Contrast echocardiography: a practical guideline from the British Society of Echocardiography

Ultrasound contrast agents (UCAs) have a well-established role in clinical cardiology. Contrast echocardiography has evolved into a routine technique through the establishment of contrast protocols, an excellent safety profile, and clinical guidelines which highlight the incremental prognostic utility of contrast enhanced echocardiography. This document aims to provide practical guidance on the safe and effective use of contrast; reviews the role of individual staff groups; and training requirements to facilitate its routine use in the echocardiography laboratory.

Giant proximal left anterior descending aneurysm causing multi-vessel myocardial ischaemia: the pressure is on-a case report

Background

Giant coronary artery aneurysms are a rare cause of myocardial ischaemia. Due to the rarity and variety of presentation of these cases, no standardized investigation or treatment has been established for management. We report a case study of a giant proximal left anterior descending (LAD) coronary aneurysm causing myocardial ischaemia due to the pressure effect from the weight of the aneurysm as well as from a change in rheology from a 'steal effect' on both the LAD and left circumflex (LCx) arteries.

Case summary

A 55-year-old patient presents initially with a history of angina. Initial investigation with computed tomography (CT) was suboptimal, requiring invasive diagnostic angiography, which detects a giant proximal LAD aneurysm. Subsequent investigations, with CT-fractional flow reserve (FFR) and stress echocardiography (ECHO), correlated to identify multi-vessel ischaemia resulting from the aneurysm. The patient was managed with multi-disciplinary team-led surgical resection and triple coronary artery bypass grafts with good results.

Discussion

This case highlights the complexity of coronary anomalies and importance of additional functional three-dimensional imaging on top of the static computational tomography coronary angiography analysis. Together, these two complimentary investigations qualitatively enabled the assessment of anomaly with surrounding structures such that the possibility of a mass effect on the LCx artery results in a positive stress test. Furthermore, this is a novel use of CT-FFR for coronary anomalies and it demonstrated good correlation of LAD territory ischaemia between CT-FFR and the stress ECHO.

Time to TAVI: streamlining the pathway to treatment

INTRODUCTION

Severe aortic stenosis is a major cause of morbidity and mortality. The existing treatment pathway for transcatheter aortic valve implantation (TAVI) traditionally relies on tertiary Heart Valve Centre workup. However, this has been associated with delays to treatment, in breach of British Cardiovascular Intervention Society targets. A novel pathway with emphasis on comprehensive patient workup at a local centre, alongside close collaboration with a Heart Valve Centre, may help reduce the time to TAVI.

METHODS

The centre performing local workup implemented a novel TAVI referral pathway. Data were collected retrospectively for all outpatients referred for consideration of TAVI to a Heart Valve Centre from November 2020 to November 2021. The main outcome of time to TAVI was calculated as the time from Heart Valve Centre referral to TAVI, or alternative intervention, expressed in days. For the centre performing local workup, referral was defined as the date of multidisciplinary team discussion. For this centre, a total pathway time from echocardiographic diagnosis to TAVI was also evaluated. A secondary outcome of the proportion of referrals proceeding to TAVI at the Heart Valve Centre was analysed.

RESULTS

Mean±SD time from referral to TAVI was significantly lower at the centre performing local workup, when compared with centres with traditional referral pathways (32.4±64 to 126±257 days, p<0.00001). The total pathway time from echocardiographic diagnosis to TAVI for the centre performing local workup was 89.9±67.6 days, which was also significantly shorter than referral to TAVI time from all other centres (p<0.003). Centres without local workup had a significantly lower percentage of patients accepted for TAVI (49.5% vs 97.8%, p<0.00001).

DISCUSSION

A novel TAVI pathway with emphasis on local workup within a non-surgical centre significantly reduced both the time to TAVI and rejection rates from a Heart Valve Centre. If adopted across the other centres, this approach may help improve access to TAVI.

The plausible effects of wearing face masks on sports performance - A scoping review

Objectives

The objectives of this scoping review are to discuss, firstly, the positive aspects of wearing face masks during training (such as a barrier to COVID-19 transmission, air pollutant exposure, and adding load on respiratory resistance flow); secondly, the negative aspects (adverse effects on body temperature and hypoxia risks); and thirdly, the training responses of wearing face masks on aerobic and anaerobic performance.

News

Besides social distancing and hand hygiene, wearing a face mask is proposed to be the prime advocacy for virus containment. During the period of high risk of contamination, the return to sport guidelines proposed by international and national sport federations included wearing face masks during training sessions. However, it is necessary to discuss the pros and cons of wearing face masks during exercise.

Prospects

Although it was essential to wear a face mask during exercise or sport-specific training, there is conflicting evidence on the implications of the use of face masks on physical, physiological as well as psychological well-being or performance. Based on the conflicting empirical findings and anecdotal evidence, certain recommendations have been made for adequate use of face masks during exercise; both to break the chain of transmission and prevent the physiological compromise expected from wearing face masks during exercise. The present review can help stakeholders balance sport guidelines in the event of a respiratory virus pandemic with athlete safety.

Conclusion

Conflicting evidence of mechanistic links between the dose of exercise and the possible adverse effects associated with exercising with face masks is available. Adequately powered studies with strong methodological quality on appropriate selection of masks and usage based on the intensity, duration, and type of sport, age, and gender is needed now for the stakeholders to make informed decisions with respect to exercising with face masks.

Left ventricular assessment with artificial intelligence increases the diagnostic accuracy of stress echocardiography

AIMS

To evaluate whether left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS), automatically calculated by artificial intelligence (AI), increases the diagnostic performance of stress echocardiography (SE) for coronary artery disease (CAD) detection.

METHODS AND RESULTS

SEs from 512 participants who underwent a clinically indicated SE (with or without contrast) for the evaluation of CAD from seven hospitals in the UK and US were studied. Visual wall motion scoring (WMS) was performed to identify inducible ischaemia. In addition, SE images at rest and stress underwent AI contouring for automated calculation of AI-LVEF and AI-GLS (apical two and four chamber images only) with Ultromics EchoGo Core 1.0. Receiver operator characteristic curves and multivariable risk models were used to assess accuracy for identification of participants subsequently found to have CAD on angiography. Participants with significant CAD were more likely to have abnormal WMS, AI-LVEF, and AI-GLS values at rest and stress (all P < 0.001). The areas under the receiver operating characteristics for WMS index, AI-LVEF, and AI-GLS at peak stress were 0.92, 0.86, and 0.82, respectively, with cut-offs of 1.12, 64%, and -17.2%, respectively. Multivariable analysis demonstrated that addition of peak AI-LVEF or peak AI-GLS to WMS significantly improved model discrimination of CAD [C-statistic (bootstrapping 2.5th, 97.5th percentile)] from 0.78 (0.69-0.87) to 0.83 (0.74-0.91) or 0.84 (0.75-0.92), respectively.

CONCLUSION

AI calculation of LVEF and GLS by contouring of contrast-enhanced and unenhanced SEs at rest and stress is feasible and independently improves the identification of obstructive CAD beyond conventional WMSI.

A case report of successful physiological pacing in a patient with lamin A/C cardiomyopathy

Background

Lamin A/C (LMNA) mutations account for 5–8% of familial dilated cardiomyopathies, and can manifest with conduction abnormalities and ventricular arrhythmias in 78% of patients. Therefore, when suspected, it is important to implant the correct type of device.

Case summary

A 52-year-old gentleman with a family history of cardiomyopathy, presented with asymptomatic atrial fibrillation and complete atrioventricular block associated with a narrow QRS interval. Investigations confirmed dilated and severely impaired left ventricular systolic function. He underwent successful conduction system pacing in combination with a primary prevention defibrillator. Genetic screening confirmed LMNA cardiomyopathy. During 3 years follow up, his left ventricular function remained unchanged with stable conduction system capture and he received appropriate therapy from his device for ventricular tachycardia.

Discussion

His-bundle pacing promotes rapid and synchronous activation of the ventricles via the intrinsic conduction system of the heart. In selected individuals with LMNA cardiomyopathy, conduction system pacing is viable alternative to conventional cardiac resynchronization therapy using coronary sinus tributaries.

Real-world evidence in a national health service: results of the UK CardioMEMS HF System Post-Market Study

Aims

The CardioMEMS HF System Post‐Market Study (COAST) was designed to evaluate the safety, effectiveness, and feasibility of haemodynamic‐guided heart failure (HF) management using a small sensor implanted in the pulmonary artery of New York Heart Association (NYHA) Class III HF patients in the UK, Europe, and Australia.

Methods and results

COAST is a prospective, international, multicentre, open‐label clinical study (NCT02954341). The primary clinical endpoint compares annualized HF hospitalization rates after 1 year of haemodynamic‐guided management vs. the year prior to sensor implantation in patients with NYHA Class III symptoms and a previous HF hospitalization. The primary safety endpoints assess freedom from device/system‐related complications and pressure sensor failure after 2 years. Results from the first 100 patients implanted at 14 out of the 15 participating centres in the UK are reported here. At baseline, all patients were in NYHA Class III, 70% were male, mean age was 69 ± 12 years, and 39% had an aetiology of ischaemic cardiomyopathy. The annualized HF hospitalization rate after 12 months was 82% lower [95% confidence interval 72–88%] than the previous 12 months (0.27 vs. 1.52 events/patient‐year, respectively, P < 0.0001). Freedom from device/system‐related complications and pressure sensor failure at 2 years was 100% and 99%, respectively.

Conclusions

Remote haemodynamic‐guided HF management, using frequent assessment of pulmonary artery pressures, was successfully implemented at 14 specialist centres in the UK. Haemodynamic‐guided HF management was safe and significantly reduced hospitalization in a group of high‐risk patients. These results support implementation of this innovative remote management strategy to improve outcome for patients with symptomatic HF.

Clinical registration number: ClinicalTrials.gov identifier: NCT02954341.

Piloting structured focused TTE in outpatients during the COVID-19 pandemic: 'old habits die hard'

Transthoracic echocardiography presents a risk of COVID-19 transmission between an echocardiographer and the patient. Reducing the scanning time is likely to mitigate this risk for them both. British Society of Echocardiography (BSE) level 1 echocardiography offers a potential framework for focused scanning in an outpatient setting. There were 116 outpatients scheduled for a level 1 scan supplemented with additional predefined views, if required. Unexpectedly, a fifth of the scans were performed as an unintended full scan for a variety of reasons. Our results showed that focused scans were performed more quickly than full scans and below the NHS Test and Trace exposure cut-off of 15 minutes. However, if more than three sets of additional measurements were required then a full scan could be performed more quickly. Seniority of the echocardiographer and scan time had an inverse relationship. By examining the patients' clinical records we were confident that all of the scans, whether focused or full, had answered the requestor's clinical question. Although the COVID-19 vaccination programme should reduce the necessity of minimising exposure time during a scan there could still be a role for level 1 scanning during the COVID-19 recovery programme to tackle the vast lists of patients waiting for an echocardiogram.

Real-world performance and accuracy of stress echocardiography: the EVAREST observational multi-centre study

Aims

Stress echocardiography is widely used to identify obstructive coronary artery disease (CAD). High accuracy is reported in expert hands but is dependent on operator training and image quality. The EVAREST study provides UK-wide data to evaluate real-world performance and accuracy of stress echocardiography.

Methods and results

Participants undergoing stress echocardiography for CAD were recruited from 31 hospitals. Participants were followed up through health records which underwent expert adjudication. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, medical management of ischaemia, acute coronary syndrome, or cardiac-related death within 6 months. A total of 5131 patients (55% male) participated with a median age of 65 years (interquartile range 57–74). 72.9% of studies used dobutamine and 68.5% were contrast studies. Inducible ischaemia was present in 19.3% of scans. Sensitivity and specificity for prediction of a cardiac outcome were 95.4% and 96.0%, respectively, with an accuracy of 95.9%. Sub-group analysis revealed high levels of predictive accuracy across a wide range of patient and protocol sub-groups, with the presence of a resting regional wall motion abnormalitiy significantly reducing the performance of both dobutamine (P < 0.01) and exercise (P < 0.05) stress echocardiography. Overall accuracy remained consistently high across all participating hospitals.

Conclusion

Stress echocardiography has high accuracy across UK-based hospitals and thus indicates stress echocardiography is being delivered effectively in real-world practice, reinforcing its role as a first-line investigation in the assessment of patients with stable chest pain.

Circadian influence on post-exercise hypotension: a review

Circadian rhythm (CR) can influence the physiological and psychological parameters in every individual. There is a sinusoidal response to blood pressure brought about by the CR. A drop in blood pressure response immediately after an exercise is termed as post-exercise hypotension (PEH). The objective of the present paper is to review the influence of CR on PEH. Comparing the types of exercises, aerobic training showed a higher magnitude of the drop in PEH than resistance training. However, the majority of the studies have not considered the CR influence on PEH. With the evidence available, we can conclude that morning exercise shows the higher magnitude of the drop in PEH and could be sustained for a longer duration.

His bundle pacing, learning curve, procedure characteristics, safety, and feasibility: Insights from a large international observational study

Background

His‐bundle pacing (HBP) provides physiological ventricular activation. Observational studies have demonstrated the techniques’ feasibility; however, data have come from a limited number of centers.

Objectives

We set out to explore the contemporary global practice in HBP focusing on the learning curve, procedural characteristics, and outcomes.

Methods

This is a retrospective, multicenter observational study of patients undergoing attempted HBP at seven centers. Pacing indication, fluoroscopy time, HBP thresholds, and lead reintervention and deactivation rates were recorded. Where centers had systematically recorded implant success rates from the outset, these were collated.

Results

A total of 529 patients underwent attempted HBP during the study period (2014‐19) with a mean follow‐up of 217 ± 303 days. Most implants were for bradycardia indications.

In the three centers with the systematic collation of all attempts, the overall implant success rate was 81%, which improved to 87% after completion of 40 cases.

All seven centers reported data on successful implants. The mean fluoroscopy time was 11.7 ± 12.0 minutes, the His‐bundle capture threshold at implant was 1.4 ± 0.9 V at 0.8 ± 0.3 ms, and it was 1.3 ± 1.2 V at 0.9 ± 0.2 ms at last device check.

HBP lead reintervention or deactivation (for lead displacement or rise in threshold) occurred in 7.5% of successful implants.

There was evidence of a learning curve: fluoroscopy time and HBP capture threshold reduced with greater experience, plateauing after approximately 30‐50 cases.

Conclusion

We found that it is feasible to establish a successful HBP program, using the currently available implantation tools. For physicians who are experienced at pacemaker implantation, the steepest part of the learning curve appears to be over the first 30‐50 cases.

Mitral Valve Diverticulum Presenting with Severe Mitral Stenosis: Case Report

The case is presented of a non-infectious anterior mitral valve leaflet diverticulum, which appeared as symptomatic mitral stenosis. Unlike previous reports, there was no histological myxomatous degeneration of the valve. To the authors' knowledge, this is the first time a mitral valve diverticulum resulting in severe mitral stenosis has been reported in the literature.

Iatrogenic mitral stenosis following transcatheter aortic valve replacement (TAVR)

A 57 year old female underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Mild iatrogenic mitral stenosis was noted intraoperatively. Attempts to reposition the device were hampered by aortic angulation. One year later, severe mitral stenosis was confirmed on transoesophageal echocardiography. It is important to recognise that iatorgenic mitral stenosis due to TAVR may progress over time. Care should be taken to minimise the risk of this rare complication.

Mechanistic insight into active chlorine species mediated electrochemical degradation of recalcitrant phenolic polymers

Degradation of recalcitrant phenolic syntan by electro-oxidation was investigated. The kinetics of mineralization of phenolic syntan was followed both in terms of TOC and COD measurements.

A microscopic evaluation of collagen-bilirubin interactions: in vitro surface phenomenon

This study is carried out to understand the morphology variations of collagen I matrices influenced by bilirubin. The characteristics of bilirubin interaction with collagen ascertained using various techniques like XRD, CLSM, fluorescence, SEM and AFM. These techniques are used to understand the distribution, expression and colocalization patterns of collagen-bilirubin complexes. The present investigation mimic the in vivo mechanisms created during the disorder condition like jaundice. Fluorescence technique elucidates the crucial role played by bilirubin deposition and interaction during collagen organization. Influence of bilirubin during collagen fibrillogenesis and banding patterns are clearly visualize using SEM. As a result, collagen-bilirubin complex provides different reconstructed patterns because of the influence of bilirubin concentration. Selectivity, specificity and spatial organization of collagen-bilirubin are determined through AFM imaging. Consequently, it is observed that the morphology and quantity of the bilirubin binding to collagen varied by the concentrations and the adsorption rate in protein solutions. Microscopic studies of collagen-bilirubin interaction confirms that bilirubin influence the fibrillogenesis and alter the rate of collagen organization depending on the bilirubin concentration. This knowledge helps to develop a novel drug to inhibit the interface point of interaction between collagen and bilirubin.

A Constraint Satisfaction Framework for Executing Perceptions and Actions in Diagrammatic Reasoning

Diagrammatic reasoning (DR) is pervasive in human problem solving as a powerful adjunct to symbolic reasoning based on language-like representations. The research reported in this paper is a contribution to building a general purpose DR system as an extension to a SOAR-like problem solving architecture. The work is in a framework in which DR is modeled as a process where subtasks are solved, as appropriate, either by inference from symbolic representations or by interaction with a diagram, i.e., perceiving specified information from a diagram or modifying/creating objects in a diagram in specified ways according to problem solving needs. The perceptions and actions in most DR systems built so far are hand-coded for the specific application, even when the rest of the system is built using the general architecture. The absence of a general framework for executing perceptions/actions poses as a major hindrance to using them opportunistically -- the essence of open-ended search in problem solving. Our goal is to develop a framework for executing a wide variety of specified perceptions and actions across tasks/domains without human intervention. We observe that the domain/task-specific visual perceptions/actions can be transformed into domain/task-independent spatial problems. We specify a spatial problem as a quantified constraint satisfaction problem in the real domain using an open-ended vocabulary of properties, relations and actions involving three kinds of diagrammatic objects -- points, curves, regions. Solving a spatial problem from this specification requires computing the equivalent simplified quantifier-free expression, the complexity of which is inherently doubly exponential. We represent objects as configuration of simple elements to facilitate decomposition of complex problems into simpler and similar subproblems. We show that, if the symbolic solution to a subproblem can be expressed concisely, quantifiers can be eliminated from spatial problems in low-order polynomial time using similar previously solved subproblems. This requires determining the similarity of two problems, the existence of a mapping between them computable in polynomial time, and designing a memory for storing previously solved problems so as to facilitate search. The efficacy of the idea is shown by time complexity analysis. We demonstrate the proposed approach by executing perceptions and actions involved in DR tasks in two army applications.

Variability of soil-water quality due to Tsunami-2004 in the coastal belt of Nagapattinam district, Tamilnadu

In this study, the Tsunami-caused deterioration of soil and groundwater quality in the agricultural fields of coastal Nagapattinam district of Tamilnadu state in India is presented by analyzing their salinity and sodicity parameters. To accomplish this, three sets of soil samples up to a depth of 30 cm from the land surface were collected for the first six months of the year 2005 from 28 locations and the ground water samples were monitored from seven existing dug wells and hand pumps covering the study region at intervals of 3 months. The EC and pH values of both the soil and ground water samples were estimated and the spatial and temporal variability mappings of these parameters were performed using the geostatistical analysis module of ArcGIS((R)). It was observed that the spherical semivariogram fitted well with the data set of both EC and pH and the generated kriged maps explained the spatial and temporal variability under different ranges of EC and pH values. Further, the recorded EC and pH data of soil and ground water during pre-Tsunami periods were compared with the collected data and generated variability soil maps of EC and pH of the post-Tsunami period. It was revealed from this analysis that the soil quality six months after the Tsunami was nearing the pre-Tsunami scenario (EC< 1.5 dS m(-1); pH<8), whereas the quality of ground water remained highly saline and unfit for irrigation and drinking. These observations were compared with the ground scenarios of the study region and possible causes for such changes and the remedial measures for taking up regular agricultural practices are also discussed.

The role of apelin in cardiovascular function and heart failure

Apelin is a novel peptide that acts through the APJ receptor, sharing similarities with the angiotensin II-angiotensin II type 1 receptor pathway. It is a peripheral vasodilator, powerful inotrope and may affect central fluid homeostasis. Animal and human studies suggest that it may play a role in the pathogenesis of heart failure by modulating the harmful effects of angiotensin II. Apelin is reduced in patients with heart failure and up regulated following favourable left ventricular remodelling. It is widely distributed in a number of tissues, mainly restricted to vascular endothelium. This comprehensive review of the literature highlights the important studies that have led to the discovery of apelin and its role in cardiovascular function and heart failure.

Synchronization of cells in the S phase of the cell cycle by 3'-azido-3'-deoxythymidine: implications for cell cytotoxicity

The mechanism of synergy between 3'-azido-3'-deoxythymidine (AZT) and anticancer agents was investigated with emphasis on cell-cycle events. Exposure of exponentially growing WiDr human colon carcinoma cells to AZT resulted in synchronization of cells in the S phase of the cell cycle. Following treatment with AZT at 50 or 200 microM, 62% +/- 3% or 82% +/- 4% of the cells were in the S phase as compared with 36% +/- 2% in the control. Bromodeoxyuridine uptake studies revealed that the synchronized cells actively synthesized DNA. At concentrations of up to 200 microM, AZT produced a cytostatic rather than cytotoxic effect as indicated by viability and cell growth measurements. At 200 microM, AZT-induced synchronization was significant (P = < 0.001) after 12 h of drug exposure, reached a maximum at 24 h, and reversed to baseline levels by 72 h even in the continued presence of the drug. This indicates that AZT-induced cytostasis is a transient and reversible effect. The cell-cycle events seen with AZT in WiDr cells were also observed in eight of nine human tumor cell lines tested. Isobologram analysis of WiDr cells preexposed to AZT for 24 h and then exposed to either AZT-5-fluorouracil or AZT-methotrexate for a further 72 h revealed synergy between AZT and the anticancer agents, indicating that AZT-induced synchronization may have therapeutic benefits.

Composite fish culture for mosquito control in rice fields in southern India

Composite culture of edible fishes (common carp, Cryprinus carpio; silver carp, Hypopthalmithys molitrix, grass carp, Ctenopharyngodon idella; catla, Catla catla; rohu, Labeo rohita; and mrigal, Cirrhinus mrigala) in rice fields in the Cauvery delta of Tamil Nadu, southern India, resulted in 81.0% reduction in the immature mosquito population of anophelines and 83.5% of culicines. Analysis of fish feces for mosquito larval head capsules showed that common carp and silver carp are effective larvivores. The selective feeding of common carp on culicines and silver carp on anophelines is correlated to their trophic niches. Net profit in the fish-cum-rice fields was 2.5 times greater than fields in which rice alone was cultured. Hence, rice-cum-fish culture can be recommended to the farming community in this area.

Designing medical informatics research and library--resource projects to increase what is learned

Careful study of medical informatics research and library-resource projects is necessary to increase the productivity of the research and development enterprise. Medical informatics research projects can present unique problems with respect to evaluation. It is not always possible to adapt directly the evaluation methods that are commonly employed in the natural and social sciences. Problems in evaluating medical informatics projects may be overcome by formulating system development work in terms of a testable hypothesis; subdividing complex projects into modules, each of which can be developed, tested and evaluated rigorously; and utilizing qualitative studies in situations where more definitive quantitative studies are impractical.

Deoxypyrimidine-induced inhibition of the cytokinetic effects of 1-beta-D-arabinofuranosyluracil

Ara-U-induced S-phase accumulation and the interaction between high concentrations of ara-U (HiCAU) and ara-C were investigated in L1210 leukemia cells in vitro. Treatment of exponentially growing L1210 murine leukemia cells with ara-U (200-1000 microM) for 48 h caused a dose-dependent accumulation of cells in the S-phase. The extent of this ara-U-induced S-phase accumulation correlated with ara-U incorporation into DNA and with increases of up to 172% and 464% in the specific activities of deoxycytidine kinase and thymidine kinase, respectively, over control values. Metabolism of 1 microM ara-C following the exposure of cells to ara-U (1 mM) resulted in 4.5 pmol araC DNA/mg protein vs 2.1 pmol/mg protein in control cells. Although 48-h exposure of cells to 200 and 400 microM ara-U is not cytotoxic, it enhances the cytotoxicity of ara-C (10-100 microM) 4- to 10-fold. Ara-U-induced S-phase accumulation is inhibited by deoxypyrimidine nucleosides but not by pyrimidine or deoxypurine nucleosides. Some of the ara-U and ara-C concentrations used in this study are achievable in clinical practice, and ara-U/ara-C interactions may explain in part the unique therapeutic utility of high-dose ara-C.

Modulation of the metabolism and pharmacokinetics of 1-beta-D-arabinofuranosylcytosine by 1-beta-D-arabinofuranosyluracil in leukemic mice

The interaction between high concentrations of 1-beta-D-arabinofuranosyluracil (HiCAU) and 1-beta-D-arabinofuranosylcytosine (ara-C) was investigated in vivo with emphasis on cell kinetics, pharmacokinetics, and drug metabolism. Mice bearing L5178Y leukemia were given a 48-h s.c. infusion of high-dose ara-U (HiDAU) to achieve a plasma level of 0.5 to 1 mM. A total dose of 7.35 g/kg/day for 2 days was nontoxic; the mean survival of control (saline treated) leukemic mice was 12.2 +/- 1.8 days and 11.7 +/- 2.0 days for the HiDAU-treated leukemic mice. Using flow cytometry, cell cycle progression of L5178Y ascites cells was monitored during HiDAU infusion. At 48 h, the proliferative index (PI) percentage of the leukemic cells is significantly different (P less than 0.001) in HiDAU-treated leukemic mice (mean = 50.8) versus control (mean = 45.6). A higher PI percentage is associated with accumulation of cells in S phase. This effect was highly variable in the ara-U-treated mice, and the ara-U "perturbed" group was defined as those mice whose cells had an increase in the PI to greater than or equal to 50%. The higher PI percentage in HiDAU-treated mice correlated with HiCAU in ascites fluid, leukemic cells, and kidney of perturbed mice. HiCAU in the "ara-U-perturbed" group altered the plasma pharmacokinetics of high-dose ara-C (HiDAC, 1 g/kg), increased the cellular metabolism of ara-C to 1-beta-D-arabinofuranosylcytidine triphosphate (ara-CTP) (3-fold), and increased ara-C-DNA synthesis (3-fold). In mice bearing the L5178Y leukemia, a 48-h infusion of ara-U followed by a 24-h s.c. infusion of 40 mg/kg resulted in a 260% increase in life span and seven 90-day survivors among 16 treated mice. In contrast, ara-U or ara-C alone had a negligible therapeutic effect. ara-U-induced alterations in the systemic pharmacokinetics of ara-C are the result of inhibition of cytidine deaminase activity by HiCAU in liver and kidneys. This results in a decrease in ara-C catabolism and prolongs the plasma half-life of ara-C. The dual alteration of the pharmacokinetics of ara-C and cytokinetics of the leukemia cells by HiCAU results in enhanced survival of leukemic mice. These results may help explain the clinical utility of HiDAC treatment programs for patients with acute leukemia.