Effect of RNAi therapeutics patisiran and vutrisiran on orthostatic hypotension due to dysautonomia in patients with hereditary transthyretin-mediated amyloidosis with polyneuropathy

Background

Hereditary transthyretin-mediated (hATTR) amyloidosis, also known as ATTRv amyloidosis, is a rapidly progressive, multisystem disease. Orthostatic hypotension, due to autonomic neuropathy, is a common yet hard-to-treat disease manifestation in patients with hATTR amyloidosis. Fatigue, muscle weakness, and deterioration in cardiac function further exacerbate orthostatic symptoms. Efficacy of RNAi therapeutics patisiran and vutrisiran was assessed in patients with hATTR amyloidosis with polyneuropathy across the APOLLO (NCT01960348), Global Open-Label Extension (OLE) (NCT02510261), and HELIOS-A (NCT03759379) studies, respectively.

Purpose

Evaluate the quantitative effect of patisiran and vutrisiran on orthostatic hypotension in patients with hATTR amyloidosis with polyneuropathy.

Methods

In APOLLO, patients were randomised 2:1 to patisiran 0.3 mg/kg or placebo, IV q3w. Patients who completed APOLLO (APOLLO-placebo, APOLLO-patisiran) were eligible to enrol into the ongoing Global OLE (patisiran 0.3 mg/kg IV q3w). In HELIOS-A, patients were randomised 3:1 to vutrisiran (25 mg SC q3m) or patisiran (0.3 mg/kg IV q3w; reference group). Primary endpoint for APOLLO and HELIOS-A was change from baseline in the modified Neuropathy Impairment Score+7 (mNIS+7) vs APOLLO placebo at M18 (APOLLO) and M9 (HELIOS-A). Orthostatic hypotension was evaluated using the postural blood pressure (PBP) component of mNIS+7, calculated as the mean of 2 supine readings of systolic BP [SBP, mmHg] taken 15 min apart minus the lowest SBP upon standing at 1, 3, and 5 min. A smaller reduction in observed SBP between supine and upright readings indicated an improved PBP.

Results

APOLLO enrolled 225 patients (placebo, n=77; patisiran, n=148), Global OLE 211 and HELIOS-A 164 (vutrisiran, n=122; patisiran, n=42). At baseline, the severity of orthostatic hypotension was similar between within-study treatment arms in APOLLO and HELIOS-A. In APOLLO, patisiran-treated patients showed PBP improvement or stabilization from baseline to M18 (mean [SD] change in SBP: baseline, −17.6 [19.4]; M18, −13.5 [16.8]) and was maintained at Global OLE 36m (−13.4 [15.6]). In contrast, placebo-treated patients in APOLLO had an increased change in PBP over 18m (baseline, −17.5 [16.5]; M18, −20.4 [16.9]); their PBP improved after patisiran initiation (Global OLE 36m, −16.6 [18.1]). In HELIOS-A, stabilization in PBP was observed in the vutrisiran arm (baseline, −11.2 [14.0], M18, −11.7 [14.6]). In the smaller patisiran arm, while the change in PBP increased, the value remained in the normal range (baseline, −11.6 [17.2]; M18, −14.2 [15.5]). Patisiran and vutrisiran have acceptable safety profiles.

Conclusions

PBP analyses quantify the benefits of RNAi therapeutics patisiran and vutrisiran on autonomic function in patients with hATTR amyloidosis with polyneuropathy. The increase in change in PBP to a symptomatic range without treatment indicates the importance of early intervention.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Alnylam Pharmaceuticals

POS0469 FALL RISK ASSESSMENT IN RHEUMATOID ARTHRITIS PATIENTS

Background:

Rheumatoid arthritis patients may have an increased risk of falls due to changes caused by the disease such as muscle weakness, joint impairment, reduced mobility and postural instability.

Objectives:

The aim of this study was to analyze the occurrence of falls in RA patients and its risk factors.

Methods:

Between January2020 and July 2020, 51 patients with RA were included in the study. fall history, and the number of falls within the past 12 month were questioned. All participants were assessed with Timed Up and Go Test (TUGT), One-Leg Stand Test (OLST), Walking and Talking Test (WTT), Sternal Push Test (SPT), Tinetti Test (TT), Four Test Balance Scale (FTBS), The Short Falls Efficacy Scale-International (FES-I), Pain Severity and Patient Global Assessment (PGA) by Visual Analog Scale (VAS), disability by the Health Assessment Questionnaire (HAQ), and disease activity by Disease Activity Score in 28 joints (DAS28) were evaluated in for for each patient. The Kolmogorov-Smirnov, Mann-Whitney and chi-square tests were performed with a significance level of P ≤ 0.05.

Results:

22 patients had at least one or more falls. The average age was 54.9±11.5 years with a female predominance (sex ratio = 0.13). Comparing the two groups of patients: those with a history of falls and those without, patients with previous falls were mainly married women (p=0.57), with a low intellectual level (p=0.63). The body mass index in this group was higher (p=0.01) with respectively a higher number of painful and swollen joints (p=0.16, p=0.07); the mean HAQ was higher (p=0.03), and the mean VAS was more important (p=0.05). 12/22 patients had co-morbidities and were poly-medicated.20/22 had joint feet deformities (hallux valgus was the most common deformity). 21/22 were on low dosage corticosteroid therapy. The mean TUGT was 18.5 seconds (>14 seconds). The OLST was less than 5 seconds in 12/22, the sternal push test was positive in 9/22, WTT was positive in 6/22 and the mean tinetti test was 22.4±5.4 suggesting a high risk of falls. The average Short FES-I was 14.6 ±4.4 reflecting a high fear of falls in this group of patients.

Conclusion:

Knowledge about risk factors can help to identify high-risk patients in order to decrease their risk of falling, thus preventing fall-related injuries.

Disclosure of Interests:

None declared

Early detection of skin and cardiac amyloid deposits among asymptomatic carriers of hereditary pathogenic transthyretin mutation with normal electroneuromyography

Introduction

During the last decade, disease modifying therapies have been proposed for hereditary amyloidogenic transthyretin (ATTRv) amyloidosis. It is essential to screen for disease onset among asymptomatic mutation carriers in order to trigger effective therapy as early as possible. We describe clinical and paraclinical data from ATTRv asymptomatic carriers, as a baseline assessment to detect disease onset and progression.

Methods

We retrospectively collected data of asymptomatic ATTRv carriers with normal electroneuromyography (ENMG), between March 1st 2015 and January 31st 2019, including: demographics, symptoms, physical exam, ENMG (initial and follow-up obtained in 73 patients, 56.2%), neurovegetative tests, skin biopsy (amyloid deposition, denervation), and cardiac evaluation (multimodal imaging, cardiac denervation and arrhythmias).

Results

We included 130 patients, aged 43.6 years (± 13.5), selected in family of a proband with an age of onset of 52.7 years (±15.7), 40.8% male, carrying 20 different variants of the TTR gene, including 63.8% Val30Met. Amyloid deposits on skin biopsy and/or cardiac fixation on bone scintigraphy, characteristic of amyloid infiltration, were found in 22/130 patients (16%). Skin biopsy was positive in 11 patients, and cardiac fixation on bone scintigraphy was positive in 15 patients. Amyloid infiltration was statistically associated with age (p=0.024), age difference from index case (p<0.001), electrophysiological carpal tunnel syndrome (p=0.022), interventricular septum thickness >12 mm (p<0.001), contrast enhancement in cardiac MRI (p=0.002), cardiac denervation using MIBG scintigraphy C/M ratio <1.85 (p=0.044). Multivariate analysis showed that age difference with index case and interventricular septum thickness were predictors for amyloid infiltration (OR=1.11, IC [1,04–1,19] and OR=1,76, IC [1,19–2,60]). Subgroup analysis showed electroneuromyography alteration during follow up in 11 patients (delay 26.9 months, range 10–49) with statistic association with amyloid deposits (55.6 versus 7.1% when ENMG was unchanged, p<0.001) and interventricular septum thickness (p<0.010).

Conclusion

Clinical and paraclinical assessment of asymptomatic carriers of ATTRv mutations shows that skin or cardiac amyloid infiltration may precede ENMG abnormalities in 16% of patients. This may trigger specific therapies in borderline cases. Age close to age of onset among index case and septum interventricular thickness appear as risk factors for developing electroneuromyogram alteration.

Funding Acknowledgement

Type of funding source: None

COVID-19 : profil patient prédisposant à une admission précoce en service de Réanimation

Introduction

Même si la majorité des patients atteints n’ont que des symptômes bénins, certains, plus graves, nécessitent une hospitalisation en service de soins voire une admission en réanimation. En raison du risque de létalité élevé, ces patients doivent être étroitement surveillés.

L’objectif de notre étude est de définir des profils patients qui pourraient favoriser une admission précoce en service de réanimation et de définir des marqueurs pouvant appuyer cette admission.

Matériels et méthodes

Étude rétrospective monocentrique du profil des patients admis en réanimation entre le 1^er mars et le 26 avril 2020. Les données démographiques des patients (âge, sexe, poids, indice de masse corporelle, statut tabagique), les données biologiques à l’admission en réanimation, les antécédents cliniques ainsi que les traitements médicamenteux ont été recueillis.

Deux groupes ont été constitués en fonction du délai entre la date de début des symptômes et la date d’entrée en réanimation : strictement inférieur à 7 jours (G1, admission précoce) et supérieur ou égal à 7 jours (G2, admission tardive). Une analyse statistique comparative par un test de Student pour les variables continues et du Chi² pour les variables catégorielle a été effectuée.

Résultats

Au total, la cohorte comprend 127 patients dont 62 dans le G1 et 65 dans le G2. L’analyse des données démographiques montre un IMC (31,5 dans le G1 vs 29,2 dans le G2 ; p = 0,04) et un âge (66,5 vs 60,6 ; p ≤ 0,01) supérieur dans le G1.

Le taux d’hypokaliémie (0,27 vs 0,09 ; p ≤ 0,01), d’hypocalcémie (0,56 vs 0,32 ; p ≤ 0,01), d’hypercréatininémie (0,42 vs 0,17 ; p ≤ 0,01) et d’hyperferritinémie (0,96 vs 0,63 ; p ≤ 0,01) semble être significativement plus élevée dans le G1.

De plus, la proportion de patients avec des antécédents cardiovasculaires (0,57 vs 0,34 ; p ≤ 0,01) et/ou diabétiques (0,25 vs 0,10 ; p = 0,02) sont plus élevés dans le G1. Le nombre de traitement moyen (4,5 vs 3,0 ; p = 0,04) et en particulier de médicaments à visée cardiovasculaire (0,60 vs 0,39 ; p = 0,02) est aussi plus fréquent dans le G1. Enfin, le taux de mortalité (0,31 vs 0,12 ; p = 0,01) est plus élevé dans le G1 que dans le G2.

Conclusion

Des profils patients se dessinent selon les données objectivées par cette étude. Les patients obèses, et en particulier en obésité morbide (avec un IMC > 35 kg/m²), ainsi que les patients âgés sont à risque d’être admis précocement en réanimation. Il en est de même pour les patients avec de nombreux antécédents cardiovasculaires et/ou diabétiques, les patients polymédiqués et notamment ceux traités par des médicaments à visée cardiovasculaire.

Parmi les éléments biologiques relevés, l’hypokaliémie, l’hyperferritinémie (avec des valeurs moyennes très hautes dans le G1), l’insuffisance rénale et l’hypocalcémie semblent favoriser une admission précoce en réanimation.

Les taux de mortalité en réanimation étant élevés (20 % à plus de 60 % selon le profil du patient), il est important de repérer les marqueurs et les facteurs prédisposant à une admission en réanimation. La priorisation de la prise en charge de ces patients permettrait d’éviter leur passage en soins intensifs et pourrait avoir un impact sur la mortalité.

Systematic review and literature appraisal on methodology of conducting and reporting critical-care echocardiography studies: a report from the European Society of Intensive Care Medicine PRICES expert panel

Background

The echocardiography working group of the European Society of Intensive Care Medicine recognized the need to provide structured guidance for future CCE research methodology and reporting based on a systematic appraisal of the current literature. Here is reported this systematic appraisal.

Methods

We conducted a systematic review, registered on the Prospero database. A total of 43 items of common interest to all echocardiography studies were initially listed by the experts, and other “topic-specific” items were separated into five main categories of interest (left ventricular systolic function, LVSF n = 15, right ventricular function, RVF n = 18, left ventricular diastolic function, LVDF n = 15, fluid management, FM n = 7, and advanced echocardiography techniques, AET n = 17). We evaluated the percentage of items reported per study and the fraction of studies reporting a single item.

Results

From January 2000 till December 2017 a total of 209 articles were included after systematic search and screening, 97 for LVSF, 48 for RVF, 51 for LVDF, 36 for FM and 24 for AET. Shock and ARDS were relatively common among LVSF articles (both around 15%) while ARDS comprised 25% of RVF articles. Transthoracic echocardiography was the main echocardiography mode, in 87% of the articles for AET topic, followed by 81% for FM, 78% for LVDF, 70% for LVSF and 63% for RVF. The percentage of items per study as well as the fraction of study reporting an item was low or very low, except for FM. As an illustration, the left ventricular size was only reported by 56% of studies in the LVSF topic, and half studies assessing RVF reported data on pulmonary artery systolic pressure.

Conclusion

This analysis confirmed sub-optimal reporting of several items listed by an expert panel. The analysis will help the experts in the development of guidelines for CCE study design and reporting.

[ST-elevation myocardial infarction (STEMI) in the elderly]

Admission in cardiology departments of patients over 80 years old, even nonagenarians, for ST-segment elevation myocardial infarction (STEMI) is not uncommon in 2018. The management of these high risk and polypathological patients, with atypical clinical presentation, is not based on international guidelines or randomized studies, but rather on retrospective studies, expert consensus, and common sense. Each decision has to be individualized to the patient's situation. This review, after a clinical case, aims to guide the clinician in the specific management of these patients, from the symptoms, to reperfusion strategy, and, as fast as possible, hospital discharge.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Reversibility of acquired amyloid polyneuropathy after liver retransplantation

Domino liver transplantation (DLT) has become an accepted procedure designed to address problems with organ limited supply. However, cases of acquired amyloid neuropathy are increasingly being recognized following this procedure. Until now, only one patient had undergone liver retransplantation and follow-up findings were not reported. We describe the case of a 72-year-old patient with partial recovery from acquired amyloid neuropathy following retransplantation with a deceased donor 7 years after DLT performed for end-stage liver disease. His clinical and paraclinical improvement is described, and the impact of this case on the indication for a domino procedure and the challenges linked to retransplantation are discussed.

The onset of left ventricular diastolic dysfunction in SHR rats is not related to hypertrophy or hypertension

Left ventricular (LV) diastolic dysfunction, particularly relaxation abnormalities, are known to be associated with the development of LV hypertrophy (LVH). Preliminary human and animal studies suggested that early LV diastolic dysfunction may be revealed independently of LVH. However, whether LV diastolic dysfunction is compromised before the onset of hypertension and LVH remains unknown. We therefore evaluated LV diastolic function in spontaneously hypertensive rats (SHR) at different ages and tested whether LV diastolic dysfunction is associated with abnormal intracellular calcium homeostasis. LV systolic and diastolic functions were evaluated by invasive and echocardiographic methods in 3-week-old (without hypertension) and 5-week-old (with hypertension) SHR and Wistar-Kyoto control rats. Basal intracytoplasmic calcium and sarcoplasmic reticulum (SR) Ca2+ contents were measured in cardiomyocytes using fura-2 AM. Sarco(endo)plasmic Ca2+-ATPase isoform 2a (SERCA 2a) and phospholamban (PLB) expressions were quantified by Western blot and quantitative RT-PCR techniques. LV relaxation dysfunction was observed in 3-week-old SHR rats before onset of hypertension and LVH. An increase in basal intracytoplasmic Ca2+ and a decrease in SR Ca2+ release were demonstrated in SHR. Decreased expression of SERCA 2a and Ser16 PLB (p16-PLB) protein levels was also observed in SHR rats, whereas mRNA expression was not decreased. For the first time, we have shown that LV myocardial dysfunction precedes hypertension in 3-week-old SHR rats. This LV myocardial dysfunction was associated with high diastolic [Ca2+]i possibly due to decreased SERCA 2a and p16-PLB protein levels. Diastolic dysfunction may be a potential predictive marker of arterial hypertension in genetic hypertension syndromes.

[Therapeutic patient education in heart failure: a program's assessment]

Heart failure is a chronic, common and severe disease. It leads to frequent hospitalizations and decrease of patient's quality of life. A therapeutic patient education program, named "school of heart failure" was implemented at Antoine-Béclère hospital.

AIM OF THE STUDY

To assess the effectiveness of this program.

PATIENTS AND METHODS

This therapeutic patient education program included patients with heart failure, hospitalized in a cardiology unit. Four types of evaluation were carried out: evaluation of patients' skills before they leave the hospital, patient's knowledge (associated with the degree of certainty), satisfaction regarding the program and self-assessment of changes in their lifestyle 3 months after discharge.

RESULTS

Twenty-four patients were included in 9 months. The program's evaluation showed promising results with respect to the acquisition of skills (94%), the improvement of patients' knowledge associated with self-confidence increase, their satisfaction towards the program (80%) and their ability to change their habits (75%). Self-assessment has demonstrated changes in their lifestyle.

CONCLUSION

These preliminary results are promising according to the program's effectiveness and its ability to meet patients' educational needs. The program was certified by French authorities in 2011. Knowledge and skills acquisition will have to be confirmed on long term.

[The best of nuclear cardiology and MRI in 2006]

In this review, original clinical studies based on scintigraphy, PET or MRI imaging are reported, regarding the main areas of cardiology including ischemia and myocardial infarction, detection of coronary artery disease in various patients subsets, cardiomyopathy and heart failure. A special topic is dedicated to tracers and technical innovations.

[The best of nuclear cardiology and MRI in 2005]

The literature concerning nuclear cardiology and cardiac MRI has been particularly rich in the fields of diagnosis, prognosis and therapeutic evaluation of coronary artery disease and cardiac failure. Almost 18 million 'conventional' myocardial scintigraphies (SPECT-single photon emission tomography, or TEM: tomography by monophotonic emission in French) are routinely performed worldwide each year. Nuclear cardiology represents the 3rd scientific domain of application for scintigraphy, after oncology and neurology. The advent of new conventional gamma cameras and PET (positron emission tomography) combined with CT will allow considerable improvement in the quality of investigation in obese or tri-truncal patients and women. We will limit ourselves to original clinical studies, based on scintigraphical techniques or magnetic resonance imaging, applied to the classic cardiological themes: myocardial infarction and ischaemia, cardiomyopathy and cardiac failure. We will also consider the new directions in nuclear cardiology regarding a new tracer and some innovative technology: rubidium-82 and TEP-CT.

Heart failure due to left ventricular systolic dysfunction: Treatment at discharge from hospital and at one year

BACKGROUND

The treatment of heart failure (HF) due to left ventricular systolic dysfunction has been defined in recent guidelines, but these guidelines are not always applied in routine clinical practice. One of the objectives of the ETICS study was to evaluate medical treatment at discharge and after 1 year in patients hospitalised for a first episode of congestive HF due to left ventricular systolic dysfunction in 2000.

METHODS

One hundred and seventy nine patients (63% males, mean age of 69+/-13 years) with an ejection fraction < or = 40% were prospectively included. The main aetiology was ischaemic heart disease (44%).

RESULTS

The drugs prescribed at discharge and at one year, respectively, were loop diuretics in 95% and 91% of cases, angiotensin-converting enzyme (ACE) inhibitors in 82% and 75%, spironolactone in 35% and 37%, beta-blockers in 25% and 41%, digitalis glycosides in 34% and 30% of cases, and nitrates in 20% and 16% of cases. ACE inhibitors were prescribed at discharge and at 1 year at dosages reaching 64+/-29% and 72+/-30% of the recommended doses, respectively, and beta-blockers were prescribed at 26+/-16% and 35+/-25% of recommended doses, respectively.

CONCLUSION

Diuretics and ACE inhibitors are largely prescribed in HF due to left ventricular systolic dysfunction, followed by spironolactone. Beta-blockers are still underused both in terms of the rate of patients receiving them and the daily doses. These results highlight the value of continuing to widely circulate official practice guidelines in order to improve the management of HF due to left ventricular systolic dysfunction.

Usefulness and clinical impact of a fractional flow reserve and angiographic targeted strategy for coronary artery stenting: FROST III, a multicenter prospective registry

BACKGROUND

Fractional flow reserve (FFR) is correlated with angiographic and intravascular ultrasound assessments of stent placement. Post-stenting FFR has been described as a good predictor of clinical events after 6 months.

OBJECTIVE

To evaluate the feasibility and clinical impact of targeting an FFR > 0.95 via incremental in-stent inflation pressures.

METHODS

In this multicenter prospective study, 100 consecutive patients underwent FFR measurement at baseline, after balloon predilatation, and after stenting with 4-atm inflation pressure increments from 8 to 20 atmospheres. Inflations were stopped when FFR increased above 0.95 and angiographic stenosis was less than 20%.

RESULTS

FFR > 0.95 was achieved in 81% of cases; this FFR target was reached at 8 atm in 47% of patients, 12 atm in 16 %, 16 atm in 15%, and 20 atm in 3%. Fifty percent of patients with adequate angiographic result had an FFR less than 0.95 and needed further higher inflations. FFR was correlated with residual stenosis when the total procedure was evaluated, and this correlation persisted when in-stent inflations alone were considered. Final FFR was significantly correlated with anginal status after 6 months.

CONCLUSIONS

Angiography guided PCI does not allow optimization of FFR. Since optimal post stenting FFR is correlated to better anginal status at 6-months, this suggests that FFR guided PCI is required to achieve optimal functional results of PCI.

Impact of inflammation and oxidative stress on vascular calcifications in chronic kidney disease

Vascular and/or valvular calcifications in patients with chronic kidney disease (CKD) appear to indicate a poor prognosis in terms of overall survival and cardiovascular morbidity and mortality. Inflammation and oxidative stress represent new features of the arterial and/or valvular calcification process. However, only limited observational and epidemiological data are available in these areas. Therefore, the link between inflammation, oxidation and vascular and/or valvular calcifications deserves careful consideration in CKD patients, since they may become targets for the development of new therapeutic strategies.

[New concepts on the physiopathology and therapy of aortic stenosis]

Calcified "degenerative" aortic stenosis is currently the most common valvulopathy in industrialised countries. In the course of the last decade, experimental studies have allowed a better understanding of the physiopathology of this vavlulopathy. The latest development is the evidence for the initiation and progression of this disease, similar to those described for atherosclerosis. Lipid disturbances, in particular hypercholesterolaemia, constitute an important factor in the initiation of valvular lesions, but also in aortic orifice calcification. Certain preliminary clinical studies are in favour of the significance of statins for slowing the progression of aortic stenosis. This potential beneficial effect requires confirmation by randomised prospective studies and raises hopes for medical therapy in order to avoid the evolution of ordinary aortic sclerosis into tight calcified aortic stenosis.

[Comparison between radial and femoral approaches in ad hoc coronary angioplasty]

Between September 1999 and June 2001, 591 patients required ad hoc coronary angioplasty. The authors compared the group of patients in whom the approach of first intent was radial (n = 328, 55%) with those in whom the femoral approach had been used (n = 263), in terms of immediate local (haematoma or thrombosis requiring surgical intervention or transfusion) and general complications (myocardial infarction, cerebrovascular accident), and major adverse cardiovascular events (infarction, angioplasty, bypass and death) at 1 year. The dose of ionising radiation during the procedures was also compared prospectively. The conversion rate from the radial (R) to the humeral or femoral (F) approach was 10%. The angioplasty, stenting, and stenting without dilatation failure rates were identical in the two groups (5% versus 5%, 0.6% versus 1.9%, 3% versus 4%, respectively). The average irradiation time was greater in the R group than in the F group (23 +/- 12 min vs 17 +/- 4 min, p < 0.001) as was the irradiation per surface unit (242 +/- 137 Gy.cm2 vs 185 +/- 117 Gy.cm2, p < 0.001). The immediate complication rate was comparable in the two groups (2.5% in group R vs 3.6% in group F) as was the major adverse cardiovascular event rate at 1 year (13% in both groups). The authors observed the same rate of immediate complications and late adverse cardiac events in patients undergoing coronary angioplasty followed by immediate angioplasty by the radial or femoral approaches with an acceptable conversion rate from the radial to the femoral approach. The procedures by the radial approach seem to be associated with a greater time and dosage of ionising radiation.

[Iatrogenic lesions of the left main coronary artery]

Reoccurrence of ischemic events several months after a percutaneous transcutaneous coronary angioplasty is usually due to a restenosis. Coronary angiography rarely shows a new stenosis on another site or on the left main coronary artery. In this series, we report 5 cases of left main coronary artery stenosis which have occurred from 3 to 12 months after a prior percutaneous angioplasty. This phenomenon which has previously been described after direct cannulation of the coronaries ostia during aortic valve replacement in the 70'. This complication is related to intimal damage caused by traumatic manipulation of the left main, which can be either already minimally altered or normal. This complication is rare after percutaneous transcutaneous coronary angioplasty (0.2-1.7%) according to various series. We compare our cases to the published cases in the literature.

Effect of linsidomine on the human radial artery

The response of the human radial artery to a direct NO donor, linsidomine or 3-morpholino-sydnonimine (Sin 1), in the therapeutic management of peri-operative spasm may increase the patency rates of these grafts in the short, medium and long term. Evaluation of the effects of Sin 1 on the human radial artery is of even greater interest as it has not been published previously. Ninety-six human radial artery rings were studied with two protocols. Rings were mounted in an isolated organ bath between two stainless steel metallic rods connected to stress gauges. Protocol 1 studied the vasorelaxant effect of Sin 1 and nitroglycerin (TNT). Protocol 2 studied the reactivity of the radial artery to the vasoconstrictor agents arginine vasopressin (AVP) and angiotensin II (ANG II). The vasorelaxant effect of Sin 1 on the human radial artery was comparable with that of TNT, but with no tolerance effect. After Sin 1 pre-incubation, the vasoconstrictor effect of ANG II was abolished, whereas AVP induced maximum vasoconstriction similar to that of the control (not statistically significant), but with a shift in the EC50 to higher concentrations, EC50=15+/-20 nM. Sin 1 vasorelaxation of rings precontracted by ANG II was maximal, whereas after contraction by AVP, relaxation remained less than 70%; Sin 1 is a potent vasorelaxant on the human radial artery, which does not exhibit cross-tolerance with nitrates. This compound may be used pre- or post-operatively, and would undoubtedly be of benefit in the peri-operative preparation bath.

Direct vascular actions of methyclothiazide in remodeled mesenteric arteries from hypertensive patients

In vitro experiments were designed to assess the inhibitory effect of the thiazide diuretic methyclothiazide (MCTZ) on contractile responses to norepinephrine (NE) of mesenteric rings from hypertensive patients and normotensive controls. Arteries were taken from portions of mesocolon from 24 patients: 13 hypertensives and 11 normotensives. Changes in the tension of mesenteric ring preparations were measured isometrically. Histologic studies showed that the arteries from hypertensive patients exhibited 1) a greater media thickness-to-lumen diameter ratio, 2) a smaller lumen diameter, and 3) identical media cross-sectional area as those of normotensive controls. At the physiologic level, the hypertensive and normotensive arteries display similar contractile responses to KCl and NE. Furthermore, our results indicate that MCTZ induces concentration-dependent inhibition of the vasoconstrictor responses to NE. This study provides evidence that hypertension is associated with the remodeling of the human mesenteric artery and that MCTZ is as efficient in inhibiting the contractile response induced by NE on hypertensive than on normotensive arteries.

Electrocardiographically gated blood-pool SPECT and left ventricular function: comparative value of 3 methods for ejection fraction and volume estimation

The current major limitation to development of electrocardiographically (ECG) gated blood-pool SPECT (GBPS) for measurement of the left ventricular (LV) ejection fraction (LVEF) and volumes is the lack of availability of clinically validated automatic processing software. Recently, 2 processing software methods for quantification of the LV function have been described. Their LVEFs have been validated separately, but no validation of the LV volume measurement has been reported.

METHODS

We compared 3 processing methods for evaluation of the LVEF (n = 29) and volumes (n = 58) in 29 patients: automatic geometric method (GBPS(G)), semiautomatic activity method (GBPS(M)), and 35% maximal activity manual method (GBPS(35%)). The LVEF provided by the ECG gated equilibrium planar left anterior oblique view (planar(LAO)) and the LV volumes provided by LV digital angiography (Rx) were used as gold standards.

RESULTS

Whereas the GBPS(G) and GBPS(M) methods present similar low percentage variabilities, the GBPS(35%) method provided the lowest percentage variabilities for the LVEF and volume measurements (P < 0.04 and P < 0.02, respectively). The LVEF and volume provided by the 3 methods were highly correlated with the gold standard methods (r > 0.98 and r > 0.83, respectively). The LVEFs provided by the GBPS(35%) and GBPS(M) methods are similar and higher than those of the GBPS(G) method and planar(LAO) method, respectively (P < 0.0001). For the LVEF, there is no correlation between the average and paired absolute difference for the 3 GBPS methods against the planar(LAO) method, and the limits of agreement are relatively large. LV volumes are lower when calculated with the GBPS(M), GBPS(G), and Rx methods (P < 0.0001). However, the GBPS(35%) and Rx methods provide LV volumes that are similar. There is no linear correlation between the average and the paired absolute difference of volumes calculated with the GBPS(G) and GBPS(35%) methods against Rx LV volumes. However, a moderate linear correlation was found with the GBPS(M) method (r = 0.6; P = 0.0001). The 95% limits of agreement between the Rx LV volumes and the 3 GBPS methods are relatively large.

CONCLUSION

GBPS is a simple, highly reproducible, and accurate technique for the LVEF and volume measurement. The reported findings should be considered when comparing results of different methods (GBPS vs. planar(LAO) LVEF; GBPS vs. Rx volume) and results of different GBPS processing methods.