Bicyclic and tricyclic thiophenes as protein tyrosine phosphatase 1B inhibitors

A novel pyridothiophene inhibitor of PTP1B was discovered by rational screening of phosphotyrosine mimics at high micromolar concentrations. The potency of this lead compound has been improved significantly by medicinal chemistry guided by X-ray crystallography and molecular modeling. Excellent consistency has been observed between structure-activity relationships and structural information from PTP1B-inhibitor complexes.

Odynophagia in a woman with known coronary artery disease and ischemia on electrocardiogram

Esophageal intramural hematoma can mimic other causes of chest pain. When the patient is known to have coronary artery disease, the diagnosis may be difficult. Moreover, the course may be complicated and may harm the patient if antiplatelet drugs, thrombolytics, and anticoagulants are used. The presence of odynophagia should alert the clinician to the possibility of an esophageal origin, even in a patient with known coronary artery disease. We present a case in which early recognition of the clinical presentation prevented potential iatrogenic complications.

Repeat aortic root replacement

BACKGROUND

Aortic root replacement in patients who have undergone previous aortic root replacement presents a formidable technical challenge, which may lead to increased surgical mortality.

METHODS

We reviewed our experience from January 1989 through November 1995. Seven consecutive patients (6 men and 1 woman) underwent eight repeat aortic root replacements. Mean follow-up was 19 months. Previous root replacement had been performed with homograft in 1 patient, with a bioprosthetic valve composite graft in 1 patient, and with a mechanical valve composite graft in 6 patients. The techniques used at the previous procedures were the Cabrol technique (2 patients), Bentall technique (3 patients), and the coronary button technique (3 patients). Reoperation was indicated for pseudoaneurysm formation in 4 patients and for endocarditis in the others.

RESULTS

Aortic homografts were implanted in all patients with endocarditis and mechanical valve composite grafts were used in the others. In all reoperations, the coronary button technique was used. No procedures were done emergently. Concomitant procedures were performed in 2 patients, including mitral valve replacement and aortic arch aneurysm repair. One patient had recurrence of his endocarditis 36 months after operation because of continued intravenous drug use requiring a second successful homograft root replacement. There were no early deaths and one late death at 16 months after operation.

CONCLUSIONS

Repeat aortic root replacement, even in the setting of endocarditis, can be done with low mortality.

Diaphragmatic hernia after right gastroepiploic artery coronary artery bypass grafting

We report a case of a diaphragmatic hernia, with perforated viscus, originating from the diaphragmatic incision that was made to accommodate the right gastroepiploic artery coronary artery bypass graft. Avoidance of an excessively large right gastroepiploic artery pedicle and interrupted sutures placed at the limits of the diaphragmatic incision, perpendicular to the direction of the musculotendinous fibers of the diaphragm, should prevent this potentially lethal complication. Prompt recognition and treatment of this complication when it occurs is lifesaving.

Molecular cardiomyoplasty: potential cardiac gene therapy for chronic heart failure

In this study, we evaluated the feasibility of converting cardiac fibroblasts into skeletal muscle cells by forced expression of the MyoD gene, one of the basic helix-loop-helix myogenic factors. Primary cardiac fibroblasts, isolated from newborn rats, were infected with retrovirus-carrying sense or antisense MyoD gene. Ten days after infection, expression of MyoD protein was demonstrated in 95% of cells infected with sense MyoD virus by intense nuclear immunostaining with a MyoD polyclonal antibody. In contrast, none of the cells infected with antisense MyoD virus showed staining. On withdrawal of serum, 95% of MyoD positive cells became elongated and, in the presence of appropriate cell density, fused to form multinucleated myotubes, morphologically similar to striated muscle cell. Expression of downstream myogenic differentiation markers, myosin heavy chain and myocyte-specific enhancer factor 2, in 95% of these myotubes were detected by intense cytoplasmic and nuclear immunostaining, respectively, with specific antibodies. In contrast, no detectable staining was noted in MyoD negative cells. Spontaneous contractile movements were noted in a few clusters of myotubes. In summary, cardiac fibroblasts were able to be converted into bonafide potentially functional skeletal myocytes as shown by definitive morphologic and biochemical changes. Further studies with in vivo models are needed to explore this unique molecular strategy to treat patients with chronic heart failure.

Cardiac myocyte terminal differentiation. Potential for cardiac regeneration

The exact mechanism of terminal differentiation in cardiac myocytes is currently unknown. Studies in the skeletal muscle system provided a model where muscle lineage termination gene directly interacts with Rb to produce and maintain the terminally differentiated state. This interaction provided the critical components for the lock in cell cycle arrest in skeletal muscle cell. Cardiac muscle appears on the surface very similar to skeletal muscle especially since they share large numbers of structural and contractile proteins. However, it is clear that cardiac muscle cells are distinct biologically at the regulatory level. First and foremost, differentiation and capacity for hyperplasia (mitosis) is not mutually exclusive, in that the heart being the first functional organ embryologically is able to grow via cell division until shortly after birth. Thereafter further growth is provided by hypertrophy. In skeletal muscle, these two processes, differentiation and ability to undergo mitosis, appear to be mutually exclusive. Second, cardiac muscles have not been shown to express any of the skeletal muscle determination basic helix loop helix factors like myoD or any proteins that are functionally similar. Third, heterokaryons of cardiac myocytes and fibroblasts reveal a lack of dominance of the cardiac muscle phenotype. This is distinctly different in skeletal muscle, whose phenotype is dominant which provided a platform to identify the skeletal muscle determination gene, myoD. Although various basic helix loop helix proteins and homeobox genes have been identified in cardiac myocytes, their function remains to be elucidated. At this time no cardiac determination gene has been identified. Despite these differences, we have shown that the biology of pocket proteins Rb and P107 is similar in skeletal and cardiac myocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Unexpected, sustained ventricular tachyarrhythmia after cardiac operations

Unexpected, sustained ventricular tachyarrhythmia after cardiac operations is differentiated from sustained ventricular tachycardia and ventricular fibrillation from known antecedent causes, such as recent or perioperative myocardial infarction, low cardiac output, preoperative ventricular arrhythmia, sympathomimetic drugs, drug toxicity, and metabolic abnormalities. Sixteen of 2364 patients (0.68%) who underwent heart operations met strict exclusion criteria for unexpected sustained ventricular tachyarrhythmia that occurred 1 hour to 12 days after operation. Recurrent ventricular tachyarrhythmias occurred in 12 patients; three died (21%), despite resuscitation from the initial episode. All patients had significant preoperative left ventricular dysfunction and 14 had ejection fractions below 30%. Fifteen of the 16 patients had monomorphic ventricular tachycardia at the initial episode. Empirically prescribed therapy was not effective in suppressing ventricular tachyarrhythmias inducible by programmed stimulation during postevent electrophysiologic studies in 10 of the 13 survivors. Inducibility was eventually prevented by drugs in nine patients, three patients received automatic implantable cardiac defibrillators, and one patient underwent successful catheter ablation of ventricular tachycardia. No patient died of recurrent ventricular tachyarrhythmias during the follow-up of 8 to 55 (mean 29) months after hospital discharge.

Sequentially paced heterotopic heart transplant in the left chest provides improved circulatory support for the failed left ventricle. A potential biologic bridge to orthotopic transplantation

Acute experimental transplantation of an allograft heart in a heterotopic position was performed in 14 sheep. The donor heart was implanted in the left side of the chest with left atrial, aortic, and pulmonary artery anastomoses. Hemodynamic studies were performed to evaluate the physiologic effects of the procedure, particularly when recipient left ventricular failure was produced by inflow and outflow obstruction. Pacing techniques were developed and tested to coordinate the rhythm of the two hearts either synchronously or sequentially with variable intervals between depolarization of the two hearts. Hemodynamic studies were performed to evaluate the rhythm that would most optimize the physiology. The cardiac index remained essentially unchanged when the dominant circulatory support was shifted from recipient left ventricle to donor left ventricle by producing recipient left ventricular failure (3.79 +/- 0.6 to 3.30 +/- 0.8, p = no significant difference). Consistent and reliable paced rhythms were achieved in each case. The cardiac index was significantly higher when the hearts were paced sequentially rather than synchronously (3.76 +/- 0.5 versus 3.29 +/- 0.5, p less than 0.04). Allograft donor hearts small in size or slightly inadequate otherwise, which may be unsuitable for orthotopic heart transplantation, may still be used heterotopically for short-term support. Their use would maximize the use of all donor organs and the survival of patients awaiting a suitable organ. Further, it may also be possible to use sequentially paced xenografts heterotopically for short-term left ventricular assistance as a bridge to orthotopic heart transplantation.

Effects of antegrade cardioplegic infusion with simultaneously controlled coronary sinus occlusion on preservation of regionally ischemic myocardium after acute coronary artery occlusion and reperfusion

This study was conducted to assess the protective effects of antegrade infusion of cardioplegic solution with simultaneously controlled coronary sinus occlusion on regionally ischemic myocardium after acute coronary occlusion and reperfusion. Twelve sheep were subjected to 1 hour of occlusion of the distal left anterior descending coronary artery. Sheep in group I (n = 6) were subjected only to infusion of potassium crystalloid cardioplegic solution into the aortic root, whereas in group II (n = 6) a stitch was snared around the proximal coronary sinus for its subsequent occlusion during antegrade infusions of cardioplegic solution. All animals were placed on cardiopulmonary bypass. Five hundred milliliters of cardioplegic solution at 4 degrees to 8 degrees C was administered in three divided doses during the total cross-clamp period of 30 minutes. The occlusion of the left anterior descending artery was then released, and the animals were weaned from bypass and studied for an additional 4 hours. Coronary sinus pressure, myocardial temperature, regional function assessed by pairs of ultrasonic crystals, global function assessed by rate of rise of left ventricular pressure and cardiac output, and the area at risk and area of necrosis were determined. The heart was excised at the end of the experiment and stained. Animals treated by the technique of antegrade infusion combined with coronary sinus occlusion had more homogeneous myocardial cooling during cardioplegic infusions and better recovery of the first derivative of left ventricular pressure and regional segment shortening at 90 and 270 minutes of reperfusion than those treated with antegrade infusion alone (p less than 0.01 and p less than 0.05, respectively). The group treated by antegrade infusion of cardioplegic solution combined with coronary sinus occlusion had an area of necrosis/area at risk ratio of 40.5% +/- 1.2%; the antegrade infusion group, 58.3% +/- 4.1% (p less than 0.01). These data suggest that antegrade infusion combined with coronary sinus occlusion may be an improved method of global and regional myocardial protection in the presence of an occluded coronary artery.