Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting for Treating In-Stent Restenosis in Unprotected-Left Main: LM-DRAGON-Registry

Background

Data regarding management of patients with unprotected left main coronary artery in-stent restenosis (LM-ISR) are scarce.

Objectives

This study investigated the safety and effectiveness of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) for the treatment of unprotected LM-ISR.

Methods

Consecutive patients who underwent PCI or CABG for unprotected LM-ISR were enrolled. The primary endpoint was a composite of major adverse cardiac and cerebrovascular events (MACCE), defined as cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), and stroke.

Results

A total of 305 patients were enrolled, of which 203(66.6%) underwent PCI and 102(33.4%) underwent CABG. At 30-day follow-up, a lower risk of cardiac death was observed in the PCI group, compared with the CABG-treated group (2.1% vs. 7.1%, HR 3.48, 95%CI 1.01–11.8, p = 0.04). At a median of 3.5 years [interquartile range (IQR) 1.3–5.5] follow-up, MACCE occurred in 27.7% vs. 29.6% (HR 0.82, 95%CI 0.52–1.32, p = 0.43) in PCI- and CABG-treated patients, respectively. There were no significant differences between PCI and CABG in cardiac death (9.9% vs. 18.4%; HR 1.56, 95%CI 0.81–3.00, p = 0.18), MI (7.9% vs. 5.1%, HR 0.44, 95%CI 0.15–1.27, p = 0.13), or stroke (2.1% vs. 4.1%, HR 1.79, 95%CI 0.45–7.16, p = 0.41). TVR was more frequently needed in the PCI group (15.2% vs. 6.1%, HR 0.35, 95%CI 0.15–0.85, p = 0.02).

Conclusions

This analysis of patients with LM-ISR revealed a lower incidence of cardiac death in PCI compared with CABG in short-term follow-up. During the long-term follow-up, no differences in MACCE were observed, but patients treated with CABG less often required TVR.

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Registration

https://www.clinicaltrials.gov; Unique identifier: NCT04968977.

QT interval dispersion as a new marker of restenosis after percutaneous transluminal coronary angioplasty of isolated single-vessel coronary artery stenosis

BACKGROUND

There are no reliable non-invasive markers of restenosis after percutaneous transluminal coronary angioplasty (PTCA). The aim of our study was to measure changes in QT interval dispersion after PTCA and to determine whether restenosis subsequently affects QT interval dispersion.

METHODS AND RESULTS

Fifty-six consecutive patients - 41 men and 15 women (mean age: 56.2 +/-8.3 years) - with isolated stenosis of the left anterior descending artery who underwent successful PTCA were studied. A symptom-limited treadmill exercise test was performed within 7 days after PTCA and then again before repeated angiography. Repeated coronary angiography revealed restenosis in 15 patients (26.8%) and no signs of significant stenosis in 41 patients (73.2%). QT interval dispersion in the group of patients with restenosis measured before exercise increased from baseline 34 +/- 7 to 49 +/- 15 ms after 6 months (p < 0.01) and QT interval dispersion measured immediately after exercise increased from baseline 38 +/- 4 to 68 +/- 21 ms after 6 months (p < 0.001). In contrast, patients without restenosis showed no significant changes in QT interval dispersion measured before (baseline: 34 +/- 9 ms; after 6 months 33 +/- 12 ms; p = NS) and immediately after exercise (baseline: 34 +/- 12 ms; after 6 months: 33 +/- 10; p = NS). When QT interval dispersion > or =60 ms (measured 6 months after PTCA procedure) was considered as a potential marker of restenosis, this indicator had very high sensitivity and specificity when measured immediately after exercise (80 and 95% respectively).

CONCLUSIONS

QT interval dispersion significantly increases in the group of patients with documented restenosis and may be a simple, non-invasive marker of restenosis. However, further studies are needed to confirm this observation.

Determinants of homocysteine-thiolactonase activity of the paraoxonase-1 (PON1) protein in humans

Homocysteine (Hcy)-thiolactonase (HTase) activity of the paraoxonase-1 (PON1) protein detoxifies Hcy-thiolactone in human blood and could thus delay the development of atherosclerosis. To gain insight into physiological role(s) of the PON1 protein, we studied HTase activities and PON1 genotypes in a group of 184 subjects, 32.6% of whom were healthy, 27.7% had angiographically proven coronary artery disease but did not have myocardial infarction (CAD), and 39.7% had myocardial infarction (MI). We found that the hydrolytic activities of the serum PON1 protein towards Hcy-thiolactone and the organophosphate paraoxon substrates were strongly correlated. PON1-192-RR and PON1-55-LL genotypes were associated with high HTase activity. HTase activity was negatively correlated with age (beta = -0.135, p =0.002), plasma total Hcy (in 192-QR subjects only; r = -0.46, p = 0.001), and positively correlated with total cholesterol (beta = 0.169, p<0.001), but not with HDL cholesterol. Mean HTase activities were similar in CAD subjects, MI subjects, and in healthy controls. However, the frequency of the PON1-192-RR genotype tended to be lower in CAD subjects than in controls (2% vs 10.0%, p = 0.057) and higher in MI subjects that in CAD subjects (10.9% vs 2.0%, p = 0.001). The R-allele was marginally associated with CAD (26.7% in controls vs 17.6% in CAD, p = 0.146) and significantly associated with MI (17.6% in CAD vs 31.5% in MI, p = 0.018). Multiple regression analysis suggests that PON1 genotype, total Hcy, total cholesterol, and age are major determinants of HTase activity in humans.

Effect of restoration of AV synchrony on stroke volume, exercise capacity, and quality-of-life: can we predict the beneficial effect of a pacemaker upgrade?

The aim of this study was to assess to what extent patients with VVIR pacemakers and without overt symptoms of a pacemaker syndrome benefit from a pacemaker upgrade, and if a preoperative noninvasive measurement of the change in stroke volume (SV) could predict the effect of a pacemaker upgrade. The study group consisted of 20 (12 women, 8 men) VVIR patients with a mean age of 60 years. The indication for the first implantation was AV block in 13 patients and SSS in 7. The mean time of a ventricular pacing was 77 months. The objective (echocardiography, an exercise capacity) and the subjective (the quality-of-life) parameters investigated in patients during ventricular pacing were compared to results obtained 2 months and 1 year after a pacemaker upgrade. To assess preoperatively a change in a SV expected after upgrading, attempts were made to restore AV synchronization by the use of a transesophageal pacemaker. An increase in SV (from 5% to > 35%) during temporary AV resynchronization was observed in each patient. Values of SV increase correlated with those obtained 2 months (r = 0.65; P < 0.01) and 1 year (r = 0.66; P < 0.01) after an upgrade. Superior hemodynamics was associated with a significant improvement of an exercise capacity in both subgroups of patients. The most significant improvement in the quality-of-life was observed in patients with SSS. We did not find correlations between SV and the quality-of-life assessed 2 months (r = 0.043; NS) or 1 year (r = 0.02; NS) after an upgrade. In conclusion, a pacemaker upgrade performed after a long-term ventricular pacing resulted almost consistently in the improvement of hemodynamics and was associated with an increase of exercise capacity. In patients with SSS it was followed by the significant improvement of their quality-of-life. Such a relation was not observed in patients with AV block as some of them (especially those with VVIR pacemakers) felt quite well during ventricular pacing. The proposed preoperative echocardiographic evaluation may precisely predict the degree of hemodynamic improvement expected after a pacemaker upgrade.

Flow cytometric analysis of tumour-infiltrating lymphocytes in patients with renal cell carcinoma

OBJECTIVE

To determine the immunophenotype of tumour-infiltrating lymphocytes (TIL) and peripheral blood lymphocytes (PBL) isolated from patients with renal cell carcinoma (RCC) and to analyse the correlations between the quantity of analysed cell subsets and the progression of the disease.

PATIENTS AND METHODS

PBL and TIL samples were obtained from 23 patients with RCC at different stages of disease. The immunophenotype of PBL and TIL was measured, and the TNM stage, tumour size, cellular type, histological grade, lymphocytic infiltration and performance status assessed.

RESULTS

The predominant mononuclear cells infiltrating the tumour, in all patients, were T lymphocytes (CD3+ median 66.9%, CD8+ median 34.6%, CD4+ median 26.7%). The cells possessing gamma/delta type T cell receptor accounted for a small fraction of the T cells in PBL and TIL (median 5.6% and 3.7%). Tumour-infiltrating T lymphocytes had a significantly higher percentage of cells expressing human leucocyte antigen (HLA) DR (median 30.9%) and CD25 (median 6.2%) antigens than the equivalent populations in peripheral blood from the same patient group (P < 0.001). The degree of T cell activation appeared to negatively correlate with the tumour stage (K = -0.3, P = 0.04). The percentage of natural killer (NK) cells among TIL (median 15.4%) did not reflect the value in PBL. The percentage of B cells in TIL was slightly lower than in PBL and accounted for 5.0% of cells. There was no relationship between the degree of lymphocytic infiltration and either tumour stage or grade but there appeared to be a positive correlation between the intensity of lymphocytic infiltration and the percentage of CD4+ cells in TIL (K = 0.5, P = 0.001). Moreover, the composition of TIL depended on tumour grade, which positively correlated with the percentage of CD8+ cells (K = 0.4, P = 0.005) and negatively with the percentage of NK cells (K = -0.5, P = 0.005). There was an inverse correlation with the percentage of gamma/delta T cells in PBL and the TIL concentration (K = -0.3, P < 0.05).

CONCLUSIONS

The TIL immunophenotype is different from PBL and is influenced by the histological grade of the tumour. The activation of TIL and its relationship with tumour progression suggests that they might be sensitized and activated by tumour cells.

Activated gamma/delta T lymphocytes infiltrating renal cell carcinoma

Gamma/delta (gamma delta) T lymphocytes have been postulated to play a role in a surveillance mechanism that eliminates transformed or otherwise damaged cells. In this study, we examined by flow cytometry the frequency and phenotype of gamma delta T cells in the tumour infiltrating lymphocytes (TIL) and peripheral blood (PBL) from renal cell carcinoma patients. The TCR gamma delta + cells comprised an average of 3.8% of the CD3+ TIL and 5.2% of circulating T cells. Analysis of surface immunophenotype revealed that activation markers of T lymphocytes: CD25 and HLA DR were highly expressed on the tumour infiltrating gamma delta + T lymphocytes (median 27.6% for CD25 and 52.0% for HLA DR). More importantly, percentage of activated gamma delta T cells was found to be much higher than compared to all activated CD3+ cells. Furthermore, an unusually high proportion of gamma delta positive TILs express CD4 or CD8 molecules (17.2 and 36.8%, respectively), indicating that they might recognise antigen presented within MHC II or I context. These results suggest that gamma delta T lymphocytes may play a certain role in immune response against tumour cells.

[A case of primary hepatocellular carcinoma with tumor thrombus in the right atrium and massive pulmonary embolism]

We present a case report of primary hepatocellular carcinoma with tumor thrombus extending into the right atrium complicated by pulmonary embolism. A 49-year-old man was admitted to our hospital for searching a cause of thrombus in the right atrium. The patient complained of shortness of breath and oedema of the lower extremities. He had a history of hepatitis B. Abdominal sonography and computed tomography revealed a tumor of the liver. A needle biopsy confirmed the diagnosis of hepatocellular carcinoma. Magnetic resonance showed a tumor thrombus also in the inferior vena cava. The diagnosis of pulmonary embolism was confirmed by pulmonary perfusion scintigraphy. This case stresses that clinicians should include hepatocellular carcinoma among the possible causes of intracardiac thrombus and pulmonary embolism.

[Evaluation of the antihypertensive efficacy of urapidil in the treatment of hypertension emergencies]

Hypertensive crisis is defined as an acute elevation of the blood pressure involving the risk of life. Agents used to the treatment of hypertensive emergencies should lower the blood pressure under control and produce minimal adverse effect. The aim of this study was to evaluate the antihypertensive efficacy of urapidil i.v. in hypertensive emergencies. Twenty three patients (pts) with the hypertensive crisis in association with ischaemic heart disease and/or acute left ventricular failure were studied. Urapidil was given intravenously in the emergent treatment to the group of 23 pts in the mean dose of 50 mg. Systolic (RRs) diastolic blood pressure (RRd) and heart rate were measured within 4 hours after the drug administration. In this group of pts the significant decrease in RRs and RRd after 2 min. of administration of urapidil was observed and the maximum effect (p < 0.05) occurred within 40 min. The heart rate decreased by 8% and was significantly different (p < 0 > 05) at the maximum point of the drug action. Urapidil administered in 25-75 mg i.v. appeared an effective antihypertensive agent in more than 90% of patients with hypertensive emergencies. What was striking, no reflex tachycardia was observed after i.v. administration of urapidil despite its antihypertensive action.

Analysis of mRNA expression for interleukin-1 genes on human testicular cells

We have investigated mRNA expression for IL-1 alpha and IL-1 beta gene on fractionated human testicular cells. Using RT-PCR and Northern blot hybridization technique we detected the presence of IL-1 alpha transcripts, predominantly in the intratubular compartment of the testis, comprising gametogenic and Sertoli cells. We were also able to detect mRNA for IL-1 alpha on the testicular interstitium, but at significantly lower levels. The intertubular compartment of the testis, mainly consisting of macrophages and Leydig cells, appeared however, to be a site for IL-1 beta gene expression. Our experimental data confirm previous results obtained in animal models indicating that the testis is capable of producing interleukin-1 under physiological conditions. Testicular IL-1 may function as a tissue-specific factor modulating both spermato- and steroidogenic activity of human testis.

Different pattern of T cell receptor delta gene rearrangement in tumour-infiltrating lymphocytes and peripheral blood in patients with solid tumours

Tumour-infiltrating lymphocytes (TIL) and peripheral blood lymphocytes (PBL) from four patients with renal-cell carcinoma (three paired with blood), two colon carcinomas (both paired with blood) and two melanomas (blood was not available) were analysed for the T cell receptor (TCR) delta gene repertoire. Polymerase chain reaction analysis, employing a panel of specific primers for TCR delta gene segments, showed different gene rearrangement patterns in TIL and PBL in all patients. Simultaneous analysis of TIL and PBL revealed the presence of lymphoid cells in the tumour tissue that were not present in the periphery. These results demonstrate that, although tumour-infiltrating lymphocytes contain gamma/delta T cells within the range observed in peripheral blood, these cells differ from those in peripheral blood in their gene repertoire and this may account for selective accumulation or/and in situ amplification of gamma/delta lymphocytes at the tumour site, indicating a unique type of host reaction against tumour.

Analysis of mRNA for class I HLA on human gametogenic cells

We have studied mRNA expression for Class I HLA (human leukocyte antigen) on male germ cells by amplification of gene fragments in PCR technique and by Northern hybridization. RNA was extracted from fractionated gametogenic cells (isolated from testis) and reversely transcribed. Then, cDNA was amplified for specific HLA sequence (HLA, -A, -B, -C). The specificity of this product was confirmed in "nested" PCR of 400 bp gene fragment coding for alpha 2 domain, alpha 3 domain, and the transmembrane portion of Class I HLA. The results indicate minimal expression of classical Class I HLA on gametogenic cells. Northern hybridization with 669 bp cDNA fragment (spanning for alpha 3 domain, transmembrane, cytoplasmic, and 3' untranslated region) resulted in a low intensity signal from gametogenic cell fractions and confirmed our findings obtained by PCR. The minimal expression of classical HLA antigens may create a neutral cover for the male reproductive system, thereby preventing an immunological response during germ cell differentiation.

[Does effective cardioversion after surgery for valvular heart disease improve hemodynamic indicators?]

In 55 patients aged 47 +/- 6 years successful electrical cardioversion of atrial fibrillation was made. 24 hours before and after cardioversion, ekg and M-mode, 2-D and Doppler echocardiography was performed. Important improvement in ejection fraction (Simpson method), (p < 0.005) and in stroke index (Simpson method, p < 0.01; Doppler method, p < 0.005) was found in 64% of pts. Pts with haemodynamic improvement (HI) were significantly younger, had smaller, left atrial area in apical two-chamber view and left ventricular diastolic diameter and longer pulmonary acceleration time. In pts with HI the duration of AF was significantly shorter and closed mitral commissurotomy less frequent (p < 0.05). Restoration of mechanical atrial function (A-wave) was found in 44% of pts. In pts with A-wave HI was more often (p < 0.001). There was no correlation between maximal peak A-wave flow velocity and HI.

[Preventive pharmacological treatment after cardiac electroversion for atrial fibrillation following surgical treatment of heart defects]

265 patients (168 women, 97 men) after cardiac surgery (mitral valve replacement--74 pts, mitral commissurotomy--158 pts, aortic valve replacement--6 pts, replacement of both valves--16 pts, closure of ASD--11 pts) were randomized after successful electro-conversion of atrial fibrillation to quinidine (63 pts), verapamil (56 pts), amiodarone (50 pts), digoxin (56 pts) or control group (40 pts). The groups were comparable regarding age, sex and mitral valve disease distribution, heart volume, echocardiographic left atrium size and time from cardiac surgery to electro-conversion. After one year sinus rhythm was still present in 43% receiving quinidine, 43% receiving verapamil, 40% receiving amiodarone, 22% receiving digoxin, 20% in the untreated group, and after two years in 14%, 11%, 20%, 0% and 0%--respectively. The treatment was discontinued because of side effects in 13% of pts in the quinidine group, 8% of pts in the amiodarone group and 4% of pts in the verapamil group. It is concluded that quinidine, amiodarone and verapamil compared with control group are significantly (p less than 0.05--after one year) more effective in preventing late relapses of atrial fibrillation. Digoxin is ineffective in preventing recurrence of the arrhythmia. There are no significant differences between quinidine, verapamil and amiodarone regarding its prophylactic efficacy.