RESUMO

O instrumento tem um mecanismo de bloqueio e é composto por uma agulha externa de ponta romba com vários furos de diâmetro de 0,5 mm. Internamente é equipada com uma agulha de mandril, que pode ser mobilizada ocluindo ou liberando os orifícios laterais. O procedimento para a produção de microlesões é feito por meio da troca do mandril de ponta romba por um mandril escova provido de microcerdas metálicas estruturalmente concebidas para preencher os orifícios com a exteriorização das pequenas cerdas. Como alternativa para mandril escova há um segundo mandril autoexpansível com o formato de uma pequena pena.

ABSTRACT

The instrument has a locking mechanism and is composed of an external needle with blunt tip, with multiple 0.5 mm diameter holes. Internally it is fitted with a mandrill needle, which can be mobilized inside occluding or releasing the lateral holes. The procedure for producing micro lesions is done by exchanging the blunt mandrill for a brush-mandrill, provided with micro bristles that are structurally designed to fill the holes with small exteriorization of bristles. As an option to brush mandrill there is a second self-expandable feather shaped mandrill.

INTRODUCTION

Sutton et al. [1] wrote, in 1964, a brief historical review reporting that percutaneous introduction of a needle into the cardiac ventricular cavities of human beings was performed many years ago for therapeutic reasons. Summaries of indications and technics were published by Henschen [2] and Lauter [3]. The feasibility of obtaining ventricular myocardial specimens from human beings either by open or closed percutaneous routes was demonstrated in 1956 [4]. These old experiences proved that the heart tolerated these procedures very well, the myocardium quickly contracting around the small effect so that bleeding spontaneously ceased.

Studies on stem cells, based on laboratory data demonstrate functional improvement and reduction of myocardial ischemia when used in animals with acute myocardial infarction. Animal studies have shown different results, depending on the route used for the injection of the cells. There is a clear superiority of results when direct myocardial injections are compared with intracoronary injections. Alternative methods of application of cell therapy products in myocardial infarction, acute or subacute, were tested. Direct injection as adjunctive therapy to revascularization surgery is a viable proposition, but it caters to a select group of patients referred for surgical revascularization immediately after an acute ischemic event [5-8].

The aim of this presentation is to describe a method of percutaneous puncture and injection of stem cells in the myocardium. This device is an adaptation Soubihe needle that was used in the fifties and sixties for myocardial biopsies [9].

METHODS

The instrument is equipped with a locking mechanism, which allows its perfect mobilization as one single unit for micro lesions, and it can be used only as a needle, so it becomes a biological injection instrument. The instrument for myocardium puncturing and injection of biological material is composed of an external needle, which contains at its end a blunt tip and multiple 0.5 mm diameter holes. Internally it is fitted with a blunt mandrill, which when introduced into the external needle, can be mobilized inside to fill the lateral holes occluding or releasing them. This instrument is harmless to myocardial fibers and coronaries as it had been proved when its first designed shape was used to perform heart biopsies, in the past (Figures 1 and 2).

The main objective of the puncturing procedure is to release steam cells into the myocardium. For that, micro lesions should be performed to "receive" the stem cells. The procedure for producing micro lesions is done by exchanging the blunt mandrill by a brush-mandrill, provided with micro bristles that are structurally designed to fill the holes with small exteriorization of bristles. As an option to brush mandrill there is a second self-expandable feather shaped mandrill.

DISCUSSION

A very important characteristic of this instrument is safety. The blunt end of the needle guaranties that during the punching process, in case of unexpected touch of a coronary artery, the vessel will not be hurt or cut, but the needle will slide sideways from it. Therefore, steam cells are injected into the heart while it is perfectly pumping, with the chest unopened. A real possibility is the direct intramyocardial injection during thoracotomy through specific or during the surgical treatment of coronary artery disease [10,11].

ACKNOWLEDGEMENTS

To FAPESP, CNPq, FAEPA and University of São Paulo for funding the research. To Dr. José Eduardo Krieger and Dr. Rafael Dariolli for their support and guidance during preliminary testing needle in INCOR-SP.

REFERÊNCIAS

1. Sutton GC, Driscoll JF, Gunnar RM, Tobin JR Jr. Exploratory mediastinotomy in primary myocardial disease. Progr Cardiovasc Dis. 1964;7:83-97.

2. Henschen K. Die wiederbelebung des herzens dureh peri- und intrakardiale injektion dureh herzaderlass und herzinfusion. Schweiz Med Wchnschr. 1920;1:261.

3. Lauter S. Kreislaufprobleme. Miinchener Med Wclmschr. 1930;77:526.

4. Kent G, Sutton DC, Sutton GC. Needle biopsy of the human ventricular myocardium. Q Bull Northwest Univ Med Sch. 1956;30(3):213-4. [MedLine]

5. Strauer BE, Kornowski R. Stem cell therapy in perspective. Circulation. 2003;107(7):929-34. [MedLine]

6. Perin EC, Geng YJ, Willerson JT. Adult stem cell therapy in perspective. Circulation. 2003;107(7):935-8. [MedLine]

7. Ladage D, Ishikawa K, Tilemann L, Müller-Ehmsen J, Kawase Y. Percutaneous methods of vector delivery in preclinical models. Gene Ther. 2012;19(6):637-41. [MedLine]

8. Krause K, Jaquet K, Schneider C, Haupt S, Lioznov MV, Otte KM, et al. Percutaneous intramyocardial stem cell injection in patients with acute myocardial infarction: first-in-man study. Heart. 2009;95(14):1145-52. [MedLine]

9. Soubihe NV. Herzbiopsie. Thoraxchirurgie. 1961;9:31.

10. Galantier M, Moreira GB, Bub RF, Galantier J, Buffolo E, Carvalho AC, et al. Revascularização transmiocárdica a laser. Rev Bras Cir Cardiovasc. 1996;11(2):67-74.

11. Dallan LA, Gowdak LH, Lisboa LA, Schettert I, Krieger JE, Cesar LA, et al. Cell therapy plus transmyocardial laser revascularization: a proposed alternative procedure for refractory angina. Rev Bras Cir Cardiovasc. 2008;23(1):46-52. [MedLine] Visualizar artigo

Work funded by CNPq, FAPESP, FAEPA and USP

Authors' roles & responsibilities

NVSJ: Original idea and design of the project

AS: Project planning

AASA: Technical support

PRBE: Study design and writing of the paper

Article receive on domingo, 7 de abril de 2013