Assessing the efficacy of saline flush in frequency-domain optical coherence tomography for intracoronary imaging

BACKGROUND

The increased amount of contrast media in frequency-domain optical coherence tomography (FD-OCT) imaging during percutaneous coronary intervention (PCI) has raised potential concerns regarding impairment of renal function.

OBJECTIVES

This study aimed to evaluate the effectiveness of heparinized saline flush in FD-OCT-guided PCI and identify clinical factors contributing to optimal image quality.

METHODS

We retrospectively collected 100 lesions from 90 consecutive patients, and a total of 200 pullbacks were analyzed for the initial and final evaluation in which saline was used as the flushing medium.

RESULTS

The study population had a mean age of 73, with 52% having chronic kidney disease (CKD). The median amount of contrast used was 28 ml, and no complications were observed associated with saline flush OCT. Imaging quality was then categorized as excellent, good, or unacceptable. Among the total runs, 87% demonstrated clinically acceptable image quality, with 66.5% classified as excellent images and 20.5% classified as good images. Independent predictors of excellent images included lumen area stenosis ≥ 70% (adjusted odds ratio [OR] 2.37, 95% confidence interval [CI] 1.02-5.47, P = 0.044), and the use of intensive flushing (adjusted OR 2.06, 95% CI 1.11-3.86, P = 0.023) defined as a deep engagement of guiding catheter (GC) or a selective insertion of guide extension catheter (GE). Intensive flushing was performed in 60% of the total pullbacks, and it was particularly effective in improving image quality in the left coronary artery (LCA).

CONCLUSION

The use of saline flush during FD-OCT imaging was safe and feasible, which had a benefit in renal protection with adequate imaging quality.

Aberrant mediastinal basal pulmonary artery encountered at anatomical lung resection: A case report and review of the literature

INTRODUCTION

Abnormal branching of the pulmonary artery is often encountered in anatomical lung resection, which can potentially result in accidental vessel injury with life-threatening bleeding or extra lung resection. The mediastinal basal pulmonary artery (Arteria Praebronchialis, AP) is a very rare but potentially critical variant.

PRESENTATION OF CASE

We present the case of a patient with lung cancer accompanied by the left basal segmental pulmonary artery, independent A8a+9, which was liable to be injured during lower lobectomy with poor interlobar fissure development. This variation was preoperatively recognized using three-dimensional contrast-enhanced computed tomography (3D-CECT) angiography, and vessel injury was avoided.

DISCUSSION AND LITERATURE REVIEW

3D-CECT angiography was effective in identifying this rare but potentially critical variation, and it is desirable to perform it routinely before anatomical lung resection. A review of 31 AP cases revealed that the branching pattern of AP was independent (15 patients, 48 %) and common trunk type (16 patients, 52 %), one half for each. Mediastinal branching of the lingular artery was more frequent among the reported AP cases (71 %) than in general reports.

CONCLUSION

When mediastinal branches of left pulmonary artery are encountered, the possibility that it is AP should be always taken into account.

Deteriorative Effect of a Combination of Hypertriglyceridemia and Low High-Density Lipoprotein Cholesterolemia on Target Lesion Revascularization after Everolimus-Eluting Stent Implantation

AIM

This study aimed to investigate the association between a combination of elevated triglyceride (TG) and reduced high-density lipoprotein cholesterol (HDL-C) levels and target lesion revascularization (TLR) following everolimus-eluting stent (EES) implantation. The adverse impact of clinical, lesion, and procedural characteristics on TLR in patients with elevated TG and reduced HDL-C levels was also assessed.

METHODS

We retrospectively collected data on 3,014 lesions from 2,022 consecutive patients, who underwent EES implantation at Koto Memorial Hospital. Atherogenic dyslipidemia (AD) is defined as a combination of non-fasting serum TG ≥ 175 mg/dL and HDL-C ＜40 mg/dL.

RESULTS

AD was observed in 212 lesions in 139 (6.9%) patients. The cumulative incidence of clinically driven TLR was significantly higher in patients with AD than in those without AD (hazard ratio [HR] 2.31, 95% confidence interval [CI] 1.43-3.73, P=0.0006). Subgroup analysis showed that AD increased the risk of TLR with the implantation of small stents (≤ 2.75 mm). Multivariable Cox regression analysis showed that AD was an independent predictor of TLR in the small EES stratum (adjusted HR 3.00, 95% CI 1.53-5.93, P=0.004), whereas the incidence of TLR was similar in the non-small-EES stratum, irrespective of the presence or absence of AD.

CONCLUSIONS

Patients with AD had a higher risk of TLR after EES implantation, and this risk was greater for lesions treated with small stents.

Postoperative aortic injury caused by a staple line formed during wedge resection of the lung

We report a case of aortic perforation caused by the staple line formed during a wedge resection for lung cancer. Six hours after an uneventful wedge resection, sudden frank drainage of blood from the chest tube occurred. A reoperation was performed, and we found bleeding from the aorta. After suturing the bleeding spot on the aorta, we found that the stapling line of the lung rode on the aorta with longitudinal contact. We speculated that the stapling line scratched the aorta in synchrony with the patient's breathing and injured the aorta.

Impact of statin therapy on late target lesion revascularization after everolimus-eluting stent implantation according to pre-interventional vessel remodeling and vessel size of treated lesion

Clinical evidence demonstrating the impact of statins for preventing late target lesion revascularization (TLR) after newer-generation drug-eluting stent implantation and differences in the effect of statins on late TLR according to pre-interventional vessel remodeling and vessel size is limited. We retrospectively evaluated 1193 de novo lesions in 720 patients who underwent everolimus-eluting stent implantation using intravascular ultrasound from January 2010 to December 2012. The primary endpoint was late TLR. Lesions were divided into the statin group (n = 825) and non-statin group (n = 368). The incidence of late TLR was significantly lower in the statin than non-statin group (1.7% vs. 5.2%, respectively; p = 0.001), and within the statin group, it was significantly lower in the follow-up low-density lipoprotein cholesterol (LDL-C) < 100 than ≥ 100 mg/dL level subgroup (1.0% vs. 3.6%, respectively; p = 0.006). Furthermore, in positive remodeling lesions and non-small vessel size lesions, the incidence of late TLR was significantly lower in the statin than non-statin group (1.6% vs. 8.5% and 1.3% vs. 5.3%, respectively; p = 0.001 and p = 0.004). Lowering the LDL-C level using statins was more effective for preventing late TLR after everolimus-eluting stent implantation. Evaluating pre-interventional vessel remodeling patterns and vessel size might be helpful to stratify lesions at high risk of late TLR.

AB0382 COMPARISON OF ADVERSE EVENTS (AEs) RELATED TO MAJOR ANTI-RHEUMATIC DRUGS, REPORTED TO THE OFFICIAL JAPANESE ADVERSE DRUG EVENT REPORT DATABASE (JADER)

Background

Currently, many disease-modifying anti-rheumatic drugs (DMARDs) are available for the treatment of rheumatoid arthritis (RA). Among them, methotrexate (MTX), biologic DMARDs (bDMARDs) and Janus kinase inhibitors (JAKi) are the major options. AEs related to these are major concerns. In Japan, the AEs data spontaneously reported to and summarized by Pharmaceuticals and Medical Devices Agency (PMDA) are freely accessible.

Objectives

The major AEs relating to MTX, bDMARDs, and JAKi observed in the real world were compared.

Methods

The number of AEs listed by JADER from 2014 to 2020 was collected. The AEs were classified by System Organ Class (SOC) of Medical Dictionary for Regulatory Activities (MedDRA) and compared using the chi-square test. The bDMARDs included were etanercept (ETN), adalimumab (ADA), golimumab (GOL), tocilizumab (TCZ), and abatacept (ABT), and JAKi was tofacitinib (TOF) and baricitinib (BAR).

Results

The total number of AEs was 27,604. The number was significantly increasing in total and MTX, GOL, TOF during these years, although the number of cases that have each DMARD is not known in this study. The proportion of SOCs among each DMARD was similar throughout the period.

The most frequent was infections/infestations in all DMARDs except for MTX, in which neoplasms were the most. The primary cause of infection was bacterial, including pneumonia. Varicella-zoster virus infection in JAKi, and tuberculosis in ADA and GOL were conspicuous.

Neoplasms were the second major in many DMARDs. Lymphoproliferative disorders were most common in MTX-related neoplasms, whereas solid tumors were more in other DMARDs like ABT or BAR.

Other SOCs include all other categories such as the musculoskeletal, nervous system, cardiac, and vascular disorders. Among them, major adverse cardiovascular events (MACE, including cardiovascular death, myocardial infarction and stroke) and venous thromboembolism (VTE) were both reported in small numbers. However, more MACE was noted in BAR and GOL, and more VTE was in BAR and TOF compared to other DMARDs.

Conclusion

The number of AEs cases related to DMARDs was increasing. Significant difference among AEs related to DMARDs was noted in the JADER database, especially regarding MTX and JAKi.

References

[1]S. Inokuma. Expert Open Drug Saf. 2021 Nov 11. Online ahead of print.

Table 1.

Total case numbers and proportion of adverse events related to each DMARD.

DMARDs (year of launch)TotalMTX (1999)ETN (2005)ADA (2008)GOL (2011)TCZ (2008)ABT (2010)TOF (2013)BAR (2017)Number of AEs2760411636297419591302424517093065714Blood/lymphatic system disorders5.89.92.03.22.64.00.92.83.5Gastrointestinal disorders5.04.13.47.55.97.73.95.24.2General disorders/administration site reactions4.63.211.34.12.23.04.07.62.5Infections/infestations28.020.321.332.234.236.537.137.049.2 Pneumonia (bacterial)6.64.06.15.210.97.712.59.415.1 Other bacterial infection9.15.95.612.39.517.69.19.810.6 Herpes zoster2.11.10.41.41.21.01.28.211.2 Tuberculosis1.40.91.96.03.50.60.60.31.0Investigations5.04.95.52.32.65.72.28.32.8Neoplasms benign, malignant, unspecified21.134.811.013.512.77.415.610.815.4 Lymphoproliferative diseases14.329.82.84.14.02.24.52.12.2 Solid tumors5.63.87.37.87.54.09.97.310.5Respiratory, thoracic, mediastinal disorders7.16.88.38.49.56.57.46.26.7Other System Organ Class23.315.937.328.830.229.228.922.215.7 Major adverse cardiovascular events1.10.41.11.62.51.51.61.32.9 Venous thromboembolism0.40.10.40.50.60.30.21.11.4

Background colors indicate: comparing to the total cases, higher with p<0.05, light pink; higher with p<0.00001, dark pink; higher with p<1E-10, red. Lower with p<0.05, light blue; lower with p<0.00001, blue; lower with p<1E-10, dark blue, using chi-square test. Yellow indicates System Organ Classes.

Figure 1.

Total number of adverse events reported from 2014 to 2020.

Linear regression is shown only for DMARDs with increasing numbers of AEs.

Disclosure of Interests

None declared

A case of thymoma-associated multiorgan autoimmunity including polymyositis and myocarditis

BACKGROUND

Polymyositis and myocarditis associated with thymoma are exceptionally rare conditions and usually accompanied by myasthenia gravis (MG) and have been recognized as critical conditions. Thymoma-associated multiorgan autoimmunity was reported recently with skin, liver, and intestinal manifestations similar to those seen in graft-versus-host disease.

CASE PRESENTATION

A 77-year-old female presented to our department with exacerbation of ptosis and local recurrence of thymoma. Chest computed tomography revealed local recurrence of thymoma. Following 6 month observation, erythema on the extremities and body trunk suddenly appeared. Afterwards, the patient developed progressive muscle weakness and fatigue. We diagnosed as myocarditis and polymyositis. She was transferred to the intensive-care unit and received artificial ventilation. Steroid pulse therapy was induced immediately. The blood test findings were markedly improved, but the symptoms of MG and weakness of the muscles persisted. Various treatment including eculizumab was induced, and the symptoms of MG and weakness of the muscles were improved. On the 136th day of hospitalization, she was discharged.

CONCLUSION

We were able to cure this patient, as we were able to start treatment immediately after the appearance of severe symptoms. An early diagnosis and treatment are important for curing such patients.

Surgical site infection at chest tube drainage site following pulmonary resection for malignant lesions

Background

We sometimes experience postoperative surgical site infection (SSI) at the chest tube drainage site (CDS) after thoracotomy. The incidence of and risk factors for SSI at the CDS have remained unclear.

Methods

We conducted a prospective study to determine the incidence and risk factors for SSI at the CDS. We analyzed 99 patients who underwent lobectomy or segmentectomy for pulmonary malignant lesions.

Results

There were 56 males and 43 females with an average age of 71 years. The postoperative drainage period was 2–15 days. Bacterial species were detected in secretions in 18 of 99 cases (18.2%). Older age was a risk factor for the detection of bacteria at the timing of chest tube removal. Eighteen cases (18.2%) were diagnosed with presence of SSI at the CDS at the timing of staple or suture removal. A pathological diagnosis of squamous cell carcinoma was regarded as a candidate risk factor for SSI. Eleven of 18 SSI patients showed delayed wound healing. A higher level of HbA1c was found in patients with delayed wound healing. Enterococcus faecalis infection may influence the development of complex SSI.

Conclusions

We identified the bacterial profiles, incidence of and risk factors for SSI at the CDS. More intense preoperative glycemic control and an understanding of the bacterial profile and may be useful for reducing the incidence of SSI chest tube drainage sites (CDS).

Effect of Glycemic Control During Follow-up on Late Target Lesion Revascularization After Implantation of New-Generation Drug-Eluting Stents in Patients With Diabetes - A Single-Center Observational Study

Background: Few studies have investigated the importance of glycemic control in patients with diabetes mellitus (DM) for reducing the incidence of late target lesion revascularization (TLR) after implantation of new-generation drug-eluting stents (DES).

Methods and Results: We retrospectively identified 1,568 patients who underwent new-generation DES implantation. Patients were divided into 3 groups based on diabetic status and glycemic control 1 year after the procedure: those without DM (non-DM group; n=1,058) and those with DM at follow-up with either good (HbA1c <7%; n=328) or poor (HbA1c ≥7%; n=182) control. The cumulative 5-year incidence of clinically driven late TLR after the index procedure was significantly higher in DM with poor control at follow-up than in those with good control at follow-up or non-DM (14%, 4.8%, and 2.9%, respectively; P<0.0001). Multivariate analysis revealed that poor control at follow-up was significantly associated with a higher risk of clinically driven late TLR compared with the non-DM group (hazard ratio [HR] 4.58, 95% confidence interval [CI] 2.50–8.16, P<0.0001). However, good control at follow-up group was not associated with a higher risk of clinically driven late TLR compared with the non-DM group (HR 1.35, 95% CI 0.68–2.56, P=0.38).

Conclusions: DM patients with poor glycemic control at follow-up had a significantly higher risk of clinically driven late TLR than non-DM patients.

Successful Surgery of Right Common Iliac Artery Injury during Lumbar Discectomy with Endovascular Balloon Occlusion of the Aorta Performed by Cardiologists

A 19-year-old woman developed hypotension and abdominal distension during lumbar discectomy. Computed tomography revealed a right common artery injury and a large retroperitoneal hematoma. She was transferred to our hospital and brought to an angiography room directly. Endovascular balloon occlusion of the aorta was performed by cardiologists while surgeons were preparing for surgery. With the hemodynamics stabilized, the injured artery was repaired. In such a case, closing the artery as soon as possible, whether by clamping or by balloon occlusion, is vital. The ability to respond with a “Heart Team” is essential for a small-manpower hospital to rescue a patient with a serious condition.

Nine cases of catamenial pneumothorax: a report of a single-center experience

Background

Catamenial pneumothorax (CP) is defined as repeated pneumothorax related to menses and thoracic endometriosis. We performed a retrospective analysis of nine patients with CP to determine the clinical features as well as the effects of treatment and recurrence rates.

Methods

A retrospective review was conducted of the clinical and pathologic data in all CP patients undergoing treatment at our institution. Nine patients underwent treatment for CP. Of these, six underwent surgical treatment 8 times.

Results

The median age was 36 years. Six patients had experienced delivery. The laterality of the pneumothorax was right in all patients. Pelvic endometriosis was diagnosed in five patients. Six patients underwent surgical treatment. Partial resection of the lung was performed in four patients and partial resection of the diaphragm in five. Of these, both resections were performed in four patients. A pathological diagnosis of endometriosis was achieved in only three patients. The observation period was 16.7 months. In the six patients with surgical resection, five experienced recurrence at various intervals. Onset of pneumothorax occurred pre- or menstrual period in most cases.

Conclusions

The diagnosis and treatment of CP is not easy. A multidisciplinary approach and skillful management are required. Recurrence of CP is common following a temporary cure of pneumothorax by surgical treatment.

Thoracoscopic Thymectomy Using a Subxiphoid Approach for Anterior Mediastinal Tumors

PURPOSE

Video-assisted thoracic surgery (VATS) techniques have been widely used for resection of mediastinal tumors. This study investigated the usefulness of the subxiphoid approach in thoracoscopic thymectomy.

METHODS

In all, 36 patients with anterior mediastinal tumor underwent thymectomy using the subxiphoid approach in two Japanese institutions. These patients were retrospectively reviewed and analyzed.

RESULTS

There were 16 females and 20 males with a mean age of 57 years. Five patients underwent partial thymectomy (PT), 27 underwent total or subtotal thymectomy, and 4 underwent thymectomy with combined resection (CR) of the surrounding organs or tissues. The mean maximum tumor diameter, amount of resected tissue, and blood loss were 4.1 cm, 72.5 g, and 20.6 g, respectively. More than half of tumors were diagnosed as thymoma (n = 19). The operation time was prolonged with a greater volume of thymectomy. The duration of chest tube drainage and postoperative stay were 1.7 ± 1.0 days and 5.9 ± 7.6 days, respectively. Four patients suffered intraoperative and postoperative complications, as follows: bleeding of the innominate vein, bleeding of the internal thoracic vein, crisis of myasthenia gravis (MG), pericarditis, and phrenic nerve paralysis. There were no mortalities after surgery.

CONCLUSION

Subxiphoid thoracoscopic thymectomy might be a safe and useful approach for mediastinal tumors.

Long-term outcomes of microvascular decompression and Gamma Knife surgery for trigeminal neuralgia: a retrospective comparison study

BACKGROUND

There is still no clear guideline for surgical treatment for patients with medically refractory trigeminal neuralgia (TN). When it comes to which surgical treatment to choose, microvascular decompression (MVD) or Gamma Knife surgery (GKS), we should know the long-term outcome of each treatment.

METHODS

We analyzed 179 patients undergoing MVD and 52 patients undergoing GKS followed for 1 year or longer. We evaluated the patient's neurological status including pain relief, complications and recurrence. Results were assessed with Barrow Neurological Institute (BNI) pain intensity and facial numbness scores. Overall outcomes were compared between the two groups based on pain relief and complications.

RESULTS

BNI pain intensity and facial numbness scores at the final visit were significantly lower in the MVD group than in the GKS group (P < 0.001, P = 0.04, respectively). Overall outcomes were superior following MVD than following GKS (P < 0.001). Following whichever treatment, there were initially high rates of pain-free status "without medication": 96.6% in the MVD group and 96.2% in the GKS group. However, 6.1% in the MVD group and 51.9% in the GKS group fell into a "with medication" state within median periods of 1.83 and 3.92 years, respectively (P < 0.001). Kaplan-Meier analysis revealed that pain recurred more often and later in the GKS group than in the MVD group (P < 0.001).

CONCLUSIONS

Considering the long-term outcomes, MVD should be chosen as the initial surgical treatment for patients with medically refractory TN.

Novel ATP-competitive Akt inhibitor afuresertib suppresses the proliferation of malignant pleural mesothelioma cells

Malignant pleural mesothelioma (MPM), an asbestos-related occupational disease, is an aggressive and incurable tumor of the thoracic cavity. Despite recent advances in MPM treatment, overall survival of patients with MPM is very low. Recent studies have implicated that PI3K/Akt signaling is involved in MPM cell survival and development. To investigate the effects of Akt inhibitors on MPM cell survival, we examined the effects of nine selective Akt inhibitors, namely, afuresertib, Akti-1/2, AZD5363, GSK690693, ipatasertib, MK-2206, perifosine, PHT-427, and TIC10, on six MPM cell lines, namely, ACC-MESO-4, Y-MESO-8A, MSTO-211H, NCI-H28, NCI-H290, and NCI-H2052, and a normal mesothelial cell line MeT-5A. Comparison of IC₅₀ values of the Akt inhibitors showed that afuresertib, an ATP-competitive specific Akt inhibitor, exerted tumor-specific effects on MPM cells. Afuresertib significantly increased caspase-3 and caspase-7 activities and apoptotic cell number among ACC-MESO-4 and MSTO-211H cells. Moreover, afuresertib strongly arrested the cell cycle in the G₁ phase. Western blotting analysis showed that afuresertib increased the expression of p21^WAF1/CIP1 and decreased the phosphorylation of Akt substrates, including GSK-3β and FOXO family proteins. These results suggest that afuresertib-induced p21 expression promotes G₁ phase arrest by inducing FOXO activity. Furthermore, afuresertib significantly enhanced cisplatin-induced cytotoxicity. Interestingly, results of gene set enrichment analysis showed that afuresertib modulated the expression E2F1 and MYC, which are associated with fibroblast core serum response. Together, these results suggest that afuresertib is a useful anticancer drug for treating patients with MPM.

A pitfall of thoracoscopic thymectomy: a case with intraoperative and postoperative complications

We have reported the usefulness of the subxiphoid approach in thymectomy. However, such a new operation method may have unknown complications that rarely occur. Surgeons cannot completely avoid intraoperative and postoperative complications. We report a case of intraoperative injury of the orifice of the left internal thoracic vein flowing to the left brachiocephalic vein and postoperative pericarditis following video-assisted thoracic surgery (VATS) thymectomy. The innominate vein has been considered to be the vessel that is most frequently injured especially at the orifice of the thymic veins. We also suggest that the orifice of the left internal thoracic vein is the second dangerous location that requires special care. In addition, postoperative pericarditis occurred in this patient. Pericardial drainage was necessary. No additional complications have been found in the 9 months since the operation. Though VATS thymectomy using the subxiphoid approach is a safe and less-invasive operation, intraoperative and postoperative complications were possible to be occurred.

Prognostic value of serial measurements of highly sensitive cardiac troponin I in stable outpatients with nonischemic chronic heart failure

BACKGROUND

Cardiac troponin I (cTnI) is a useful biomarker in patients with chronic heart failure (CHF), and a highly sensitive cTnI (hs-cTnI) commercial assay has become available. However, the prognostic role of serial measurements of hs-cTnI in stable outpatients with CHF remains unknown.

METHODS

At entry to the study, we evaluated 95 stable outpatients with nonischemic CHF showing a serum hs-cTnI (Centaur TnI-Ultra [Siemens Medical Solution Diagnostics, New York, NY], lower limit of detection 0.006 ng/mL) value ≥0.006 ng/mL. To evaluate the role of repetitive measurements of hs-cTnI, we performed echocardiography and measured serum levels of cTnI and N-terminal proBNP at baseline and 6 months later and then prospectively followed up these patients for 4.25 years.

RESULTS

During long-term follow-up, there were 27 cardiac deaths. On multivariate analyses, high plasma N-terminal pro-brain natriuretic peptide (≥711 pg/mL, P = .0008), high serum hs-cTnI at baseline (≥0.03 ng/mL, P = .0011), and an increase in hs-cTnI (Δhs-cTnI ≥0 ng/mL, P = .022) after 6 months were independent significant prognostic predictors. The hazard ratio for mortality of patients with high hs-cTnI (≥0.03 ng/mL) and an increase in hs-cTnI (Δhs-cTnI ≥0 ng/mL) was 3.59 (95% CI 1.3-9.9, P = .014) compared with that of those with high hs-cTnI (≥0.03 ng/mL) and a decrease in hs-cTnI (Δhs-cTnI <0 ng/mL).

CONCLUSIONS

These findings indicated that not only the serum concentration of hs-cTnI at baseline but also an increase in hs-cTnI were independent and useful prognostic predictors in patients with nonischemic CHF.

Prognostic role of high-sensitivity cardiac troponin T in patients with nonischemic dilated cardiomyopathy

BACKGROUND

Cardiac troponin T (cTnT) is useful biomarker in patients with chronic heart failure (CHF). However, its clinical use is limited by the low sensitivity of the conventional commercial assay system. Recently, a highly sensitive cTnT (hs-cTnT) assay has become commercially available.

METHODS AND RESULTS

To compare the prognostic value of conventional cTnT and hs-cTnT in patients with nonischemic dilated cardiomyopathy (DCM), hemodynamic parameters and the serum levels of conventional cTnT, hs-cTnT and brain natriuretic peptide (BNP) were measured in 85 consecutive CHF patients with nonischemic DCM and then these patients were followed for a mean of 4.1 years. During long-term follow up, there were 20 cardiac deaths. In 85 DCM patients, conventional cTnT was elevated (≥0.03ng/ml) in 4 patients (5%) and hs-cTnT was elevated (≥0.01ng/ml) in 46 patients (54%). In non-survivors (n=20), conventional cTnT was elevated (≥0.03ng/ml) in 2 patients (2%) and hs-cTnT was elevated (≥0.01ng/ml) in 17 patients (85%). In the stepwise multivariate analyses, a high plasma level of BNP (P=0.002), low left ventricular ejection fraction (<30%, P=0.012) and high hs-cTnT (≥0.01ng/ml, P=0.006) were independent significant prognostic predictors, but conventional cTnT (≥0.03ng/ml) was not.

CONCLUSIONS

The findings of the present study indicated that a high serum concentration of hs-cTnT is a useful prognostic predictor that is independent of LVEF or BNP in CHF patients with non-ischemic DCM, suggesting that an increased hs-cTnT concentration sensitively reflects ongoing myocardial damage.

Biological variation of brain natriuretic peptide and cardiac events in stable outpatients with nonischemic chronic heart failure

BACKGROUND

To evaluate the biological variation and prognostic value of brain natriuretic peptide (BNP) for stable outpatients with nonischemic chronic heart failure (NICHF).

METHODS AND RESULTS

Biological variation in BNP was evaluated using an automated assay system in 140 outpatients with NICHF. The stable clinical condition during the 2-month study period was defined as unchanged NYHA and unchanged left ventricular ejection fraction; therefore, 7 patients were excluded during the 2 months. Thereafter, 133 patients were prospectively followed and the relationship between cardiac events and the plasma BNP concentrations (at baseline and after 2 months) were evaluated as well as the changes in BNP. The biological variation in BNP (2-month interval) was calculated as 22.3%. During a mean follow-up period of 42 months, 26 patients had cardiac events. According to stepwise multivariate analyses, plasma BNP after 2 months (P=0.0002) and % change in BNP (P=0.0067) were significant independent predictors of cardiac events.

CONCLUSIONS

These findings indicated that a combination of the absolute value of BNP after 2 months and % increase in BNP (2-month interval) is useful for predicting cardiac events in stable outpatients with NICHF.

Prognostic role of highly sensitive cardiac troponin I in patients with systolic heart failure

BACKGROUND

Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) are useful biomarkers in patients with chronic heart failure (CHF). However, the clinical use has limitations due to the low sensitivity of a conventional commercial assay system. Recently, a high sensitive-cTnI (hs-cTnI) commercial assay has become available.

METHODS

To compare the prognostic value of cTnT and hs-cTnI, we measured hemodynamic parameters and serum levels of cTnT, hs-cTnI and N-terminal pro-brain natriuretic peptide (NT-proBNP)in 258 consecutive CHF patients and then followed these patients for a mean period of 2.6 years. In both assays of cTnT and hs-cTnI, the lowest concentration at which the coeffi cient of variation was < or =10% were 0.03 ng/mL, respectively. Therefore, in the present study, an elevated cTnT or cTnI test was defined as a level of > or =0.03 ng/mL.

RESULTS

During long-term follow up, there were 20 cardiac deaths. In 258 CHF patients, serum cTnT were elevated (> or =0.03 ng/mL) in 32 patients (12%) and serum hs-cTnI was elevated (> or =0.03 ng/mL) in 112 patients (43%). On stepwise multivariate analyses, high plasma NT-proBNP (> or =627 pg/mL, P = .0063) and hs-cTnI (> or =0.03 ng/mL) (P = .016) were independent significant prognostic predictors but cTnT (> or =0.03 ng/mL) was not. The hazard ratio for mortality of patients with high plasma NT-proBNP (> or =627 pg/mL) and hs-cTnI (> or =0.03 ng/mL) was 5.74 (95% CI, 2.33-14.28, P < .0001) compared to that of those with low NT-proBNP (<627 pg/mL) or hs-cTnI (<0.03 ng/mL).

CONCLUSIONS

These findings indicate that a high plasma concentration of hs-cTnI is an independent and useful prognostic predictor in patients with CHF.

Mediators of nonadrenergic, noncholinergic relaxation in Sprague Dawley rat intestine: comparison with the mediators of other strains

Participation of nitric oxide, vasoactive intestinal peptide (VIP) and pituitary adenylate cyclase activating peptide (PACAP) in nonadrenergic, noncholinergic (NANC) relaxation of longitudinal muscle of various intestinal regions in Sprague Dawley rats (8-week-old) was studied in vitro. Nitric oxide was suggested to participate in NANC relaxation of every intestinal region studied. But the participation was partial and its extent varied among the regions: significant in the proximal colon and rectum, and moderate in the jejunum, ileum and distal colon. Participation of PACAP in NANC relaxation was suggested only in the distal colon, while that of VIP was not detected in any of regions. Results obtained in the present study indicate that extent of participation of nitric oxide in NANC relaxation in Sprague Dawley rat intestine is more significant than those of other strains, Wistar and Wistar-ST.

1H-[1,2,4] oxadiazolo[4,3-a]quinoxalin-1-one (ODQ) inhibits cyclic GMP-PKG pathway-independent nonadrenergic, noncholinergic relaxation in longitudinal muscle of the rectum of Wistar-ST rats

Participation of the nitric oxide-cyclic GMP pathway in nonadrenergic, noncholinergic (NANC) relaxation induced by electrical field stimulation of longitudinal muscle of the rectum of Wistar-ST rats was studied by using a selective inhibitor of soluble guanylyl cyclase, 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one (ODQ). ODQ concentration dependently inhibited the relaxation and at 10 microM, maximally inhibited it by 83%. However, results obtained with N(G)-nitro-L-arginine, L-arginine and exogenously added nitric oxide excluded the participation of nitric oxide in the relaxation. An inhibitor of cyclic GMP-dependent protein kinase (PKG) partially (39%) inhibited the relaxation. ODQ also significantly inhibited the relaxation, which persisted after the PKG inhibitor-treatment, by 85%. The results strongly suggest that ODQ inhibits the NANC relaxation in a cyclic GMP-PKG pathway-independent manner.

Tyrosine kinase involvement in apamin-sensitive inhibitory responses of rat distal colon

1. It has been suggested that pituitary adenylate cyclase activating peptide (PACAP) may be involved in the non-adrenergic, non-cholinergic (NANC) inhibitory response of longitudinal muscle of rat distal colon. In this study, we have investigated the intracellular mechanism of PACAP-induced relaxation in this muscle. 2. PACAP induced an apamin-sensitive relaxation of the longitudinal muscle. The tyrosine kinase inhibitors genistein at 10 microM and tyrphostin 25 at 30 microM, but not the cyclic AMP-dependent protein kinase inhibitor Rp-8-bromoadenosine-3',5'-cyclic monophosphorothioate at 30 microM significantly inhibited the PACAP-induced relaxation to 60% and 25% of control values, respectively. PACAP did not increase the cyclic AMP content of the muscle. 3. Tyrphostin 25 at 10 microM significantly inhibited the relaxation of longitudinal muscle induced by electrical field stimulation (EFS), to 50% of control values. Apamin at 1 microM, an antagonist of small conductance Ca2+-activated K+ channels, also inhibited the relaxation, to 42 % of control values. The inhibitory effects of tyrphostin 25 and apamin were not additive (44 % of control values). 4. PACAP induced an apamin-sensitive, slow hyperpolarization of the cell membrane of the muscle. Tyrphostin 25 at 3 microM inhibited this PACAP-induced hyperpolarization. Tyrphostin 25 at 10 microM and genistein at 10 microM inhibited the apamin-sensitive inhibitory junction potentials induced by a single pulse of EFS. 5. The PACAP-induced relaxation of longitudinal muscle occurred with a concomitant decrease in intracellular Ca2+ levels ([Ca2+]i). Tyrphostin 25 at 10 microM and apamin at 1 microM abolished these PACAP-induced responses. 6. From these findings it is suggested that the activation of tyrosine kinase is involved in PACAP-induced relaxation of longitudinal muscle from rat distal colon, 'upstream of' the activation of apamin-sensitive K+ channels.