Early Increase in Myocardial Perfusion After Stem Cell Therapy in Patients Undergoing Incomplete Coronary Artery Bypass Surgery
Incomplete revascularization is associated with worse long-term outcomes. Autologous bone marrow cells (BMC) have recently been tested in patients with severe coronary artery disease. We tested the hypothesis that intramyocardial injection of autologous BMC increases myocardial perfusion in patients undergoing incomplete coronary artery bypass grafting (CABG). Twenty-one patients (19 men), 59 ± 7 years old, with limiting angina and multivessel coronary artery disease (CAD), not amenable to complete CABG were enrolled. BMC were obtained prior to surgery, and the lymphomonocytic fraction separated by density gradient centrifugation. During surgery, 5 mL containing 2.1 ± 1.3 × 108 BMC (CD34+ = 0.8 ± 0.3%) were injected in the ischemic non-revascularized myocardium. Myocardial perfusion was assessed by magnetic resonance imaging (MRI) at baseline and 1 month after surgery. The increase in myocardial perfusion was compared between patients with <50% (group A, n = 11) with that of patients with >50% (group B, n = 10) of target vessels (stenosis ≥ 70%) successfully bypassed. Injected myocardial segments included the inferior (n = 12), anterior (n = 7), and lateral (n = 2) walls. The number of treated vessels (2.3 ± 0.8) was significantly smaller than the number of target vessels (4.2 ± 1.0; P < 0.0001). One month after surgery, cardiac MRI showed a similar reduction (%) in the ischemic score of patients in group A (72.5 ± 3.2), compared to patients in group B (78.1 ± 3.2; P = .80). Intramyocardial injection of autologous BMC may help increase myocardial perfusion in patients undergoing incomplete CABG, even in those with fewer target vessels successfully treated. This strategy may be an adjunctive therapy for patients suffering from a more advanced (diffuse) CAD not amenable for complete direct revascularization.
KeywordsStem cells Coronary artery disease Ischemia Cardiac surgery Magnetic resonance imaging
The authors would like to express their gratefulness to Teresa Cristina B. F. da Silva, RN, for her dedication to the care of patients; to Maria de Lourdes Junqueira, BS, for technical assistance; and to Meyrielli Alves Vieira, for secretarial assistance. This study was supported by grants from Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP Grant 01/00009-0 to JEK), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq Grant 552320/2005/6 to LHWG, and 552324/2005-1 to JEK) and Fundação Zerbini.
- 2.Caines, A. E., Massad, M. G., Kpodonu, J., Rebeiz, A. G., Evans, A., & Geha, A. S. (2004). Outcomes of coronary artery bypass grafting versus percutaneous coronary intervention and medical therapy for multivessel disease with and without left ventricular dysfunction. Cardiology, 101, 21–28.CrossRefPubMedGoogle Scholar
- 3.Hueb, W., Soares, P. R., Gersh, B. J., et al. (2004). The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. Journal of the American College of Cardiology, 43, 1743–1751.CrossRefPubMedGoogle Scholar
- 4.Serruys, P. W., Ong, A. T., van Herwerden, L. A., et al. (2005). Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial. Journal of the American College of Cardiology, 46, 575–581.CrossRefPubMedGoogle Scholar
- 9.McLellan, C. S., Ghali, W. A., Labinaz, M., et al. (2005). Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) Investigators. Association between completeness of percutaneous coronary revascularization and postprocedure outcomes. American Heart Journal, 150, 800–806.CrossRefPubMedGoogle Scholar
- 28.Eagle, K. A., Guyton, R. A., Davidoff, R., et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology website. Available at http://www.acc.org/clinical/guidelines/cabg/cabg.pdf.
- 29.Gibbons RJ, RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients with Chronic Stable Angina). 2002. Available at http://www.acc.org/clinical/guidelines/stable/stable.pdf.
- 40.Sousa Uva, M., Cavaco, S., Oliveira, A. G., et al. (2010). Early graft patency after off-pump and on-pump coronary bypass surgery: a prospective randomized study. Eur Heart J (in press).Google Scholar
- 43.Scott, R., Blackstone, E. H., McCarthy, P. M., et al. (2000). Isolated bypass grafting of the left internal thoracic artery to the left anterior descending coronary artery: late consequences of incomplete revascularization. The Journal of Thoracic and Cardiovascular Surgery, 120, 173–184.CrossRefPubMedGoogle Scholar