Selenoprotein deficiency disorder predisposes to aortic aneurysm formation

Aortic aneurysms, which may dissect or rupture acutely and be lethal, can be a part of multisystem disorders that have a heritable basis. We report four patients with deficiency of selenocysteine-containing proteins due to selenocysteine Insertion Sequence Binding Protein 2 (SECISBP2) mutations who show early-onset, progressive, aneurysmal dilatation of the ascending aorta due to cystic medial necrosis. Zebrafish and male mice with global or vascular smooth muscle cell (VSMC)-targeted disruption of Secisbp2 respectively show similar aortopathy. Aortas from patients and animal models exhibit raised cellular reactive oxygen species, oxidative DNA damage and VSMC apoptosis. Antioxidant exposure or chelation of iron prevents oxidative damage in patient's cells and aortopathy in the zebrafish model. Our observations suggest a key role for oxidative stress and cell death, including via ferroptosis, in mediating aortic degeneration.

A randomised controlled trial evaluating arrhythmia burden, risk of sudden cardiac death and stroke in patients with Fabry disease: the role of implantable loop recorders (RaILRoAD) compared with current standard practice

Background

Fabry disease (FD) is a genetic disorder caused by a deficiency in the enzyme alpha-galactosidase A, leading to an accumulation of glycosphingolipids in tissues across the body. Cardiac disease is the leading cause of morbidity and mortality. Advanced disease, characterised by extensive left ventricular hypertrophy, ventricular dysfunction and fibrosis, is known to be associated with an increase in arrhythmia. Data identifying risk factors for arrhythmia are limited, and no Fabry-specific risk stratification tool is available to select those who may benefit from initiation of medical or device therapy (implantable cardiac defibrillators). Current monitoring strategies have a limited diagnostic yield, and implantable loop recorders (ILRs) have the potential to change treatment and clinical outcomes.

Aim

The aim of this study is to determine whether ILRs can (1) improve arrhythmia detection in FD and (2) identify risk predictors of arrhythmia.

Methods

A prospective, 5-year, open-label, international, multi-centre randomised controlled trial of a minimum of 164 participants with genetically or enzymatically confirmed FD (or both) who have evidence of cardiac disease will be recruited from five centres: Queen Elizabeth Hospital, Birmingham, UK; Salford Royal Hospital, Salford, UK; Royal Free Hospital, London, UK; Addenbrookes Hospital, Cambridge, UK; and Westmead Hospital, Sydney, Australia. Participants will be block-randomised (1:1) to two study arms for cardiac monitoring (i) control arm: standard of care with annual 24 h or 5-day Holter monitor or (ii) treatment arm: continuous cardiac monitoring with ILR implantation plus standard of care. Participants will undergo multiple investigations—blood/urine biomarkers, 12-lead and advanced electrocardiogram (ECG) recording, echocardiography and cardiovascular magnetic resonance (CMR) imaging—at baseline and 6–12 monthly follow-up visits. The primary endpoint is identification of arrhythmia requiring initiation or alteration in therapy. Secondary outcome measures include characterising the risk factors associated with arrhythmia and outcome data in the form of imaging, ECG and blood biomarkers.

Discussion

This is the first study evaluating arrhythmia burden and the use of ILR across the spectrum of risk profiles in Fabry cardiomyopathy. This will enable detailed characterisation of arrhythmic risk predictors in FD and ultimately support formulation of Fabry-specific guidance in this high-risk population.

Trial registration

ClinicalTrials.gov (NCT03305250). Registered on 9 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3425-1) contains supplementary material, which is available to authorized users.

Early Clinical and Hemodynamic Outcomes After Stented and Stentless Aortic Valve Replacement: Results From a Randomized Controlled Trial

BACKGROUND

Stentless aortic bioprostheses were shown to be hemodynamically superior to earlier generations of stented bioprostheses. Modern stented valve designs have improved hemodynamics. A prospective randomized controlled trial was undertaken to compare stentless versus modern stented valves. Our aim was to determine any differences in early postoperative clinical and hemodynamic outcomes.

METHODS

Patients with severe aortic valve stenosis (n = 161) undergoing aortic valve replacement were randomized intraoperatively to receive either the C-E Perimount (Edwards Lifesciences, Irvine, CA) pericardial stented bioprosthesis (n = 81) or the Prima Plus (Edwards Lifesciences) (porcine stentless bioprosthesis (n = 80). Transthoracic echocardiograms were performed at one week and eight weeks postoperatively to assess left ventricular mass (LVM) and transvalvular gradients (TVG).

RESULTS

There were no differences between the two groups in baseline characteristics. Cardiopulmonary bypass and ischemic times were longer in the stentless group. Despite similar native aortic annular diameters, the mean size of the prosthesis used in the stentless group was 2.1 mm (SD = 2.8) larger (p < 0.001). Early (30-day) mortality (stentless 3.7% vs stented 2.5%; p = 0.68) and morbidity was similar between groups. Eight weeks postoperatively, LVM (stentless 199 +/- 70 vs stented 204 +/- 66 grams; p = 0.32) and TVG decreased in both groups (mean systolic gradient; stentless 10 +/- 3 vs stented 10 +/- 4 mm Hg; p = 0.54) but there was no significant difference between groups.

CONCLUSIONS

Despite longer ischemic times in the stentless group, early postoperative outcomes were similar. Both stented and stentless aortic valve replacement offers excellent hemodynamics and can be achieved with low perioperative mortality.

Sublingual captopril--a pharmacokinetic and pharmacodynamic evaluation

In this study we compared the pharmacokinetics and pharmacodynamics of captopril after sublingual and peroral administration. Single 25 mg doses of captopril were administered sublingually and perorally on two different occasions in a randomised cross-over fashion to eight healthy volunteers aged 22-35 years. The kinetics of unchanged captopril, plasma renin activity (PRA). BP and heart rate were studied over three hours after both peroral and sublingual administration of captopril. Mean pharmacokinetic parameters for unchanged captopril after sublingual administration were: Cmax, 234 ng.ml-1; tmax, 45 min; AUC (0-3 h), 15.1 micrograms.ml-1.min. Mean pharmacokinetic parameters for unchanged captopril after peroral administration were; Cmax, 228 ng.ml-1; tmax, 75 min; AUC (0-3 h), 17.0 micrograms.ml-1.min.tmax was significantly shorter when captopril was administered sublingually; all other pharmacokinetic parameters were equivalent. The plasma captopril concentrations achieved post drug administration led to increases in PRA and reductions in BP.tmax for PRA was 86 min for sublingual captopril and 113 min for perorally administered drug. Peak PRA values were, however, not significantly different. BP, as expected, was not reduced dramatically in these healthy volunteer subjects, however, in systolic BP vs time profiles, BP was significantly lower after volunteers received sublingual captopril. Heart rate increased slightly after captopril administration; there were no differences between the two routes of administration. Administration of captopril sublingually, therefore led to a more rapid attainment of plasma captopril concentrations and had a more rapid onset of pharmacological effect when compared with peroral administration.

Comparison of the utility of two abbreviated forms of the MMPI for psychiatric screening of the elderly

Assessed the utility of the Faschingbauer Abbreviated MMPI (FAM) and MMPI-168 for use with the elderly. FAM and MMPI-168 items were extracted from the MMPIs of 24 older male veteran medical or alcoholic patients. The results indicate that both abbreviated forms are highly correlated with and yield similar diagnostic inferences to the standard MMPI. For this sample population, the FAM was significantly (p less than .001) more in accordance with the standard MMPI than the MMPI-168.