos vigentes e dando início a inúmeros estudos que vieram elucidar a fisiopatologia da isquemia e reperfusão. A segunda publicação de grande
importância foi a de Murry, Jennings e Reimer(2) que
trouxeram o conceito do pré-condicionamento isquêmico como forma de minimizar as lesões de isquemia
e reperfusão. Estes autores descreveram o efeito benéfico de curtos períodos de oclusão coronária seCARDIOVASCULAR SCIENCES FORUM
guidos também por curtos períodos de reperfusão,
antes de se iniciar a fase de isquemia propriamente
dita, observando redução na lesão miocárdica isquêmica em cães. Este efeito protetor tem também
sido descrito mais recentemente em outros órgãos
como intestinos, rins, fígado, cérebro, medula espinhal, retina e músculo esquelético(3).
Entretanto, existem situações em que a
isquemia é identificada já quando as lesões estão
instaladas, não havendo oportunidade para emprego do pré-condicionamento.
Em 2003, Zhao, Corvera, Halkos et al.(4)
apresentaram o conceito do pós-condicionamento
isquêmico, que consiste na realização de um ou
mais ciclos curtos de reperfusão seguidos por um
ou mais ciclos curtos de isquemia, imediatamente
após a fase de isquemia e antes de se dar a reperfusão permanente. Estes autores demonstraram que
o PrCI foi tão eficaz quanto o PoCI na prevenção
das lesões de reperfusão.
Este estudo levou a outros trabalhos que de
forma semelhante têm demonstrado a capacidade
do PoCI de prevenir as lesões de isquemia e reperfusão, tanto quanto o PrCI(5).
Curtos e repetidos períodos de reperfusão
realizados no PoCI estão relacionados a baixos
níveis de malondialdeído, sugerindo atenuação
da peroxidação lipídica e redução da produção de
ânions superóxido(4). O PoCI pode limitar a oferta de oxigênio, que atua como substrato da produção de ERTO, e, assim, atenuar a lesão celular de
reperfusão. Desta forma, uma diminuição na produção de ERTO pode reduzir a ativação endotelial
e a adesão de polimorfonucleares.
Além disso, o PoCI pode também agir de
forma mecânica durante a reperfusão. O aumento
da pressão na parede do vaso que ocorre de maneira
abrupta na reperfusão pode causar injúria tecidual
e edema pelo estiramento endotelial e aumento do
extravasamento líquido para o parênquima tecidual(6). Uma gradual restauração da pressão sobre o
endotélio na reperfusão reduz a injúria microvascular, o tamanho do infarto e o edema tecidual(7).
O PoCI pode agir na modulação das forças hidrodinâmicas durante a reperfusão e assim diminuir o
edema e a injúria endotelial.
Dentre as várias possíveis formas de atuação do PoCI na proteção contra as lesões teciduais por isquemia e reperfusão estão a redução do
estresse oxidativo e do acúmulo de neutrófilos, a
disfunção endotelial e a atenuação da apoptose e
do acúmulo de cálcio mitocondrial(8). No PoCI
ocorre ainda a ativação dos canais de potássioATP mitocondriais, inibindo o aumento de permeabilidade mitocondrial, e, conseqüentemente,
prevenindo a produção de peróxido e a depleção
de glutatião(9).
Sun, Wang, Kerendi et al.(10) também
acreditam que a proteção oferecida pelo PoCI é
decorrente da diminuição da produção das ERTO,
da redução da peroxidação lipídica e do acúmulo
intracelular e mitocondrial de cálcio. Estes autores
demonstraram que in vitro, mesmo na ausência de
células inflamatórias, ocorre aumento da produção
de ERTO durante a reoxigenação e que esta produção é menor quando se realiza o PoCI.
Staat, Rioufol, Piot et al.(11) já demonstraram os efeitos benéficos do PoCI em seres humanos, realizando reperfusão intermitente durante
angioplastia em pacientes com infarto agudo do
miocárdio, tendo observado redução da injúria
miocárdica. Também LOUKOGEORGAKIS, Panagiotidou, Yellon et al.(12) realizaram estudo experimental em seres humanos em que provocavam
isquemia transitória no membro superior seguida
de reperfusão, observando efeito protetor do PoCI.
Estes autores também demonstraram que os primeiros momentos da reperfusão são fundamentais
20
para a proteção endotelial.
Na isquemia e reperfusão miocárdica já
está bem estabelecido que a proteção oferecida
pelo PoCI não é acidental, resultado de um único
estudo, ou exclusiva de um modelo experimental
ou espécie animal, uma vez que tem sido demonstrada sua eficácia em cardiomiócitos isolados, corações isolados, em corações in situ de ratos, camundongos, coelhos, porcos e cães(5). Isquemia
cardíaca e da medula espinhal(13) já foram tratadas de forma eficaz por este método.
Assim, parece bastante promissor o emprego do PoCI no tratamento das lesões por isquemia
e reperfusão, principalmente naquelas situações clínicas em que a isquemia já está instalada quando do
diagnóstico, não havendo oportunidade de emprego
do PrCI. Entretanto, novos estudos precisam ser realizados para possibilitar seu uso em seres humanos.
Objetivo
O objetivo deste estudo é avaliar de forma
preliminar o efeito protetor do pré e pós-condicionamento isquêmico na mucosa intestinal de ratos
submetidos a isquemia e reperfusão mesentérica.
Método
O estudo obteve aprovação prévia do Comitê de Ética da Universidade Federal de Mato
Grosso do Sul.
Foram estudados nove ratos (Rattus norvegicus albinus, Rodentia, Mammalia), da linhagem Wistar, machos, adultos, com peso variando
de 270 a 350 gramas, com média de 305 gramas,
provenientes do Biotério da Universidade Federal
de Mato Grosso do Sul.
Os animais foram distribuídos nos seguintes grupos (figura 1):
- Grupo A – Isquemia e Reperfusão: três ratos submetidos a isquemia intestinal por 30 minutos
por oclusão da artéria mesentérica cranial com clampe vascular, seguida por reperfusão de 60 minutos.
- Grupo B – Pré-condicionamento isquêmico: três ratos submetidos ao procedimento de
isquemia durante 30 minutos por oclusão da artéria mesentérica cranial com clampe vascular e
reperfusão por 60 minutos. A fase de isquemia foi
precedida por três ciclos de isquemia (dois minutos cada) intercalados com três ciclos de reperfusão (dois minutos cada).
- Grupo C – Pós-condicionamento isquêmico: três ratos submetidos ao procedimento de
isquemia durante 30 minutos por oclusão da artéria mesentérica cranial com clampe vascular e
reperfusão por 60 minutos. Entre a isquemia e a
reperfusão foram realizados três ciclos de reperfusão (dois minutos cada) intercalados com três
ciclos de isquemia (dois minutos cada).
Figura 1. Demonstração esquemática
dos períodos de isquemia e reperfusão
nos grupos A, B e C (os números correspondem ao tempo em minutos).
21
Os animais foram anestesiados com injeção intraperitoneal de solução de 2:1 de Cloridrato
de Cetamina (Cetamin®), 50mg/ml, e Cloridrato
de Xilazina (Xilazin®), 20mg/ml, respectivamente, na dose de (0,1ml/100g).
Foi realizada laparotomia longitudinal mediana de aproximadamente quatro centímetros,
exteriorização do intestino delgado, identificação
e dissecção da artéria mesentérica cranial, a qual
foi ocluída por diferentes períodos de acordo com
o grupo pertencente (figura 1). Após completado
o procedimento, foi ressecado um segmento de
aproximadamente um centímetro do íleo, cinco
centímetros proximal à transição ileocecal para
posterior análise histológica de acordo com a classificação de Chiu, McArdle, Brown et al. (14):
• Grau 0: mucosa sem alterações.
• Grau 1: vilosidades bem constituídas, sem
lise celular ou processo inflamatório, porém, com
formação do espaço subepitelial de Grunhagen.
• Grau 2: presença de lises celulares, formação do espaço subepitelial de Grunhagen e espaçamento aumentado entre as vilosidades.
• Grau 3: destruição da porção livre das
vilosidades, presença de capilares dilatados e de
células inflamatórias.
• Grau 4: destruição estrutural das vilosidades, havendo apenas esboço de algumas, formadas
por células inflamatórias e material necrótico, com
hemorragia e ulceração glandular basal.
• Grau 5: destruição de toda túnica mucosa, não mais sendo observado qualquer estrutura
glandular, mas apenas material amorfo depositado
sobre a tela submucosa.
Resultados
Obtiveram-se os seguintes resultados (gráfico 1): no grupo A, dois animais com lesão grau 3 e
um com lesão grau 4 (média 3,3); nos grupos B e C
todos os animais obtiveram lesão grau 1 (média 1).
Gráfico 1. Gráfico comparativo da análise histológica dos graus de lesão das mucosas intestinais dos ratos dos
grupos A, B e C segundo a classificação de CHIU et al. (14).
22
Discussão
Nos últimos 20 anos muitas formas de tratamento para a isquemia e reperfusão foram testadas
sem grande sucesso(15,16). Com o advento do PrCI
houve um grande avanço no tratamento da Síndrome de Isquemia e Reperfusão, entretanto, especificamente em relação à isquemia e reperfusão mesentérica, seu uso é limitado pelo fato de na maioria
dos casos a isquemia já está instalada no momento
do diagnóstico(17). Este é o principal motivo que
valoriza o PoCI, porque, confirmada sua eficácia
também na isquemia e reperfusão mesentérica, sua
aplicabilidade clínica poderia ser de grande importância. Apesar disso, não há ainda estudos avaliando sua ação na isquemia e reperfusão mesentérica.
Zhao et al.(4) foram os primeiros a relatar
a semelhança dos resultados do PrCI e do PoCI na
prevenção das lesões decorrentes do processo de
isquemia e reperfusão. O estudo foi realizado em
cães, realizando-se oclusão da artéria descendente anterior esquerda por 60 minutos e reperfusão
por três horas. O PrCI foi efetuado por um ciclo
de isquemia com duração de cinco minutos e reperfusão de dez minutos. O PoCI consistiu de três
ciclos de reperfusão e isquemia com duração de
30 segundos cada. A área de infarto foi semelhante
nos grupos PrCI e PoCI e significativamente menor que no grupo controle.
A maioria dos estudos que analisaram os
efeitos do PoCI foram realizados na isquemia e
reperfusão miocárdica. Donato, D’Annunzio, Sabán et al.(19) compararam o PrCI e o PoCI em
corações isolados de coelhos, realizando isquemia
e reperfusão de 30 minutos. O PrCI foi realizado
por um ciclo de isquemia e reperfusão de cinco
minutos cada, e, o PoCI por dois ciclos de reperfusão e isquemia de 30 segundos cada. Concluíram
que o PoCI reduz o tamanho do infarto na mesma
magnitude que o PrCI, sem modificar a disfunção
23
ventricular pós-isquêmica.
Estes resultados também foram obtidos por
Darling, Jiang, Maynard et al.(20) em estudo experimental avaliando infarto em corações de coelhos.
O PoCI foi capaz de minimizar a área de infarto em
comparação ao grupo controle, realizando-se quatro ciclos de reperfusão e isquemia com duração de
30 segundos antes de se dar a fase de reperfusão.
Tang, Sato, Tiwari et al.(21) demonstraram
que o PoCI é tão eficaz quanto o PrCI na prevenção das lesões decorrentes do processo de isquemia e reperfusão coronariana em ratos, desde que
o tempo de isquemia não ultrapasse 45 minutos.
Após este período, segundo estes autores, o PrCI
apresenta resultados melhores quanto à diminuição da área de infarto.
O mecanismo de proteção do PoCI no processo de isquemia e reperfusão mesentérica ainda
não é totalmente claro, mas existem evidências de
que o PoCI possa estar relacionado a uma diminuição significativa nos níveis de malondialdeído
e produtos relacionados a peroxidação lipídica.
Estas observações sugerem uma redução na produção de ERTO e menor injúria mediada por oxidantes com o PoCI(4).
No presente estudo obteve-se média 3,3
para o grupo controle, em contraste com média 1
para os grupos PrCI e PoCI, sugerindo uma possível equivalência entre ambas as técnicas contra as
lesões de isquemia e reperfusão mesentérica, embora ainda com número reduzido de animais estudados. Estes resultados demonstram a necessidade
de melhor avaliação a fim de se comprovar a eficácia do PoCI em minimizar as lesões da mucosa
intestinal submetida a isquemia e reperfusão.
Conclusão
Os resultados preliminares obtidos neste
estudo apontam para uma possível equivalência na
capacidade do PrCI e PoCI de minimizar as lesões
da mucosa intestinal resultantes do processo de isquemia e reperfusão mesentérica em ratos, havendo necessidade de se avaliar um maior número de
animais para se confirmar tais resultados.
Referências Bibliográficas
1.
Parks DA, Granger DN. Contributions of ischemia and reperfusion to mucosal lesion formation. Am J Physiol 1986;
250: 749-753.
2.
Murry CE, Jennings RB, Reimer KA. Preconditioning
with ischemia: a delay of lethal cell injury in ischemic
myocardium. Circulation 1986; 74:1124-1136.
3.
Hotter G, Closa D, Prados M, Fernandez-Cruz L, Prats
N, Gelpi E, Roselló-Catafau J. Intestinal preconditioning
is mediated by a transient increase in nitric oxide. Biochem
Biophys Res Commun 1996; 222(1):27-32.
4.
Zhao ZQ, Corvera JS, Halkos ME, Kerendi F, Wang NP,
5.
Schipke JD, Halkos ME, Kerendi F, Gams E, VintenJohansen J. Postconditioning: a brief review. Arch Med Sci
2006; 2: 137-145.
6.
Halldorsson AO, Kronon MT, Allen BS, Rahman S, Wang
T. Lowering reperfusion pressure reduces the injury after
pulmonary ischemia. Ann Thorac Surg 2000; 69: 198-204.
7.
Sato H, Jordan JE, Zhao ZQ, Sarvotham SS, VintenJohansen J. Gradual reperfusion reduces infarct size
and endothelial injury but augments neutrophil
accumulation. Ann Thorac Surg 1997; 64: 1099-1107.
8.
Kerendi F, Kin H, Halkos ME, Jiang R, Zatta AJ, Zhao
ZQ, GuytON RA, Vinten-Johansen J. Remote postconditioning. Brief renal ischemia and reperfusion applied
before coronary artery reperfusion reduces myocardial infarct size via endogenous activation of adenosine receptors. Basic Res Cardiol 2005; 100: 404-412.
9.
10.
Couvreur N, Lucats L, Tissier R, Bize A, Berdeaux A,
Ghaleh B. Differential effects of postconditioning on
myocardial stunning and infarction: a study in conscious
dogs and anesthetized rabbits. Am J Physiol Heart Circ
Physiol 2006; 291: 1345-1350.
Sun HY, Wang NP, Kerendi F, Halkos M, KIN H,
Guyton RA, Vinten-Johansen J, ZHAO ZQ. Hypoxic
postconditioning reduces cardiomyocyte loss by inhibiting
ROS generation and intracellular Ca2+ overload. Am J
Physiol Heart Circ Physiol 2005; 288: 1900-1908.
11. Staat P, Rioufol G, Piot C, Cottin Y, Cung TT, L’Huillier I,
Aupetit JF, Bonnefoy E, Finet G, Andre-Fouet X, Ovize
M. Postconditioning the human heart. Circulation 2005;
112: 2143-2148.
12. Loukogeorgakis SP, Panagiotidou AT, Yellon DM, Deanfield JE, McAllister RJ. Postconditioning protects against
endothelial ischemia-reperfusion injury in the human forearm. Circulation 2006; 113: 1015-1019.
13. Huang H, Zhang L, Wang Y, Yao J, Weng H, Wu H, Chen
Z, LIU J. Effect of ischemic post-conditioning on spinal
cord ischemic-reperfusion injury in rabbits. Can J Anaesth 2007; 54: 42-48.
14. Chiu CJ, McArdle AH, Brown R, Scott HJ, Gurd FN.
Intestinal Mucosal Lesion in Low-Flow States. Arch Surg
1970; 101: 478-483.
15. Santos CHM, Gomes OM, Pontes JCDV, Miiji LNO, Higa
EI. Uso do propofol (2,6 diisopropilfenol) como inibidor
da lesão tecidual na isquemia e reperfusão mesentérica.
Estudo experimental em ratos. Acta Cir Bras 2003; 18(4):
347-354.
16. Santos CHM, Gomes OM, Pontes JCDV. Terapêutica
medicamentosa na isquemia e reperfusão mesentérica:
revisão da literatura. Rev Bras Coloproctol 2006; 26(1):
28-33.
17.
Santos CHM. Evolution and Challenges in the Phisiopatology of the Ischemia and Reperfusion. Cardiovasc Sciences Forum 2006; 1(3): 6-8.
18. Zhao ZQ, Corvera JS, Halkos ME, Kerendi F, Wang NP,
19. Donato M, D’Annunzio V, Sabán M, Flor L, Gelpi RJ.
Poscondicionamiento: un nuevo mecanismo protector.
Su comparación con el precondicionamiento en el infarto
experimental. Rev Arg Cardiol 2004; 72(4): 258-262.
20. Darling CE, Jiang R, Maynard M, Whittaker P, Vinten-Johansen J, Przyklenk K. “Postconditioning” via Stuttering
Reperfusion Limits Myocardial Infarct Size in Rabbit
Hearts: Role of ERK 1/2. Am J Physiol Heart Circ Physiol 2005; 289: 618-626.
21. Tang XL, Sato H, Tiwari S, Dawn B, Bi Q, LI Q, Shirk
G, Bolli R. Cardioprotection by postconditioning in
conscious rats is limited to coronary occlusions < 45 min.
Am J Physiol Heart Circ Physiol 2006; 291: 2308-2317.
24
SPECIAL ARTICLE
The Isolated Perfused Heart According to
Langendorff (History and presence) Modifications
and Aplications*
H.J. Döring
1. Historical development
The history of the isolated perfused heart
actually starts 153 years ago: the Physiologist
Carl Ludwig (then working in Marburg/Germany)
designed a method for the artificial nutrition of an
isolated mammalian heart by parabiotic perfusion.
Wild (1846), a coworker of Ludwig, elaborated this
method and published it in an article concerning
the movements of the oesophagus and the gut (!).
For this purpose the aorta of an isolated heart was
to be tied into the carotic artery of a living, intact
animal. The blood of the donor animal then had to
perfuse the coronary arteries of the receiver heart.
However, this method gained no major popularity,
probably due to coagulation problems with the
blood.
After this failure with the perfusion of
isolated mammalian hearts the subject was not
taken up by LUDWIG again until 20 years later.
He motivated the Physiologist Elie von CYON
from St. Petersburg /Russia, who was working as
a guest in Ludwig’s laboratory in Leipzig at that
time, to develop a perfusion apparatus for the
isolated frog heart in order to investigate the effects
of temperature on cardiac activity (Cyon (1866)).
Since the frog heart has no coronary arteries
and only one single ventricle, the perfusion was
technically less complicated than in the case of the
mammalian heart with its coronary vasculature (see
Figs. 1a and 2). Rabbit serum served as a perfusate. From this simple preparation Otto
Frank (1895) subsequently obtained
decisive information on the autoregulation of cardiac contractile force which
is still valid today. Later his results
were confirmed by E.H. STARLING in
experiments in the mammalian heart
and extended to cover natural contraction of two chamber heart conditions.
Successful experiments on artificially
perfused mammalian hearts were not performed
until 1881 when the English Physiologist Newell
Martin (who later worked at Johns Hopkins
University, Baltimore/USA) developed a heart
preparation for dogs and cats with natural, intact
lung circulation, mechanically ventilated lungs
and artificial peripheral circulation, in which
preload and afterload could be varied (see Figs.
1b and 3) (Martin (1881, 1883)). The perfusate
was defibrinated canine or calf’s blood. Heart and
lung remained in the body of the animal but were
functionally isolated (in-vivo isolated).
*Republished from LA Arch Cardiovasc Sci 2000; 1:9-30
25
Fig.1:
Development of the variants of perfused heart preparations.
(a) Perfused frog heart according to Cyon (1866) with one ventricle and two atria.
(b) Perfused mammalian heart according to Martin (1881). Left and right ventricles perform p-V work in an
artificial systemic circulation and the natural pulmonary circulation (with ventilated lungs).
(c) Perfused heart according to Langendorff (1885). The heart is completely isolated; only the coronary vascular system is perfused, while
both ventricles beat empty and thus perform no p-V work.
Fig.2:
The isolated perfused frog heart according to Cyon
(1866). b-f: mercury manometer; s - q: side socket for
the reception of a thermometer; v, w, z: artificial circulation from vitreous tubings; i-m vitreous cylinder
Fig. 3.:
Apparatus for the perfusion of a dog heart according to Martin (1883).
The figure in Martin’s publication from 1881 is misleading, since for
reasons of clarity he has drawn only the heart in over-proportional
magnification. Indeed, the glazed moist chamber (125 x 65 cm area)
took the total cadaver of the dog. In the considered figure from 1883
Martin also refrained from indicating the heart.
26
Later Martin published a technically easier
method (Martin and Applegarth (1889)). Here, the
coronary arteries were perfused retrogradely via the
aorta from a separate reservoir (Fig. 1c). However,
the lungs were still necessary to oxygenate the
blood. Here, too, heart and lungs remained in the
animals’ cadaver.
Martin was already 2 years dead - he died
in 1893 at the age of 45 - when in 1895 Oscar
Langendorff published another preparation system
for the study of cardiac function (Langendorff
(1895, 1897, 1898)). Compared to Martin he
went a step further towards isolating the heart. He
discarded the oxygenating function of the lungs by
removing the heart completely from the body of the
animal (ex-vivo isolated). In his preparation only
the coronary vessels were perfused retrogradely
from the aorta (see Fig. 1d). The advantages
of this method are the clear arrangement and
the simplicity of preparation. Unlike Martin’s
arrangement in which both ventricles always pump
varying quantities of blood, the left ventricle in the
Langendorff heart preparation beats empty. Only
the right ventricle is passed by part of the blood
from the coronary sinus, and the blood leaves the
right ventricle by gravity. In Fig. 4 Langendorff’s
perfusion apparatus from the original publication in
Pflügers Archiv (1895) is reprinted. The contractile
force of the heart was measured using a small
hook, inserted into the heart’s apex and connected
via a thread to a MAREY capsule for recording
purposes. Perfusion pressure was checked by
means of a mercury manometer.
Numerous authors have improved and
modified LANGENDORFF’s preparation in the
subsequent decades. Among the improvements
only the assessment of cardiac contractile force by
measurement of left ventricular pressure will be
emphasised.
Fig.4:
Perfusion apparatus according to Langendorff (1895). The measurement of contractile force by means of a hook and a
MAREY capsule (H) is indicated.
27
- For this purpose the physiologists Magrath and
Kennedy (1897) from Harvard University, Boston, used an open catheter, introduced via the
left atrium and tied into the left ventricle.
- In 1904, problems caused by the connection
of the Thebesian veins with the ventricle’s cavum and thus with the catheter, motivated the
pharmacologists Gottlieb and Magnus (1904)
from Heidelberg/Germany, to introduce a
balloon catheter instead of an open catheter
into the left ventricle. Siegel and Sonnenblick
(1963) were the first to use this procedure
again. Today this method can be said to represent the state-of-the-art technique for isovolumetric measurement of ventricular pressure in
isolated hearts.
An interesting variant was introduced
by Avkiran and Curtis (1991). With a special
double-lumen aortic cannula the authors could
independently perfuse the left and right coronary
artery in isolated rat hearts (see also Avkiran
(1995)).
An overview on the genealogy of isolated
heart preparations is given in Fig. 5.:
Development of Isolated Perfused Mammalian Heart Preparations
Fig. 5:
Genealogy of isolated perfused mammalian heart preparations. R+L-HLP: right and left heart-lung preparation; L-HLP: left heart-lung
preparation; IPH: isolated perfused heart; L-WH: left working heart; R-WH: right working heart.
From MARTIN’s method, Knowlton
and Starling (1912) developed the well-known
heart-lung preparation which offered important
advantages over MARTIN’s preparation due to
the artificial arterial resistance (the STARLING
resistance) and the greatly reduced blood priming
volume of the artificial circuit.
All the classical experiments in which pressurevolume (p-V) work of the heart was set in relation to:
- atrial pressure (Patterson et al., 1914; Starling,
1918);
coronary flow (Starling, 1919);
- oxygen consumption (Starling and Visscher,
1927; Gollwitzer-Meier and Krüger, 1937)
were carried out on the Starling HLP.
In another variant of a left heart-lung
preparation (L-HLP) introduced by D.de Barenne
(1921) the pressure in the pulmonary circulation is
not generated by the work of the right ventricle but
by hydrostatic pressure. Thus, the right ventricle
beats empty.
28
From LANGENDORFF’s method two isolated
cardiac preparations, where the hearts perform p-v
work, have been developed:
- The preparation introduced by Rhode (1910)
in which the left ventricle presses auxobarically on a liquid-filled balloon introduced into
the left ventricle. The heart is filled via the
left atrium and ejects its filling liquid afterloaded through a valve system against a flow
resistance and it is refilled via the same valve
system. Hereby the pumping circuit is completely insulated from the ventricular tissue.
The coronary vessels are perfused separately
according to LANGENDORFF’s method (see
Fig. 6a). The normal Thebesian venous admixture to the systemic circulation is omitted
by this separation of coronary perfusate and
artificial “systemic” circulation.
Janicki et al. (1974) first adapted Rhodes
“working heart preparation” to current technical
developments; however, today the preparation
is only used for special applications (cf.
Bardenheuer and Schrader, 1983; Korbmacher
et al, 1995a + b; Korbmacher et al, 1997).
- The “Vorhofkammerkreislaufpräparat” (atrioventricular-circulation preparation) introduced by Rigler (1932). From a reservoir under
hydrostatic pressure the left ventricle is filled
via the left atrium. The perfusate is then pumped back to the reservoir against hydrostatic
pressure or an artificial STARLING-like resistance by the force of the ventricle. Only the
left ventricle performs p-v work, because the
pulmonary circulation is by-passed (see Fig.
6b). Thus, the perfusate must be oxygenated
artificially. Only the coronary effluate leaves
this circulation through the cannulated pulmonary artery and is continuously re-pumped
into the reservoir.
The American Physiologist Neely adapted
this preparation to current technical and
biochemical developments, and is now
termed as the “Working Heart” (Neely et al.
(1967), Neely and Rovetto (1975), Neely et
al. (1976)).
-
Werchan and McDonough (1987) inaugurated
a p-v performing right-heart preparation in
which the left ventricle functionally is excluded
and only the right ventricle is working.
Fig. 6:
Isolated heart preparations performing pressure
volume work
(a) Perfused heart according to Rhode (1910). In a
systemic circulation hermetically sealed from the
myocardial tissue (LV balloon with artificial tubing
system, resistance and valves filled with water) the
left ventricle pumps the systemic fluid and performs pV work. The coronary vessels are supplied separately
with perfusate (see also Bardenheuer and Schrader
1983).
(b) Perfused heart according to Rigler (1932). The left
ventricle pumps perfusate into an artificial systemic
circulation (aorta, reservoir, pulmonary veins) and
performs p-V work against a variable f low resistance.
The coronary circuit is perfused naturally via the
ostiae and its outflow can be analysed separately
(split circulation). Now: Working Heart according to
Neely et al. (1967).
29
2. Present developments
In the second part a few examples
will be given, which may explain the present
possibilities of data evaluation obtained from the
LANGENDORFF heart.
The experiments were performed in guinea
pig or rat hearts. The preparation of the animals
was performed under barbiturate anaesthesia and
artificial ventilation. The perfusion of the hearts
was already started in situ after insertion of the
aortic cannula using an extension tube between
Langendorff apparatus and animal (see Fig. 7).
This technique shortens the anoxic or ischemic
period of the heart during the preparation and the
transfer to the recipient up to a maximum of 3 - 4
seconds.
After transfer to the recipient, the guinea
pig hearts were initially perfused at constant
perfusion pressure (PP) of 50 mm Hg. Rat hearts
were perfused at a PP of 70 mmhg. The perfusate
was a filtered KREBS-HENSELEIT solution
(Micropore filter 0.8 µm) with the addition of
2 mmol/l Na pyruvate and equilibrated with
carbogen (95 vol% O2, 5 vol% CO2). The hearts
were stimulated electrically at a constant rate of
270/min. A block diagram of the set-up is given in
Fig 8. The recipient consists of a water-jacketed
thermoconstant bath, filled with perfusate in
which the heart was immersed (see Fig. 7). For
methodical details see Döring and Dehnert (1988),
Döring (1990).
Three basic measurements were performed
continuously: - left ventricular isovolumetric pressure (LVP)
(intraventricular balloon catheter connected
to a Statham P23Db transducer),
- coronary flow (CF) above the aortic cannula
(electromagnetic flowmeter, Biotronex)
- perfusion pressure (Statham P23Db).
PP could either be kept constant or could be changed abruptly by an electronic PP control unit.
Fig. 7:
Explanation of the operation technique of an anaesthetised, ventilated animal (guinea pig) using an extension tube. Left:
operating table with the animals’ cadaver and the aortic cannula, already inserted into the aorta. Right: Fragment of a
LANGENDOFF set-up with an oxygenator (only the lower part can be seen) and the recipient (water-jacketed thermoconstant
bath, filled with perfusate) in which the heart will be immersed.
Oxygenator (containing the perfusate) and aortic cannula are connected by means of the perfusate-filled extension tube.
Immediately before the incision of the aorta a low perfusate flow will be released from the extension tube, which proceeds
during the insertion and tying of the aortic cannula. Then full perfusate flow is released from the oxygenator (or any other
perfusate storage). Just the heart by itself is to be isolated from the cadaver of the animal, the extension tube will be removed
and the aortic cannula placed at the oxygenator.
30
Fig.8:
Block diagram of a modern LANGENDORFF set-up with electronic
measuring devices.
All data were fed into a personal computer,
which controlled the experimental protocol by
specially developed software. From the measuring
parameters the following data were calculated:
developed left ventricular pressure (dLVP), +dp/
dtmax and -dp/dtmax as well as the quotient -dp/
dtmax: +dp/dtmax abbreviated “Q”. Examples of
recordings in a guinea pig and a rat heart are given
in Figs. 9 and 13.
An important but often neglected procedure
consists of the functional testing of the various
tissue elements of the heart (working myocardium,
specific conduction system, coronary musculature,
autonomous nervous system) by specific load
tests. In the context of this paper the knowledge of
the range of physiological load possibilities and of
the functional reserves of the myocardium as well
as of the coronary musculature are of particular
importance. Based on such - individually to be
prepared - standards it is possible to quantify
experimental variations more sensitively than
with steady state reactions (cf. Bünger et al.
(1979); Grupp (1984); Schulze (1995); Döring and
Dehnert (1988); Döring (1990)). Thus, as a routine
we performed a load test before and after each
physiological or pharmacological intervention.
The test regarding the myocardium, is
31
based on the so called GREGG effect (Gregg
and Shipley (1944), Salisbury et al. (1960),
GREGG (1963)). The GREGG-effect depends
on the pressure-induced unwinding tendency of
the coronary vessels which causes a stretch of
the myocardial fibres. The consecutive increase
in contractile force would then be comparable to
the FRANK-STARLING effect. SARNOFF et
al. (1960) termed this characteristic of the heart
“heterometric autoregulation”.
The test was performed by a computercontrolled stepwise increase of perfusion pressure
which causes an immediate stepwise increase in
the contractile force of the myocardial fibres.
The test regarding the coronary vascular
system is based on the measurement of flow during
the stepwise increase of perfusion pressure, which
then results in the pressure-flow curve (Figs.10,
11, 12).
By means of quantitative analysis of these
data the following function curves were obtained
(cf. figs. 10 (guinea pig heart) and 14 (rat heart)):
1. A substitute of FRANK-STARLING function
curves: this is dLVP vs. PP. At a PP between
40
and 100 mm Hg the guinea pig heart is working
under conditions found on the ascending
branch of the FRANK-STARLING function
curve. Details concerning this function
curve will be discussed in the presentation
by Döring: Load dependence of systolic and
diastolic function of the myocardium, in this
volume.
2. Pressure-flow curve (PF) of the coronary vessels. The pressure-flow curve is a better delineator of the performance of coronary vessels
than the absolute flow value; in particular, it is
a measure of myogenic autoregulation (MA)
of the coronary musculature (cf. Döring et al.
(1989); Schlicht et al. (1989)). In this diagram
MA can be recognised in the lower flat course
of the curve between PP of 50 and 90 mm Hg.
From 90 mm Hg on the course of the curve
becomes steeper, signifying decreasing MA at
these high perfusion pressures.
3. Finally, we calculated the above mentioned
quotient “Q” for each PP step. The Q-values
were then plotted versus PP. In guinea pig
hearts the Q/PP curve takes a course, which
almost parallels the abscissa at a level of 0.8
to 0.9 (see for comparison Fig. 13, rats).
Two examples of the application of this
evaluation type will be given.
In Fig. 11 the effects of Magnesium-free
perfusate (Mg++ 0) and its interrelationship with
ouabain on the isolated heart are demonstrated.
Mg++ 0 decreases dLVP by 18% (calculated for 90
mm Hg PP). However, at the same PP the additional
application of ouabain causes a reduction by 56%
of the controls.
An imbalance between -dp/dtmax and
+dp/dtmax causes a decrease of “Q” (by 25% and
45%, resp.); however, the parallel downward shift
of the curves during PP load points out that this
imbalance is not particularly aggravated during
load.
The course of the PF curves of the coronary
bed also show a gradual decrease: a depression by
33% under Mg++ 0 perfusion and by 50% under
the additional application of ouabain (PP = 90 mm
Hg). This PP-dependent augmentation in flow
decrease points on an increase of MA, in the first
step during Mg++ 0-perfusion and in a second step
after ouabain application.
It is worth mentioning that at the steadystate PP of 50 mm Hg the differences in coronary
flow between all three experimental groups are
only small. Significant differences result only
during the progression of the PP-load.
The second example shows an important
relationship between the extracellular Mg++ concentration and the relaxing properties of the
“endothelium derived factor” nitric oxide (NO)
on the blood vessels. Blockade of NO synthesis
exerts the reversed effect, namely vasoconstriction.
In Fig. 12 an example of the influence of NO
synthesis blockade is demonstrated. In our model
we investigated the influence of NW-nitro-Larginine (LNWNA) on myocardial contractile force
and coronary flow (1) in the presence of normal
Krebs-Henseleit perfusate and (2) of Mg++-free
perfusate.
As expected, during perfusion with LNWNA only no specific effects on the cardiac mechanical parameters mentioned could be found; the
decrease in “Q” is statistically not significant (see
also Bunsiricomchai et al. (1991)). Also, the perfusion with Mg++-free solution and additional LNWNA exerted no inotropic effects in excess of those
described for Mg++-free solution in Fig. 11.
The influences on coronary flow (CF)
and MA, resp. appear quite differently: already
the perfusion with LNWNA only (5 x 10-6 mol/l)
induced a decrease in flow by 25% of control
values (at a PP of 90 mm Hg). Mg++-free perfusion
reduced CF by 35% of controls (cf. Fig. 11). The
combination of Mg++ 0 and LNWNA resulted in a
reduction of CF by 52% compared to controls: this
indicates that MA was stimulated to a maximum.
The function curves also show pronounced
species differences. For instance, rat hearts
generally can sustain higher loads than guinea pig
hearts and develop higher ventricular pressures
(cf. Fig. 13). In Fig. 14 another arrangement of
the function curves was created: the pressure-flow
curves of the coronary vessels were replaced by
the function curves of +dp/dtmax and -dp/dtmax.
The figure demonstrates that up to a PP of 150
mm Hg the ascending branch of the function
curve corresponds to the rise in dLVP from 140 to
205 mm Hg. Moreover, the course of the curves
of +dp/dtmax and -dp/dtmax is different from that
32
of the corresponding curves of guinea pig hearts
in Fig. 10: +dp/dtmax takes a PP-dependent steep
increase up to 6000 mm Hg/s at a PP of 150 mm
Hg. However, at a PP of approximately 110 mm
Hg -dp/dtmax reaches a maximum at a comparably
low level of 3100 mm Hg/s. This indicates that
in rat hearts diastolic relaxation is less preloaddependent than in guinea pigs. As a result, “Q”
amounts to 0.70 in rat hearts, as opposed to 0.80 to
0.9 in guinea pig hearts. This is in accordance with
results of György et al. (1999) and Docherty et al.
(1999), who found values of positive and negative
dp/dtmax, from which a Q-value of 0.68 and 0.55,
Fig. 09:
Recording of an experiment in the isolated perfused guinea pig
heart (BW 330 g). Preparation of the animal and isolation of the
heart were performed during Pentothal-Na anaesthesia and artificial
ventilation. Using an extension tube the perfusion was already
started in situ after insertion of the aortic cannula (see Schlicht et
al. (1989)). This technique shortens the anoxic or ischemic period
of the heart during the preparation and the transfer to the recipient
to maximum of 3 - 4 seconds. Composition of the perfusate see
Döring (1989). Loading of the heart by step-wise increase of the
perfusion pressure using an electronic perfusion pressure control
unit (Hugo Sachs Elektronik, Germany).
33
resp. could be calculated.
When compared to guinea pig hearts “Q”
also decreases with increasing PP load. Over the
range of the ascending branch of the FRANKSTARLING-curve this decrease amounts to 24%
instead of a maximum of 5% in guinea pigs.
The reason for these differences is not
known. However, rat hearts show exceptions
with respect to other functions: the activity of the
sarcolemmal K/Na-ATPase is less than in other
mammals including humans. As a consequence,
rats are remarkably less sensitive to cardiac
glycosides than most other mammals.
Fig.10:
Function curves of guinea pig hearts from recordings as shown
in Fig. 9. In all 3 sub-diagrams the abscissa represents perfusion
pressure (PP) in the same scale. Above: dLVP vs. PP; middle: CF
vs. PP; below., Q vs. PP. Q = -dp/dtmax : +dp/dtmax.
Under experimental routine condition guinea pig hearts were
loaded to only 90 mm Hg to prevent overload of the heart.
Fig.11:
Effects of ouabain (3.4 x 10-7 mol/l) on Mg++ -free perfused
guinea-pig hearts. Mg exerts negative effects on contraction
(dLVP) and relaxation (-dp/dtmax, not shown in the diagram) of the
myocardium whereby -dp/dtmax was depressed more than +dp/
dtmax. Thus, “Q” is reduced by about 27%, independently of PP
load. MA is increased (indicated by the decrease in CF). Ouabain
enhances all these effects.
Fig.12:
Relationship between Mg++ -free perfusate and the NO synthesis
inhibitor Nw-Nitro-L-arginine (LNwNA) on myocardial contractile
force and coronary flow.
During perfusion with LNwNA no specific effects on dLVP, +dp/
dtmax, -dp/dtmax and “Q” could be recorded. Perfusion with Mg++free solution and supplementary LNwNA did not exert any effects
on the heart either.
However, marked influences on coronary flow and myogenic
autoregulation were observed: perfusion with LNwNA only induced
a decrease in flow by 25%, perfusion with Mg++-free solution
only a decrease by 35% of the controls (at a PP of 90 mm Hg).
When Mg++-free perfusion was combined with LNwNA an almost
complete elimination of MA, i.e. no PP-induced increase in coronary
flow, was observed.
Fig.13:
Recording of an experiment in the isolated perfused rat heart
(BW 310 g). The curve of -dp/dtmax is not recorded here. Perfusion pressure is increased from 50 to 210 mm Hg in steps of
20 mm Hg.
34
Pag. 14:
Left ventricular function curves of 22 isolated rat
hearts, perfused with standard perfusate. The
pressure-flow curves were replaced by the function
curves of +dp/dtmax and -dp/dtmax.
At first glance it can be recognized that rat hearts
can sustain much higher PP (150 mm Hg compared
to 90 mm Hg in guinea pig hearts). Consequently
at peak PP they develop a 50% higher LVP and a
three-fold +dp/dtmax compared to isolated guinea
pig hearts. Also the value of -dp/dtmax amounts to
3290 mm Hg/s and is 40% higher than that of guinea
pig hearts. The curve of -dp/dtmax also peaks
already at a PP of 130 mm Hg. As a consequence,
the Q/PP curve takes a downsloping course.
3. Summary
1. The historical development and genealogy of
isolated heart preparations was demonstrated
in a short synopsis. Two directions of the
evolution can be followed:
in-vivo isolation = Martin, Starling;
ex-vivo isolation = Langendorff, Rhode, Neely.
2. Using a modern, computer-assisted version
of a LANGENDORFF apparatus various
possibilities of experimental evaluation were
demonstrated.
Studies at constant PP: dLVP, +dp/dt; -dp/dt,
CF
Studies with stepwise increase of PP-Ioad:
load dependence of systolic contraction and
35
diastolic relaxation, relation of contraction to
relaxation calculating the quotient -dp/dtmax:
+dp/dtmax, myogenic autoregulation of the
coronary vessels.
The efficiency of the evaluation technique
using a load test was presented by three experimental examples concerning myocardial contractile parameters and coronary vascular mechanics:
a) Differences between guinea pigs and rats;
b) Additive effects of ouabain and Mg++-free
perfusate;
c) Additive effects of Mg++-free perfusate and a
NO synthesis inhibitor NW-nitro-L-arginine.
01. Avkiran, M.; Curtis, M.J.: Independent dual perfusion
of left and right coronary arteries in isolated rat hearts.
Am.J.Physiol. 261:H2082-H2090 (1991)
02. Avkiran, M.: Dual coronary perfusion. A model for the
study of ischemia and reperfusion arrhythmogenesis
in isolated hearts. In: 9th Freiburg Focus on
Biomeasurement: Pharmacological evaluation of
cardioprotective substances. Experimental induction and
indicators of myocardial injury and myocardial protection.
Biomesstechnik-Verlag March, pp. 89- 96, 1995
03. Bardenheuer, H.; Schrader, J.: Relationship between myocardial oxygen consumption, coronary flow, and adenosine release in an improved isolated working heart preparation of guinea pigs. circulation Res. 52:263-271 (1983).
04. Bünger, R.; Haddy, F.J.; Querengässer, A.; Gerlach, E.: An
isolated guinea pig heart preparation with in vivo like
features. Pflügers Arch. 353:317-326 (1975).
05.
Bunsiricomchai, P.; Döring, H.J.; Hiller, V.: Nitric oxide
synthesis inhibitor, NwNitro-L-Arginine (LNwNA), enhances myogenic autoregulation (MA) of coronary vessels in isolated perfused guinea pig hearts. Pflügers Arch.
419 (Suppl.):RIII (1991)
06. Cyon, E: Über den Einfluss der Temperaturänderungen
auf Zahl, Dauer und Stärke der Herzschläge (On the
influence of temperature variations on the number,
duration and strength of the heart beats). Ber.Verh.
königl.sächsischer Ges.d.Wiss. zu Leipzig, Math-Phys.
Classe 18:256-306 (1866)
07. Döring, H.J.: Differentiation of various cardiovascular
drugs by means of specific myocardial and vascular
load tests. Experiments on the isolated perfused heart.
Arzneim.-Forsch. 39/II 1535-1542 (1989).
08. Döring H.J.: The isolated perfused heart according to
LANGENDORFF. Technique - Function - Application.
Physiologia Bohemslovaca 39:481-496 (1990)
12. Docherty, J.C.; Kuzio, B.; Silvester, J.A.; Bowes, J.; Thiemermann, C.: An inhibitor of poly (ADP-ribose) synthetase activity reduces contractile dysfunction and preserves
high energy phosphate levels during reperfusion of the
ischaemic heart. Br. J. Pharmacol. 127:1518-1524 (1999)
13. Dusser de Barenne, J.G.: Über eine Methode zur genauen
Bestimmung des gesamten Koronarkreislaufs. (on a
method for accurate determination of the total coronary
circulation). Pflügers Arch. ges. Physiol. 188:281-286 (1921)
14. Frank, 0.: Zur Dynamik des Herzmuskels. Z.Biol. 32:370447 (1895)
15. Fye, W.: H. Newell Martin and the isolated heart preparation: the link between the frog and open heart surgery.
Circulation 73:857-864 (1986)
16. Gollwitzer-Meier, K.; Krüger, E.: Zur Verschiedenheit
der Herzenergetik und Herzdynamik bei Druck- und
Volumenleistung. Pflügers Arch. ges. Physiol. 238:279****** (1937)
17. Gottlieb, R.; Magnus, R.: Digitalis und Herzarbeit. Nach
Versuchen am überlebenden Warmblüterherzen. Arch.
exper. Path. Pharmakol. 51:30-63 (1904)
18. Gregg, D.E.: Effect of coronary perfusion pressure or
coronary flow on oxygen usage of the myocardium. Circ.
Res. 13:497- 500 (1963).
19. Gregg, D.E.; Shipley, R.E.: Augmentation of left coronary
inflow with elevation of left ventricular pressure and
observations on the mechanism for increased coronary
inflow with increased cardiac load. Am. J. Physiol.
142:44-51 (1944)
20. Grupp, G.: Derived indices of myocardial function in
isolated work-performing hearts. In: Schwartz, A. ed.:
Methods in pharmacology. Vol. 5, pp. 129-139, Plenum
Press, New York and London, 1984
09. Döring, H.J., H.Dehnert: The isolated perfused heart
according to LANGENDORFF. Biomesstechnik-Verlag
March GmbH, 1988
21. György, K.; Muller, B.; Viägh, A.; Kleschyov, A.; Stoclet,
J.-C.: Triggering role of nitric oxide in the delayed
protective effect of monophosphoryl lipid A in rat heart.
Br. J. Pharmacol. 127:1892-1898 (1999)
10. Döring, H.J.; Hauf, G.: Kontraktilität sowie ATP- und
Kreatinphosphat-Konzentrationen des Meerschweinchenmyokards bei Normoxie und verschiedenen Hypoxiegraden. Der Einfluß von Strophanthin, Isoproterenol
und Kalziumchlorid. Herz/Kreislauf 9:926-933 (1977)
22. Janicki, J.S., R.C. Reeves, K.T. Weber, T.C. Donald,
A.A. Walker: Application of a pressure servo system
developed to study ventricular dynamics. J.Appl.Physiol.
37:736-741 (1974).
11. Döring, H.J.; Schlicht, I.; Hiller, V.; Jiang, X.-R.: Myogenic
autoregulation of coronary vessels and heterometric
autoregulation of the myocardium. Korean J.Physiol.
23:225- 236 (1989)
23. Kennedy, R.H.; Akera, T.; Brody, T.M.: The effect of
stimulation frequency and calcium concentration on
maintenance of developed tension in isolated heart muscle
preparations. J.Pharmacol.Meth. 17:95-110 (1987)
36
24. Knowlton, F.P.; Starling, E.H.: The influence of variations
in temperature and blood-pressure on the performance of
the isolated mammalian heart. J.Physiol. 44:206-219 (1912)
25. Korbmacher, B.; Sunderdiek, U.; Schulte, H.G.; Arnold,
G.; Schipke, J.D.., Comparison between the effects of a
novel Ca++ sensitizer and a phosphodiesterase inhibitor
on stunned myocardium. J. Pharmacol. exp. Therap.
275:1433-1441 (1995)
26. Korbmacher, B.; Sunderdiek, U.; Schwanke, U.; Schwenen,
M.; Arnold, G.; Schipke, J.D.: Studies on postischemic
dysfunction using isolated, blood-perfused rabbit hearts. In:
9th Freiburg Focus on Biomeasurement: Pharmacological
evaluation of cardioprotective substances. Experimental
induction and indicators of myocardial injury and
myocardial protection. Biomesstechnik-Verlag March,
pp. 120-127, 1995.
27. Korbmacher, B.; Sunderdiek, U.; Selcan, G.; M.; Arnold,
G.; Schipke, J.D.: Different responses of non-ischemic
and postischemic myocardium towards Ca2+ sensitization. J.Mol. Cell. Cardiol. 29:2053-2066 (1997)
28. Langendorff, 0.: Untersuchungen am überlebenden Säugethierherzen. Pflügers Arch. ges. Physiol. 61:291-307
(1895).
29. Langendorff, 0.: Untersuchungen am überlebenden Säugethierherzen. II. Abhandlung. Über den Einfluss von
Wärme und Kälte auf das Herz der warmblütigen Thiere. Pflügers Arch. ges. Physiol. 66:355-400 (1897)
30. Langendorff, 0.: Untersuchungen am überlebenden Säugethierherzen. Ill. Abhandlung. Vorübergehende Unregelmäßigkeiten des Herzschlags und ihre Ausgleichung.
Pflügers Arch. ges. Physiol. 70:473-486 (1898)
31. Magrath, G.B.; Kennedy, H.: On the relation of the volume of the coronary circulation to the frequency and
force of the ventricular in the isolated heart of the cat. i.
exp. Med. 2:13-34 (1897)
36.
Neely, J.R.; Rovetto, M.J.: Techniques for perfusing isolated rat hearts. Meth. Enzym. 39:43-60 (1975)
37. Opie, L.H.: Coronary flow rate and perfusion pressure
as determinants of mechanical function and oxidative
metabolism of isolated perfused rat heart. J.Physiol.
180:529-541 (1965)
38. Opie, L.H.: Adequacy of oxygenation of isolated perfused
rat heart. Basic Res.Cardiol. 79:300-306 (1984).
39. Patterson, S.W.; Piper, H.; Starling, E.H.: The regulation
of the heart beat. J.Physiol. 48:465-513 (1914)
40. Rhode, E.: Stoffwechseluntersuchungen am überlebenden
Warmblüterherzen. I. Mitteilung. Zur Physiologie des
Herzstoffwechsels. Z.physiol. Chem. 68:181-235 (1910)
41.
Rigler, R.: Das Vorhofkammerkreislaufpräparat. Arch.
exper. Path. Pharmakol. 163:295-310 (1932)
42. Salisbury, P.F.; Cross, C.E.; Rieben, P.A.: Influence of
coronary artery pressure upon myocardial elasticity. Circ.
Res. 8:794- 800 (1960)
43. Sarnoff, S.J.; Mitchell, J.H.; Gilmore, J.P.; Remensnyder,
J.P.: Homeometric autoregulation in the heart. Circ. Res.
8:1077–1091 (1960)
44. Schlicht, I.; Schuler, E.; Döring, H.J.: Isolated heart according to LANGENDORPF under constant-pressure
and constant-flow conditions. In: 5th Freiburg Focus on
Biomeasurement: Isolated perfused organ preparations.
Biomesstechnik-Verlag March GmbH, pp 13-25, 1989
45. Schulze, K.: Physical and pharmacological load tests on
the isolated “working heart”. In: 9th Freiburg Focus
on Biomeasurement: Pharmacological evaluation of
cardioprotective substances. Experimental induction and
indicators of myocardial injury and myocardial protection.
Biomesstechnik-Verlag March, pp, 48-57, 1995
32. Martin, H.N.: A new method of studying the mammalian
heart. Stud. Biol. Lab. Johns Hopkins University 2:119130 (1881)
46. Schrader, J., F.J. Haddy, E. Gerlach: Release of adenosine,
inosine and hypoxanthine from the isolated guinea pig
heart during hypoxia, flow-autoregulation and reactive
hyperemia. Pflügers Arch. ges. Physiol. 369:1-6 (1977).
33. Martin, H.N.: The direct influence of gradual variations
of temperature upon the rate of beat of the dog’s heart.
Philosoph. Trans. Royal Soc. Lond. 174:663-688 (1883)
47. Siegel, J.H.; Sonnenblick, E.H.: Isometric time-tension
relationships as an index of myocardial contractility. Circ.
Res. 12:597-610 (1963)
34. Martin, H.N.; Applegarth, E.C.: On the temperature limits
of the vitality of the mammalian heart. Stud. Biol. Lab.
Johns Hopkins Univ. 4:275 (1889); cit. after Fye (1986)
48. Starling, E.H.: The Linacre Lecture on the law of the
heart. Given at Cambridge, 1915. Longmans, Green and
Co. London, 1918
35. Neely, J.R.; Liebermeister, H.; Battersby, E.J.; Morgan, H.E.:
Effect of pressure development on oxygen consumption
by isolated rat heart. Am.J.Physiol. 212:804-814 (1967).
49.
37
Starling, E.H.: On the circulatory changes associated with
exercise. Lecture given at the Royal Army Medical College, 1919. Cited after Chapman, C.B. and Mitchell, J.H.
(eds.) Starling on the heart. Dawsons of Pall Mall, London, 1965
50. Starling, E.H.; Visscher, M.B.: The regulation of the energy output of the heart. J.Physiol. 62:243 - (1927)
51. Werchan, P.M.; McDonough, K.h.: The right ventricular
working heart preparation. Proc. Soc. exper. Biol. Med.
185:339-346 (1987)
52. Wild, F.: Ueber die peristaltische Bewegung des Oesophagus, nebst einigen Bemerkungen über diejenigen des
Darms. Zschr. rat. Med. 5:76-132 (1846)
53. Prof. Dr. H.J. Döring, Weihermattenweg 11, D-79256
Buchenbach
38
CASE REPORT
Pappilary Fibroelastoma: A Case Report
José Oscar R. Brito, Mariana Boaretto Tostelly, Clara Weksler,
Ivan Antonio Machado de Paula Flávio Gouveia, Odilon Nogueira Barbosa
Abstract
This article describes the clinical,
diagnostic and therapeutical evolution of a 59 year
old female patient with progressive complaints of
palpitation from cardiac origin without episodes of
syncope. The transesophageal echocardiography
revealed a mobile tumor on the aortic side of
the aortic valve, suggestive of fibroelastoma.
This patient underwent a surgical ressection of
this tumor, without removal of the native aortic
valve. The histopathologic exam confirmed
the initial diagnosis of papillary fibroelastoma.
Key words: embolism, tumor; transesophageal
echocardiography; heart neoplasms.
Introduction
The Pappilary Fibroelastoma is a primary
and benign cardiac tumor, originary of cardiac
valves and adjacent endocardium tissue (1). The
AV valves and semilunar valves are affected with
similar frequencies (2).
The cytomegalovirus has been found inside
of the nucleus of fibroelastoma tumor cells; maybe
suggesting tumoral induction of this tumor and
chronic viral endocaditis (3).
39
This tumor was formerly thought to be an
innocuous and its diagnosis has been an incidental
finding during cardiac surgery or an autopsy
exam (2). However, contemporary knowledge
allows to describe episodes of coronary ostial flow
obstruction (4,5,6). embolic episodes (7), such
as stroke (8), pulmonary thromboembolism and
peripheric embolism as consequences of the above
mentioned tumor.
Due to the widespread use of
echocardiogram, the diagnosis of the pappilary
fibroelastoma has been made in its early stages
(2,4,5,10) mostly without symptoms, permitting
the surgical excision of this tumor without
consequences, such as stroke, acute myocardial
infarction and peripheric embolic episodes.
The tumoral excision, with safe margins of
ressection, without the need of valve replacement
is the ideal surgery in this disease (10).
This article describes the clinical evolution
of a 59 year old female patient with paroxystic atrial
fibrilation and a suggestive diagnosis of pappilary
fibroelastoma (an echocardiographic finding).
Case Report
A 59 year old female patient was admitted
to the INCL ambulatory service with symptoms
of thoracic pain and episodes of palpitations. At
her physical exam, an irregular cardiac rythm
and tachycardia were observed. Eletrocardiogram
findings were atrial fibrilation with ventricular
frequency of 120 beats per minute. The laboratory
exams (hemogram, urea, creatinin, electrolytes,
glicemy) and level of thyreodian hormones
were within normal limits.The transesophageal
echocardiogram was observed a mobile, oval
tumor (0.6 x 0.8 cm of diameter), situated on the
aortic face of aortic valve, on the right coronary
leaflet, associated with a mild degree of aortic
regurgitation (Figure 1). Mitral valve prolapse with
mild degree of mitral regurgitation were observed
at the same exam.
Endereço para correspondência: José Oscar Reis Brito
- Instituto Nacional de Cardiologia de Laranjeiras
Rua das Laranjeiras, 374 - Laranjeiras - Rio de Janeiro.
CEP: 22240-006 - Tel:21-2285-3344 ramal: 2267
Surgical approach was performed with
Figure 1 - Echocardiographic image of the
Pappilary Fibroelastoma, showing a mobile
and pedunculated tumor, in the aortic face of
the aotic valve.
median sternotomy incison and cardiopulmonary
bypass, through the cannulation of ascending aorta
and right atrial appendage with two stage cannula.
After aortic clamping and transverse aortotomy, the
tumor previously described was located. The tumor
was situated on the right coronary leaflet of the
aortic valve, pink colored and mobile, as described
earlier in the transesophageal echocardiogram
(Figure 2). The tumor was excised, preserving the
native aortic valve. The extracorporeal time was of
50 minutes and clamping time was of 46 minutes.
Figure 2 - Intraoperatory image of the Pappilary Fibroelastoma.
40
Intraoperatory echocardiographic control,
after tumor ressection and the end of pump, normal
aortic valve function was observed.
During the recovery period at the intensive
care unit, an episode of atrial flutter was registered,
with subsequent reversion to normal cardiac
rythm.
The diagnosis of pappilary fibroelastoma
was confirmed at histopathologic exam, composed
of rich conjunctive tissue, with mixoid characteristics and abundant polysaccharide matrix and
endothelium covered elastic fibers (Figure 3).
Figure 3 - Histologic plans showing the
pappilary surface of the lesion, composed of
oblong projections covered by endothelium
cells. The axis is hialine, avasculated, with
no signs of malignancy. Compatible with
Pappilary Fibroelastoma.
1.
Edwards FH, Hale D, Cohen A et al: Primary cardiac valve
tumors. An Thorac Surg 1991; 52:1127
6.
2.
Di Mattia DG; Assaghi A; Mangini A et al: Mitral valve
repair for anterior leaflet papillary fibroelastoma: two case
descriptions and a literature review. Eur J Cardiothorac
Surg 1999; 15:103.
Mazzuco A; Bortolloti V; Thiene G et al: Left ventricular
papillary fibroelastoma with coronary embolizationa. Eur
J Cardiothorac Surg 1989; 3:471.
7.
McFadden PM, Lacy JR: Intracardiac papillary fibroelastoma: an occult case of embolic neurologic deficit. Ann
Thorac Surg 1987; 43:667.
8.
Topol EJ, Biern RO; Reitz BA: Cardiac papillary fibroelastoma and stroke: echocardiographic diagnosis and guide
to excision.Am J Med 1986; 80:129.
9.
Raqui T, Grande AM, Capuccio G et al: Embolizing fibroelastoma of the aortic valve. J Thorac Cardiovasc Surg
1994; 2:639.
3.
Grandmougin D; Fayad G; Moukassa D et al: Cardiac
valve pappilary fibroelastomas: clinical, histological and
immunohistochemical studies and a physiopathogenic
hypothesis. J Heart Valve Dis 200; 9:832.
4.
Israel DH, Sherman W, Ambrose JA et al: Dynamic coronary
ostial occlusion due to pappilary fibroelastoma leading to
myocardial ischemic and infarction. Am J Cardiol 1991;
67:104.
5.
41
Grote J, Mugge A, Schfers HJ: Multiplane transesophageal
echocardiography detection of a papillary fibroelastoma
of the aortic valve causing myocardial infarction. Eur
Heart J 1995; 16:426.
10. Grinda JM, Coetil JP, Chauvaud S et al: Cardiac valve papillary fibroelastoma: surgical excision for revealed or potential embolization. J Thorac Cardiovasc Surg 1999; 117:106.
Fibroelastoma Papilar: Relato de Caso
José Oscar R. Brito, Mariana Boaretto Tostelly, Clara Weksler,
Ivan Antonio Machado de Paula Flávio Gouveia, Odilon Nogueira Barbosa
Resumo
Descreve-se a evolução clínica, diagnóstica
e terapêutica de uma paciente de 59 anos, sexo
feminino, com queixas progressivas de palpitação
de origem cardíaca, sem episódios de síncope. Ao
exame ecocardiográfico, por via transesofágica, foi
evidenciada uma tumoração móvel, pedunculada,
na face aórtica da valva aórtica, sugestiva de
fibroelastoma papilar. Esta paciente foi submetida à
ressecção cirúrgica deste tumor, sem a necessidade
da remoção da valva aórtica nativa. Ao exame
histopatológico da tumoração ressecada, foi
confirmado o diagnóstico de fibroelastoma papilar.
Palavras-chave: tumor embólico; ecocardiografia
transesofagiana; neoplasias cardíacas.
Introdução
O fibroelastoma papilar é um tumor
cardíaco primário, benigno, que se origina
caracteristicamente das valvas cardíacas ou
do endocárdio adjacente a estas (1). As valvas
atrioventriculares, bem como as semilunares, são
acometidas com igual freqüência (2).
O citomegalovírus tem sido encontrado
dentro do núcleo das células tumorais do
fibroelastoma, podendo sugerir a possibilidade de
indução tumoral, bem como de endocardite viral
crônica (3).
Pensava-se inicialmente que esse tumor
fosse inócuo, sendo o diagnóstico um achado
de autópsia ou pela sua constatação durante o
inventário de uma operação cardíaca (2). Sabe-se
atualmente que o fibroelastoma papilar pode causar
obstrução ao fluxo sanguíneo, particularmente
do fluxo coronariano (4,5,6) e apresentar
comportamento emboligênico, (7) causando
principalmente acidente vascular cerebral (8).
Embolia pulmonar e embolia vascular periférica
são também potenciais sítios emboligênicos (7).
Devido ao amplo uso da ecocardiografia,
o diagnóstico desse tumor tem sido feito de forma
precoce (2,4,5,10), possibilitando a abordagem
terapêutica adequada, antes da instalação das
complicações obstrutivas ou emboligênicas.
A ressecção tumoral, respeitando a
adequada margem de segurança, com a preservação
da valva cardíaca, é a opção terapêutica ideal para
o tratamento desse tumor (10).
Nesse artigo é descrita a evolução clínica
de uma paciente de 59 anos, do sexo feminino, com
fibrilação atrial paroxística e diagnóstico sugestivo
de fibroelastoma papilar ao ecocardiograma
transesofágico.
42
Endereço para correspondência: José Oscar Reis
Brito - Instituto Nacional de Cardiologia de Laranjeiras
Rua das Laranjeiras, 374 - Laranjeiras - Rio de Janeiro. CEP: 22240-006 - Tel:21-2285-3344 ramal: 2267
Relato de Caso
Paciente de 59 anos, do sexo feminino,
branca, procurou o ambulatório do Instituto
Nacional de Cardiologia de Laranjeiras (INCL) com
queixas intermitentes de palpitação e dor torácica.
Ao exame físico, foi encontrado ritmo cardíaco
irregular e taquicardia. Ao eletrocardiograma,
o ritmo era de fibrilação atrial, com freqüência
ventricular de 120 batimentos por minuto. Os
exames laboratoriais (hemograma, uréia, creatinina,
eletrólitos, glicemia) e a dosagem dos hormônios
tireoideanos encontravam-se dentro dos limites
normais. Ao ecocardiograma (transesofágico) foi
observado tumoração móvel, ovalada, de 0,6 por
0,8 cm de diâmetro, localizada na face aórtica
da valva aórtica, no folheto coronariano direito,
com regurgitação aórtica de grau leve (Figura 1).
Prolapso de valva mitral, com insuficiência mitral
leve foram observados nesse mesmo exame.
Fig.1 - Imagem ecocardiográfica do Fibroelastoma
Papilar, evidenciando a tumoração móvel,
pedunculada, na face aórtica da valva aórtica.
A abordagem operatória deu-se através
de esternotomia mediana, com instalação de
circuito extracorpóreo através de canulação da
aorta ascendente e cava única. Após o pinçamento
aórtico e aortotomia transversa, foi encontrada a
tumoração descrita previamente no ecocardiograma
transesofágico, de coloração rósea, pendente,
localizada no folheto coronariano direito da
valva aórtica (Figura 2). Foi realizada a ressecção
tumoral com a preservação da valva aórtica nativa.
O tempo de circulação extracórporea foi de 50
minutos e o de anóxia foi de 46 minutos.
43
Fig. 2 - Imagem intraoperatória do Fibroelastoma Papilar.
O controle ecocardiográfico intraoperatório,
após a retirada do tumor e a saída da circulação
extracórporea comprovou o funcionamento normal
da valva aórtica, sem regurgitação.
Durante o período de recuperação na
unidade de terapia intensiva, a paciente apresentou
episódio de flutter atrial com posterior reversão ao
ritmo sinusal.
O diagnóstico de Fibroelastoma Papilar
foi confirmado pelo exame histopatológico, com
abundante tecido conjuntivo de característica
mixóide, abundante matriz rica em polissacarídeos
e fibras elásticas cobertas por endotélio (Figura
3).
Fig. 3 - Cortes histológicos mostram a
lesão com superfície papilífera, formada
por projeções alongadas e revestidas por
camada única de células endoteliais. O eixo
é hialínico, avascularizado, não havendo
sinais de malignidade. Compatível com
Fibroelastoma Papilar.
Referências Bibliográficas
1.
Edwards FH, Hale D, Cohen A et al: Primary cardiac valve
tumors. An Thorac Surg 1991; 52:1127
6.
2.
Di Mattia DG; Assaghi A; Mangini A et al: Mitral valve
repair for anterior leaflet papillary fibroelastoma: two case
descriptions and a literature review. Eur J Cardiothorac
Surg 1999; 15:103.
Mazzuco A; Bortolloti V; Thiene G et al: Left ventricular
papillary fibroelastoma with coronary embolizationa. Eur
J Cardiothorac Surg 1989; 3:471.
7.
McFadden PM, Lacy JR: Intracardiac papillary fibroelastoma: an occult case of embolic neurologic deficit. Ann
Thorac Surg 1987; 43:667.
8.
Topol EJ, Biern RO; Reitz BA: Cardiac papillary fibroelastoma and stroke: echocardiographic diagnosis and guide
to excision.Am J Med 1986; 80:129.
9.
Raqui T, Grande AM, Capuccio G et al: Embolizing fibroelastomaof theaorticvalve.JThoracCardiovascSurg1994;2:639.
3.
Grandmougin D; Fayad G; Moukassa D et al: Cardiac
valve pappilary fibroelastomas: clinical, histological and
immunohistochemical studies and a physiopathogenic
hypothesis. J Heart Valve Dis 200; 9:832.
4.
Israel DH, Sherman W, Ambrose JA et al: Dynamic coronary
ostial occlusion due to pappilary fibroelastoma leading to
myocardial ischemic and infarction. Am J Cardiol 1991;
67:104.
5.
Grote J, Mugge A, Schfers HJ: Multiplane transesophageal
echocardiography detection of a papillary fibroelastoma
of the aortic valve causing myocardial infarction. Eur
Heart J 1995; 16:426.
10. Grinda JM, Coetil JP, Chauvaud S et al: Cardiac valve papillary fibroelastoma: surgical excision for revealed or potential embolization. J Thorac Cardiovasc Surg 1999; 117:106.
44
INSTRUCTIONS FOR AUTHORS
1- Objectives: The Cardiovascular Sciences Forum aims to serve all the Cardiovascular Sciences fields of investigation to hold together
multiprofessional experience to optimize the
generation of new ideas, improving mankind
resources in the prevention and treatment of
cardiovascular diseases.
2 - Advertising: Cardiovascular Sciences Forum
does not hold itself responsible for statements
made by any authors. Statements or opinions
expressed in Cardiovascular Sciences Forum
of the authors(s) and do not represent official
policy of the Sponsor Institutions unless so
especified.
No responsability is assumed by the
Cardiovascular Sciences Forum Sponsor
Institutions any neither by it’s Publising
Enterprises, for any injury and/or damage
to persons or propertty as a matter of
products liability, negligence or from any
use or operation of any methods, products,
instructions or ideas contained in the material
herein. No suggest test or procedure should be
carried out unless, in the reader’s judgment,
its risk is justified. Because of rapid advances
in the medical sciences we recommend that
the independent verification of diagnosis and
drug dosages should be made. Discussions,
views and recommendations as to medical
procedure, choice of drugs and drug dosages
are the responsability of the authors.
Although all advertising material published
in Cardiovascular Sciences Forum is expected
to conform to ethical (medical) standards,
inclusion in this publication does not constitute
a guarantee or endorsement by it’s Sponsor
45
Institutions or the Publisher of the quality or
value of such product or of the claim made by
its manufacture.
3 - Papers sent for publication in Cardiovascular
Sciences Forum (Editorials, original articles,
conferences, case reports, actualizations
brief communications) should be related to
cardiovascular sciences and unpublished.
4 - Although the stem language of the Archives,
happens to be English, articles may also be
published in spanish or portuguese. When
published in spanish or portuguese for original
reports an abstract version in english must be
included.
5 - They should be typed in double spacing on
foolscap paper, with 3 cm margins all around
and in 3.5” diskettes, Word 6.0 or superior.
Illustrations do not need to be printed in
diskettes.
6 - Manuscripts should be arranged as follow: a)
title page consisting of concise and informative
title, full name of authors, b) The Service or
Institution name should be displayed in the
bottom of the first page. Folowing that, the
name of the corresponding author, together
with the address, phone, fax and e-mail.
c) abstract not exceeding 250 words and
three key words that can be called in www.
decsbvs.br and/or www.nlmnih.gov/mesh,
d) Introduction, e) material and methods,
f) results, g) comments, h) conclusions,
i) bibliographic references, j) name of the
Service or Institution where the study was
performed, k) address for correspondence.
7 - All articles should be sent together with a
Submission Letter, mentioning the Section in
wich the article is to be part of (see list above),
statement from the author and co-authors to
the fact that all are in agreement with the
contents mentioned in the material, making it
clear presence or not of conflict of interest and
the absence of ethical problem related. That
letter must by all means be sent by fax (55 31.3452.6514) or by mail.
8 - Illustrations and Tables should be printed
in separated pages, with their numbers and
legends.
9 - The Cardiovascular Sciences Forum adopt
the Vancouver Norms (www.icmje.org).
10.1 - Bibliographic references: listed in the
order in which they are first mentioned in
the text. Identify references in text in arabic
numerals within parenthesis marks. Titles
of journals are abbreviated according to the
Index Medicus / Medline. References should
be numbered sequentially, as per appearance
in the text, References cannot have indented
paragraphs, but lined up on the left. Personal
communications and data that have not been
published, should not be included in the list of
references, but just mentioned in the text and in
the footnotes on the page where mentioned.
10.1.1 - Journals: Author (s) name (s) based on rule
explained in item 10.1) - Article title. Journal
title (see item 10.1). year; Volume: first page
- last page.
10.1.2 - Books: Authors (s) name (s) - Title. Edition
(if not the first). City: Publisher, Year: Number
of pages (or that specific for reference).
10.1.3 - Chapter in a book: Author (s) name (s) of
the chapter. Title of the chapter. In: Author (s)
name (s) of the book, eds. Title of the book.
Edition (if not the first). City: Publisher, Year:
first and last pages of the referred chapter.
10.1.4 - Thesis: Autor’s Name, Title (Thesis
degree), City, University, Year.
10.1.5 - Annals of Congress: Name of the author
(s) - Title of the paper published. In: Annals
of the... name of the Congress. City: Promoter
Society of Institution, Year: page.
11 - “Unpublished observations” and “personnal
communications” should not be used as
references. They are included in the text, within
parenthesis marks, or, if extensive, appear as
footnotes. Include among references: papers
accepted but not yet published, designating
the journal and adding “In press” (within
parenthesis marks).
46
UPCOMING MEETINGS
INTENSICARDIO III
III BRAZILIAN CONGRESS OF INTENSIVE CARDIOLOGY
29 e 30 de Junho de 2007/ June 29, 30, 2007
Tropical Hotel, Av. Pepê - n° 500
Barra da Tijuca, Rio de Janeiro - RJ, Brasil
Informações e inscrições/ Information and Registration: www.servcor.com
XVI FORUM DA SOCIEDADE CENTRO-OESTE DE CIRURGIA CARDIOVASCULAR
XVI FORUM OF THE CENTRO-OESTE SOCIETY OF CARDIOVASCULAR SURGERY
24 e 25 de Agosto de 2007/ August 24 - 25, 2007
Bahamas Apart Hotel. Rua José Antônio Pereira, 1117 - Centro - Campo Grande - MS
Informações/ Information: Andréa - (67) 3364.1634/ 8401.6627
LXII CONGRESSO BRASILEIRO DE CARDIOLOGIA
LXII BRAZILIAN CONGRESS OF CARDIOLOGY
07 a 11 de setembro de 2007/ September 07 - 11, 2007
Transamérica Expo Center, São Paulo - SP
Informações/ Information: http://www.cardiol.br
FORUM CIENTÍFICO XVII
XVII INTERNATIONAL CONGRESS ON CARDIOVASCULAR SCIENCES
22 a 25 de Novembro de 2007/ November 22 - 25, 2007
MINASCENTRO, Belo Horizonte - MG - Brasil
Informações e inscrições/ Information and Registration: www.servcor.com
47
XXXV CONGRESSO BRASILEIRO DE CIRURGIA CARDIOVASCULAR 2007
XXXV BRAZILIAN CONGRESS OF CARDIOVASCULAR SURGERY 2007
12 a 14 de Abril de 2007/ April 12 - 14. 2007
Costão do Santinho Resort - Florianópolis/ SC
Informações e inscrições/ Information and Registration:
http://www.sbccv.org.br
CONGRESSO BRASILEIRO DE CARDIOLOGIA DA FAMÍLIA
BRAZILIAN CONGRESS ON CARDIOLOGY FOR THE FAMILY
www.cardiologiadafamilia.com.br
SAÚDE SHOW - PLANETA PLUG
www.planetaplug.com.br
48

apr. / jun. 2007 - vol. 2 - number 2

Transcrição

Documentos relacionados

Monroe: Coagulation Factor Interaction with Platelets

HLA Alloimmunization: Clinical and Laboratory Aspects of

In addition, platelets contain many tissue growth factors. These

Simultaneous Thrombosis in Two Epicardial Coronary Arteries

04-Rosane Nery EN.pmd

Variations in the anatomy of the coronary arteries

Complete Article

Coronary Angiography with Gadolinium in Patients with Severe

blood12116toc 7..10

Perfusion

H Housing Catalog