Potent neutralizing antibodies elicited by dengue vaccine in rhesus macaque target diverse epitopes

There is still no safe and effective vaccine against dengue virus infection. Epidemics of dengue virus infection are increasingly a threat to human health around the world. Antibodies generated in response to dengue infection have been shown to impact disease development and effectiveness of dengue vaccine. In this study, we investigated monoclonal antibody responses to an experimental dengue vaccine in rhesus macaques. Variable regions of both heavy chain (VH) and light chain (VL) were cloned from single antibody-secreting B cells. A total of 780 monoclonal antibodies (mAbs) composed of paired VH and VL were characterized. Results show that the vaccination induces mAbs with diverse germline sequences and a wide range of binding affinities. Six potent neutralizing mAbs were identified among 130 dengue envelope protein binders. Critical amino acids for each neutralizing antibody binding to the dengue envelope protein were identified by alanine scanning of mutant libraries. Diverse epitopes were identified, including epitopes on the lateral ridge of DIII, the I-III hinge, the bc loop adjacent to the fusion loop of DII, and the β-strands and loops of DI. Significantly, one of the neutralizing mAbs has a previously unknown epitope in DII at the interface of the envelope and membrane protein and is capable of neutralizing all four dengue serotypes. Taken together, the results of this study not only provide preclinical validation for the tested experimental vaccine, but also shed light on a potential application of the rhesus macaque model for better dengue vaccine evaluation and design of vaccines and immunization strategies.

Dengue virus (DENV) is a leading cause of human illness in the tropics and subtropics, with about 40% of the world’s population living in areas at risk for infection. There are four DENV serotypes. Patients who have previously been infected by one dengue serotype may develop more severe symptoms such as bleeding and endothelial leakage upon secondary infection with another dengue serotype. This study reports the extensive cloning and analysis of 780 monoclonal antibodies (mAbs) from single B cells of rhesus macaques after immunization with an experimental dengue vaccine. We identified a panel of potent neutralizing mAbs with diverse epitopes on the DENV envelope protein. Antibodies in this panel were found to bind to the lateral ridge of DIII, the I-III hinge, the bc loop adjacent to the fusion loop of DII, and the β-strands and the loops of DI. We also isolated one mAb (d448) that can neutralize all four dengue serotypes and binds to a novel epitope at the interface of the DENV envelope and membrane proteins. Further investigation of these neutralizing monoclonal antibodies is warranted for better vaccine efficacy evaluation and vaccine design.

SELfies and CELLfies: Whole Genome Sequencing and Annotation of Five Antibiotic Resistant Bacteria Isolated from the Surfaces of Smartphones, An Inquiry Based Laboratory Exercise in a Genomics Undergraduate Course at the Rochester Institute of Technology

Are touchscreen devices a public health risk for the transmission of pathogenic bacteria, especially those that are resistant to antibiotics? To investigate this, we embarked on a project aimed at isolating and identifying bacteria that are resistant to antibiotics from the screens of smartphones. Touchscreen devices have become ubiquitous in society, and it is important to evaluate the potential risks they pose towards public health, especially as it pertains to the harboring and transmission of pathogenic bacteria that are resistant to antibiotics. Sixteen bacteria were initially isolated of which five were unique (four Staphylococcus species and one Micrococcus species). The genomes of the five unique isolates were subsequently sequenced and annotated. The genomes were analyzed using in silico tools to predict the synthesis of antibiotics and secondary metabolites using the antibiotics and Secondary Metabolite Analysis SHell (antiSMASH) tool in addition to the presence of gene clusters that denote resistance to antibiotics using the Resistance Gene Identifier (RGI) tool. In vivo analysis was also done to assess resistance/susceptibility to four antibiotics that are commonly used in a research laboratory setting. The data presented in this manuscript is the result of a semester-long inquiry based laboratory exercise in the genomics course (BIOL340) in the Thomas H. Gosnell School of Life Sciences/College of Science at the Rochester Institute of Technology.

Probing the antigenicity of hepatitis C virus envelope glycoprotein complex by high-throughput mutagenesis

The hepatitis C virus (HCV) envelope glycoproteins E1 and E2 form a non-covalently linked heterodimer on the viral surface that mediates viral entry. E1, E2 and the heterodimer complex E1E2 are candidate vaccine antigens, but are technically challenging to study because of difficulties in producing natively folded proteins by standard protein expression and purification methods. To better comprehend the antigenicity of these proteins, a library of alanine scanning mutants comprising the entirety of E1E2 (555 residues) was created for evaluating the role of each residue in the glycoproteins. The mutant library was probed, by a high-throughput flow cytometry-based assay, for binding with the co-receptor CD81, and a panel of 13 human and mouse monoclonal antibodies (mAbs) that target continuous and discontinuous epitopes of E1, E2, and the E1E2 complex. Together with the recently determined crystal structure of E2 core domain (E2c), we found that several residues in the E2 back layer region indirectly impact binding of CD81 and mAbs that target the conserved neutralizing face of E2. These findings highlight an unexpected role for the E2 back layer in interacting with the E2 front layer for its biological function. We also identified regions of E1 and E2 that likely located at or near the interface of the E1E2 complex, and determined that the E2 back layer also plays an important role in E1E2 complex formation. The conformation-dependent reactivity of CD81 and the antibody panel to the E1E2 mutant library provides a global view of the influence of each amino acid (aa) on E1E2 expression and folding. This information is valuable for guiding protein engineering efforts to enhance the antigenic properties and stability of E1E2 for vaccine antigen development and structural studies.

Broadly neutralizing antibodies with few somatic mutations and hepatitis C virus clearance

Here, we report the isolation of broadly neutralizing mAbs (bNAbs) from persons with broadly neutralizing serum who spontaneously cleared hepatitis C virus (HCV) infection. We found that bNAbs from two donors bound the same epitope and were encoded by the same germline heavy chain variable gene segment. Remarkably, these bNAbs were encoded by antibody variable genes with sparse somatic mutations. For one of the most potent bNAbs, these somatic mutations were critical for antibody neutralizing breadth and for binding to autologous envelope variants circulating late in infection. However, somatic mutations were not necessary for binding of the bNAb unmutated ancestor to envelope proteins of early autologous transmitted/founder viruses. This study identifies a public B cell clonotype favoring early recognition of a conserved HCV epitope, proving that anti-HCV bNAbs can achieve substantial neutralizing breadth with relatively few somatic mutations, and identifies HCV envelope variants that favored selection and maturation of an anti-HCV bNAb in vivo. These data provide insight into the molecular mechanisms of immune-mediated clearance of HCV infection and present a roadmap to guide development of a vaccine capable of stimulating anti-HCV bNAbs with a physiologic number of somatic mutations characteristic of vaccine responses.

Lower IgG somatic hypermutation rates during acute dengue virus infection is compatible with a germinal center-independent B cell response

BACKGROUND

The study of human B cell response to dengue virus (DENV) infection is critical to understand serotype-specific protection and the cross-reactive sub-neutralizing response. Whereas the first is beneficial and thus represents the ultimate goal of vaccination, the latter has been implicated in the development of severe disease, which occurs in a small, albeit significant, fraction of secondary DENV infections. Both primary and secondary infections are associated with the production of poly-reactive and cross-reactive IgG antibodies.

METHODS

To gain insight into the effect of DENV infection on the B cell repertoire, we used VH region high-throughput cDNA sequencing of the peripheral blood IgG B cell compartment of 19 individuals during the acute phase of infection. For 11 individuals, a second sample obtained 6 months later was analyzed for comparison. Probabilities of sequencing antibody secreting cells or memory B cells were estimated using second-order Monte Carlo simulation.

RESULTS

We found that in acute disease there is an increase in IgG B cell diversity and changes in the relative use of segments IGHV1-2, IGHV1-18, and IGHV1-69. Somewhat unexpectedly, an overall low proportion of somatic hypermutated antibody genes was observed during the acute phase plasmablasts, particularly in secondary infections and those cases with more severe disease.

CONCLUSIONS

Our data are consistent with an innate-like antiviral recognition system mediated by B cells using defined germ-line coded B cell receptors, which could provide a rapid germinal center-independent antibody response during the early phase of infection. A model describing concurrent T-dependent and T-independent B cell responses in the context of DENV infection is proposed, which incorporates the selection of B cells using hypomutated IGHV segments and their potential role in poly/cross-reactivity. Its formal demonstration could lead to a definition of its potential implication in antibody-dependent enhancement, and may contribute to rational vaccine development efforts.

Dengue virus envelope protein domain I/II hinge determines long-lived serotype-specific dengue immunity

The four dengue virus (DENV) serotypes, DENV-1, -2, -3, and -4, are endemic throughout tropical and subtropical regions of the world, with an estimated 390 million acute infections annually. Infection confers long-term protective immunity against the infecting serotype, but secondary infection with a different serotype carries a greater risk of potentially fatal severe dengue disease, including dengue hemorrhagic fever and dengue shock syndrome. The single most effective measure to control this threat to global health is a tetravalent DENV vaccine. To date, attempts to develop a protective vaccine have progressed slowly, partly because the targets of type-specific human neutralizing antibodies (NAbs), which are critical for long-term protection, remain poorly defined, impeding our understanding of natural immunity and hindering effective vaccine development. Here, we show that the envelope glycoprotein domain I/II hinge of DENV-3 and DENV-4 is the primary target of the long-term type-specific NAb response in humans. Transplantation of a DENV-4 hinge into a recombinant DENV-3 virus showed that the hinge determines the serotype-specific neutralizing potency of primary human and nonhuman primate DENV immune sera and that the hinge region both induces NAbs and is targeted by protective NAbs in rhesus macaques. These results suggest that the success of live dengue vaccines may depend on their ability to stimulate NAbs that target the envelope glycoprotein domain I/II hinge region. More broadly, this study shows that complex conformational antibody epitopes can be transplanted between live viruses, opening up similar possibilities for improving the breadth and specificity of vaccines for influenza, HIV, hepatitis C virus, and other clinically important viral pathogens.

Transmitted/founder and chronic subtype C HIV-1 use CD4 and CCR5 receptors with equal efficiency and are not inhibited by blocking the integrin α4β7

Sexual transmission of human immunodeficiency virus type 1 (HIV-1) most often results from productive infection by a single transmitted/founder (T/F) virus, indicating a stringent mucosal bottleneck. Understanding the viral traits that overcome this bottleneck could have important implications for HIV-1 vaccine design and other prevention strategies. Most T/F viruses use CCR5 to infect target cells and some encode envelope glycoproteins (Envs) that contain fewer potential N-linked glycosylation sites and shorter V1/V2 variable loops than Envs from chronic viruses. Moreover, it has been reported that the gp120 subunits of certain transmitted Envs bind to the gut-homing integrin α4β7, possibly enhancing virus entry and cell-to-cell spread. Here we sought to determine whether subtype C T/F viruses, which are responsible for the majority of new HIV-1 infections worldwide, share biological properties that increase their transmission fitness, including preferential α4β7 engagement. Using single genome amplification, we generated panels of both T/F (n = 20) and chronic (n = 20) Env constructs as well as full-length T/F (n = 6) and chronic (n = 4) infectious molecular clones (IMCs). We found that T/F and chronic control Envs were indistinguishable in the efficiency with which they used CD4 and CCR5. Both groups of Envs also exhibited the same CD4+ T cell subset tropism and showed similar sensitivity to neutralization by CD4 binding site (CD4bs) antibodies. Finally, saturating concentrations of anti-α4β7 antibodies failed to inhibit infection and replication of T/F as well as chronic control viruses, although the growth of the tissue culture-adapted strain SF162 was modestly impaired. These results indicate that the population bottleneck associated with mucosal HIV-1 acquisition is not due to the selection of T/F viruses that use α4β7, CD4 or CCR5 more efficiently.

Most new HIV-1 infections worldwide are caused by the sexual transmission of subtype C viruses, which are prevalent in Asia and southern Africa. While chronically infected individuals harbor a genetically diverse set of viruses, most new infections are established by single variants, termed transmitted/founder (T/F) viruses. This raises the question whether certain viral variants have particular properties allowing them to more efficiently overcome the transmission bottleneck. Preferential binding of the viral envelope (Env) to the integrin α4β7 has been hypothesized as one important feature of transmitted viruses. Here, we compared Envs from subtype C viruses that were transmitted to those that were prevalent in chronic infections for efficiency in utilizing α4β7, CD4 and CCR5 for cell entry and replication. We found that transmitted and chronic Envs engaged CD4 and CCR5 with equal efficiency, and that blocking the interaction between Env and α4β7 failed to inhibit replication of T/F as well as control viruses. While the search for determinants of transmission fitness remains an important goal, preferential CD4, CCR5 or α4β7 interactions do not appear to represent distinguishing features of T/F viruses.

Primary infection by a human immunodeficiency virus with atypical coreceptor tropism

The great majority of human immunodeficiency virus type 1 (HIV-1) strains enter CD4+ target cells by interacting with one of two coreceptors, CCR5 or CXCR4. Here we describe a transmitted/founder (T/F) virus (ZP6248) that was profoundly impaired in its ability to utilize CCR5 and CXCR4 coreceptors on multiple CD4+ cell lines as well as primary human CD4+ T cells and macrophages in vitro yet replicated to very high titers (>80 million RNA copies/ml) in an acutely infected individual. Interestingly, the envelope (Env) glycoprotein of this clade B virus had a rare GPEK sequence in the crown of its third variable loop (V3) rather than the consensus GPGR sequence. Extensive sequencing of sequential plasma samples showed that the GPEK sequence was present in virtually all Envs, including those from the earliest time points after infection. The molecularly cloned (single) T/F virus was able to replicate, albeit poorly, in cells obtained from ccr5Δ32 homozygous donors. The ZP6248 T/F virus could also infect cell lines overexpressing the alternative coreceptors GPR15, APJ, and FPRL-1. A single mutation in the V3 crown sequence (GPEK->GPGK) of ZP6248 restored its infectivity in CCR5+ cells but reduced its ability to replicate in GPR15+ cells, indicating that the V3 crown motif played an important role in usage of this alternative coreceptor. These results suggest that the ZP6248 T/F virus established an acute in vivo infection by using coreceptor(s) other than CCR5 or CXCR4 or that the CCR5 coreceptor existed in an unusual conformation in this individual.

The web browser as a unifying agent for radiology and the health care enterprise

A variety of information systems in the health care enterprise are used to store patient information. The hospital information system (HIS), the picture archiving and communications system (PACS), the radiology information systems (RIS), and patient records, for example, are often supported by separate and distinct systems. A referring physician reviewing a radiologist's report often does not have convenient access to the original radiologic images. A radiologist interpreting a radiologic examination may not have convenient access to clinical information generated outside of the radiology department. Clearly, convenient and quick access to all relevant patient information is the ideal in delivering quality patient care. Recently, the web browser has become increasingly well accepted as the "universal client" for viewing a wide variety of information. We believe that the web browser may provide the universal "window" to the variety of distinct information sources required by the physician, and may provide unification of these information sources through hypertext links. We specifically looked at the feasibility of using the web browser to view scanned patient charts. A total of 5,200 patient charts (131,000 pages) were scanned into a structured query language (SQL) database. Access to these records was made available on the hospital local area network (LAN), and on the Internet over the worldwide web. Comparison measurements were made of the time required to access patient records using a dedicated viewing application and using a web browser.

Mammographic changes after excisional breast biopsy for benign disease

OBJECTIVE

The purpose of this study was to establish the incidence and natural history of mammographic changes in patients within 5 years of an excisional breast biopsy.

MATERIALS AND METHODS

We reviewed the records of 428 consecutive patients who had undergone excisional biopsy for benign breast disease. We recorded year by year the mammographic changes seen after surgery. Because the site of surgery was known in each patient and because follow-up imaging continued for at least 2 years after biopsy, our analysis was able to exclude interval malignancy in the area of surgery. We then applied linear regression analysis to determine trends regarding progression, stability, or regression of changes after surgery.

RESULTS

We evaluated 293 patients with 296 biopsies for which the initial mammographic study occurred within 5 years of surgery. Of those 293 patients, 237 (81%) underwent serial mammographic studies. Of the 293 patients studied, 146 patients (50%) showed no changes related to surgery. Of the remaining 147 patients (50%) who showed mammographic changes, the most common changes at initial mammographic follow-up were architectural distortion (98/205, 48%), skin thickening (35/205, 17%), and increased focal density (parenchymal scar) (30/205, 15%). Regression analysis showed no significant change of mammographic features in all patients during 5 years of follow-up (p > .2).

CONCLUSION

Mammographic changes after excisional breast biopsy were seen in 50% of patients. When mammographic changes were seen, they remained stable during 5 years of follow-up. Recognition of such trends during routine surveillance should facilitate the identification of changes that represent developing malignancy.

Mammographic features after conservation therapy for malignant breast disease: serial findings standardized by regression analysis

OBJECTIVE

The purpose of this study was to determine the incidence and natural history of mammographic changes in patients within 5 years of conservation therapy for malignant breast disease.

MATERIALS AND METHODS

We reviewed the records of 164 consecutive patients with a history of conservation therapy for malignant disease. We recorded mammographic changes related to treatment for each year after surgery. Linear regression analysis was applied to determine trends for progression, regression, or stability of findings.

RESULTS

We evaluated 158 patients with 162 lesions for which initial mammographic evaluation had occurred within 5 years of surgery. Of these 158 patients, 121 (77%) underwent serial studies. A total of 152 patients (96%) showed changes on mammograms that represented scarring, usually in multiple locations. Findings at initial evaluation included architectural distortion (n = 110; 82%), increased regional density or scarring (n = 106; 79%), skin thickening (n = 73; 54%), masses (n = 16; 12%), and calcifications (n = 4; 3%). All findings except calcifications showed partial resolution over time, with architectural distortion showing the most significant resolution (p = .05).

CONCLUSION

Mammographic features after conservation therapy for breast cancer are common at 1 year after treatment. With the exception of calcifications, we found that all changes showed decreased prominence during the next 5 years. Recognition of such trends during routine surveillance should facilitate the early identification of changes that represent recurrence or do novo malignancy.

Digital angiographic impulse response analysis of regional myocardial perfusion. Estimation of coronary flow, flow reserve, and distribution volume by compartmental transit time measurement in a canine model

A system impulse response function that describes the kinetics of radiographic contrast material transit through the coronary circulation was calculated from 175 selective digital angiograms of normal and stenotic arteries in 10 dogs during rest and hyperemia. The goal of the study was to determine if the flow and distribution volume characteristics of the epicardial coronary arteries and the myocardial microcirculation could be stimulated by specific mathematical compartments of a lagged normal density model impulse response function in which the flow/distribution volume ratio is the inverse of the mean transit time. The arterial compartment mean transit time correlated with flow (r = 0.75); however, the correlation was significantly improved in individual dogs (r = 0.83 +/- 0.13; p less than 0.005) and was highly dependent on the length of the conduit vessel. The microcirculation compartment mean transit time was distributed as two populations with respect to flow. There was a linear correlation during hyperemia (r = 0.87) and a nonlinear relation during rest, which was characteristic of an autoregulating system. Resting values of microcirculation compartment mean transit time correlated with coronary flow reserve (r = 0.84) and differed significantly between vessels that were normal and those with subcritical stenosis, critical stenosis, or total occlusion (p less than 0.01 for all comparisons). The estimated microcirculation compartment distribution volume increased from a minimum of 4.0 +/- 1.5 ml/100 g myocardium in normal vessels with resting flow to 11.2 +/- 3.5 ml/100 g during hyperemia. These data suggest that the model compartments functionally describe the physiological behavior of their anatomic analogues and permit the quantification of microcirculatory autoregulation from a single measurement at rest without provoking hyperemia.

Digital angiographic impulse response analysis of regional myocardial perfusion: linearity, reproducibility, accuracy, and comparison with conventional indicator dilution curve parameters in phantom and canine models

The system mean transit time (Tsys) of the impulse response function describing contrast material transit through the coronary circulation was determined from serial digital angiographic images. The linearity, reproducibility, and relations with regional myocardial perfusion and conventional time-density curve parameters, time to peak concentration (TPC), and exponential washout rate (k) were assessed in a dynamic flow x-ray phantom (n = 46) and in six open-chest dogs (n = 102) while coronary flow was altered by stenosis and/or hyperemic stimuli. In the phantom studies, the inverse of the system mean transit time (Tsys-1) closely predicted flow/volume (r = 0.99, slope = 0.99). In dogs, Tsys-1 was independent of the shape of the contrast bolus injection (single or double-peaked), class of contrast agent (ionic or nonionic), the type of hyperemic stimulus (dipyridamole, dipyridamole plus norepinephrine, transient total occlusion, or ionic contrast media), and was highly reproducible between adjacent myocardial regions served by the same artery (r = 0.98 +/- 0.01). There was a strong correlation between Tsys-1 and regional coronary flow for stenotic and/or hyperemic vessels (r = 0.94, distribution volume = 14.9 ml/100 g) over a wide range (0-514 ml/min/100 g). Tsys-1 performed better than conventional time-density curve parameters TPC-1 and k for predicting phantom flow/volume ratios and regional myocardial blood flow in the dog. These data suggest that both digital coronary angiography and coronary contrast transit can be modeled as linear systems and that impulse response analysis may provide accurate and reproducible estimates of regional myocardial blood flow.

Computer analysis of Doppler color flow mapping images for quantitative assessment of in vitro fluid jets

To determine the ability of Doppler color flow mapping to accurately and reproducibly assess the flow volume and kinetic energy of in vitro fluid jets, a Doppler color flow mapping system was interfaced with an image processing computer. An aliasing correction algorithm was used to extend the upper limit of measurable velocity to 184 cm/s. Images were analyzed for jet area (equal to the total number of image pixels) and jet energy (equal to the sum of all pixel velocities squared), both integrated over all frames of the injection and in single maximal frames. The Doppler flow mapping area and energy measurements were compared with known flow volume and delivered kinetic energy, and the effects of four experimental variables (orifice area, gain setting, chamber compliance and chamber size) were evaluated. Jet area correlated nonlinearly with flow volume and was markedly affected by each of these experimental variables, increasing by 40 to 150% from the smallest to the largest orifice size, 15 to 94% with the highest versus the lowest gain setting, 1 to 54% with greater chamber compliance and 7 to 70% in the large versus the small chamber. In contrast, jet energy correlated linearly with delivered kinetic energy up to 350,000 ergs, at which point velocities started to exceed the extended velocity range and second wrap aliasing occurred. The relation was not affected by orifice area, gain or compliance, and was only minimally affected by chamber size.(ABSTRACT TRUNCATED AT 250 WORDS)

Digital angiographic measurement of radiographic contrast material kinetics for estimation of myocardial perfusion

We studied the use of digital angiography for the quantification of regional myocardial perfusion in the dog using selective left coronary arterial injection of radiographic contrast material as a flow dilution indicator. We developed algorithms for generating time-intensity curves from regions of interest over the proximal coronary artery and the myocardium and for densitometric error correction by subtraction of the intensity curve over a small lead blocker before logarithmic transformation. The resultant myocardial time-density curves were analyzed for time from injection to peak concentration (TPC) and for exponential washout rate (k). A linear correlation was found between absolute coronary arterial blood flow and both k (slope = 0.13, r = .85) and 1/TPC (slope = 0.18, r = .85). Reproducibility of TPC and k for repeated studies was 11% and 16%. Induced hyperemia significantly improved the sensitivity to stenosis by increasing the average difference in TPC and k between regions served by normal and stenotic coronary arteries to 65% and 80%, respectively. By combining selective coronary arterial injection with the left lateral x-ray projection it was possible to avoid most overlap of regional perfusion beds in the dog. This study suggests that contrast dilution measurements made during digital coronary angiography provide a means for assessing the hemodynamic significance of stenoses and the efficacy of therapeutic interventions.

Digital quantification eliminates intraobserver and interobserver variability in the evaluation of coronary artery stenosis

A leading problem with subjective interpretation of coronary angiography is high intraobserver and interobserver variability. Four experienced angiographers independently determined percent diameter narrowing of 36 stenoses using 3 methods: by subjective analysis of single-frame cine film images (film), by subjective analysis of digitized nonenhanced single-frame images (digital), and by using a semiautomated digital caliper quantification system (Corona). The reproducibility of interpretations was assessed by comparison of estimated intraclass correlation coefficients. Digital and Corona readings correlated well with subjective interpretation of film (r greater than 0.85 for both). In contrast to Corona, the angiographers systematically overestimated the magnitude of stenoses in the intermediate (50 to 75%) range. Corona markedly improved intraobserver (p less than 0.005) and interobserver (p less than 0.001) reproducibility. Corona less frequently misclassified individual observations than did film when categories of less than 50%, 50 to 75% and more than 75% diameter stenosis were used (3.7% vs 31.5%, p less than 0.001). Our results suggest that digitization of a coronary angiogram in a 512 X 512 matrix has no significant adverse effects on the perception and quantification of stenosis by angiographers. Additionally, automatic measurement of coronary stenosis has 2 major advantages: It is accurate compared with a group of experienced angiographers and for the practical purpose of clinical decision-making, it eliminates intraobserver and interobserver variability.

Fibrinolytic therapy of St. Jude valve thrombosis under guidance of digital cinefluoroscopy

Fibrinolytic therapy is an alternative to urgent reoperation for patients with St. Jude prosthetic valve thrombosis, but requires an accurate method for repeated assessment of prosthetic function. Since the St. Jude valve is not well visualized by conventional cinefluoroscopy, digital subtraction techniques were developed that improved visualization of the value and allowed assessment of leaflet separation and velocity. A 74 year old woman with prosthetic valve thrombosis 5 years after St. Jude aortic valve placement had an opening angle of 58 degrees (normal range 10 to 13; n = 8) with a maximal opening velocity of 1.37 degrees/ms (normal range 2.46 to 2.93). The closing angle was 125 degrees (normal range 120 to 127) with a maximal closing velocity of 1.38 degrees/ms (normal range 2.24 to 3.60). The patient received 250,000 U of streptokinase intravenously, then 100,000 U/h for 72 hours. Improvement in auscultatory findings occurred at 12 hours; repeat digital cinefluoroscopy showed an opening angle of 20 degrees with a maximal velocity of 2.77 degrees/ms, and a closing angle of 126 degrees with a maximal velocity of 1.91 degrees/ms. Digital cinefluoroscopy 4 weeks after discharge on warfarin and dipyridamole therapy was unchanged. There have been no thromboembolic complications after 6 months of follow-up. Thus, digital cinefluoroscopy is a new noninvasive technique that permits accurate measurement of normal and abnormal St. Jude leaflet function. Intravenous streptokinase dissolution of prosthetic valve thrombosis under digital cinefluoroscopic guidance may be an acceptable alternative to emergency reoperation. The frequency and significance of residual subclinical leaflet dysfunction after fibrinolytic therapy and the indications for elective reoperation require further evaluation.