Immediate pharmacotherapy intensification after cardiac resynchronization therapy: incidence, characteristics, and impact

AIMS

Cardiac resynchronization therapy (CRT) is an established treatment for drug-refractory heart failure (HF) in patients with left bundle branch block (LBBB). Acute haemodynamic improvement after CRT implantation may enable the intensification of HF medication soon thereafter. Immediate pharmacotherapy intensification (IPI) after CRT implantation achieves a synergetic effect, possibly leading to a better prognosis. This study aimed to explore the incidence, characteristics, and impact of IPI on real-world outcomes among CRT recipients with a history of hospitalization for acute HF.

METHODS AND RESULTS

This multicentre retrospective study enrolled CRT recipients with LBBB morphology, a QRS width ≥120 ms, a left ventricular ejection fraction ≤35%, and New York Heart Association II-IV HF symptoms. All patients had previous HF hospitalizations within the previous year and received guideline-directed medical therapy before CRT implantation. Patient baseline characteristics, including HF medication, were collected. IPI was defined as the intensification of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists within 30 days of CRT implantation. The primary endpoint was all-cause death or first hospitalization for HF; the secondary endpoint was all-cause death. We enrolled 194 patients (75% male; mean age, 65 ± 13 years; 78% with non-ischaemic cardiomyopathy). One hundred five (54%) patients received IPI. Patients who received IPI exhibited a significantly shorter QRS duration (159 ± 26 vs. 171 ± 32 ms; P = 0.004), higher estimated glomerular filtration rate (55.2 ± 20.0 vs. 47.8 ± 24.7 mL/min/1.73 m2 ; P = 0.022), and more dilated cardiomyopathy. During a median follow-up period of 29 months, 70 (36%) patients reached the primary endpoint and 42 (22%) patients died. Patients with IPI showed significantly better outcomes for the primary and secondary endpoints than patients without IPI. The volumetric responder ratio at 6 months after implantation was not significantly different between patients with and without IPI; however, patients who received IPI had reduced mortality even at 6 months after implantation. In the multivariate analysis, IPI was an independent predictor of the primary endpoint (hazard ratio, 0.51; 95% confidence interval, 0.27-0.97; P = 0.043).

CONCLUSIONS

Immediate intensification of HF medication was achieved in 54% of CRT recipients and was significantly higher in patients without excessive QRS prolongation, preserved renal function, and dilated cardiomyopathy than others. In patients with LBBB morphology and QRS ≥ 120 ms, IPI was associated with a significantly better prognosis and fewer HF hospitalizations after CRT implantation than others.

Unidirectional conduction characterizing epicardial connections in patients with atrial tachyarrhythmias

INTRODUCTION

Electrophysiological characteristics of epicardial connections (ECs) in atria and pulmonary veins (PVs) are unclear despite their important contributions to atrial fibrillation (AF). Unidirectional conduction associated with source-sink mismatch can occur in ECs due to their fine fibers with abrupt changes in orientation. We detailed the prevalence and electrophysiological characteristics of unidirectional conduction in the atria and investigated its association with the clinical manifestation of AF.

METHODS

This study retrospectively reviewed electrophysiological studies and radiofrequency catheter ablation in 261 consecutive patients with AF.

RESULTS

Unidirectional conduction was observed during ablation encircling the PVs in eight (3.1%) patients, and all occurred in the suspected (N = 4) or definitively (N = 4) recognized ECs. These ECs included three intercaval bundles, four septopulmonary bundles, and one Marshall bundle, and were first manifested in a second procedure in 6 (75%) patients. The unidirectional property was from PV to atrium (exit conduction) in all intercaval bundles and three septopulmonary bundles, and from atrium to PV (entrance conduction) in the remaining two bundles. Intercaval bundles acted as a limb of bi-atrial macro-reentrant tachycardia (50%, three of the six including previous cases). Ablation of the exit outside the PVs, including the right atrium, eliminated ECs in three (38%) patients. All patients remain free from arrhythmia recurrence after a mean 13-month follow-up.

CONCLUSION

A unidirectional conduction property was closely associated with the EC, as estimated by histological findings. Recognition of this fact by electrophysiologists may help to clarify mechanisms for AF and atrial tachycardia and guide the creation of efficient and safe ablation lesion sets.

Inter-atrial epicardial muscular fibers as a possible source of atrial tachyarrhythmias

A 22-year-old woman without structural heart disease underwent catheter ablation of frequent premature atrial contractions (PACs). Radiofrequency applications from both the right and left atrium were effective in suppressing or eliminating these PACs. The distance between the right atrial ablation site and the successful ablation site at the right-sided pulmonary venous carina measured 18 mm on the CARTO map, and no cardiac structure, i.e. the inter-atrial septum, was present between those sites. Taken together, the epicardial muscular fibers in the inter-atrial groove were considered to play a role as an arrhythmogenic source of this atrial tachyarrhythmia.

Learning objective

Epicardial muscular fibers connecting the right atrium and right-sided pulmonary venous carina are known to preclude isolation of the veins. This epicardial connection in the interatrial groove can be an arrhythmogenic source or part of a reentrant circuit of atrial tachyarrhythmias.

An Epicardial Connection With a Unidirectional Conduction Property From the Left Atrium to Pulmonary Vein

The presence of an epicardial connection between the left-sided pulmonary vein and left atrium was suggested during catheter ablation of atrial fibrillation because of sustainable unidirectional entrance conduction after complete endocardial ablation, centrifugal breakout deep inside the pulmonary vein, and immediate elimination of the conduction by point ablation. (Level of Difficulty: Advanced.)

Epicardial Connections as Intra-Atrial Conduction Routes in a Patient With Advanced Atrial Remodeling

In a patient with long-standing persistent atrial fibrillation, elimination of an epicardial connection between the right-sided pulmonary venous carina and the right atrium during catheter ablation resulted in intra-atrial conduction injuries in the presence of advanced atrial remodeling. (Level of Difficulty: Advanced.).

Comparison of Soluble ST2, Pentraxin-3, Galectin-3, and High-Sensitivity Troponin T of Cardiovascular Outcomes in Patients With Acute Decompensated Heart Failure

BACKGROUND

Data regarding a direct comparison of soluble suppression of tumorigenesis-2 (sST2), pentraxin 3 (PTX3), galectin-3 (Gal-3), and high-sensitivity troponin T of cardiovascular outcome in patients with heart failure (HF) are lacking.

METHODS AND RESULTS

A total of 616 hospitalized patients with HF were evaluated prospectively. Biomarker data were obtained in the stable predischarge condition. sST2 levels were associated with age, sex, body mass index, inferior vena cava diameter, B-type natriuretic peptide (BNP), PTX3, C-reactive protein, and Gal-3 levels. During follow-up, 174 (28.4%) primary composite end points occurred, including 58 cardiovascular deaths and 116 HF rehospitalizations. sST2 predicted the end point after adjustment for 13 clinical variables (hazard ratio 1.422; 95% confidence interval [CI] 1.064 to 1.895, P = .018). The association between sST2 and the end point was no longer statistically significant after adjustment for BNP (P = .227), except in the subgroup of patients with preserved ejection fraction (hazard ratio 1.925, 95% CI 1.102-3.378, P = .021). Gal-3 and high-sensitivity troponin T predicted the risk for the end point after adjustment for age and sex, but were not significant after adjustment for clinical variables. The prognostic value of PTX3 was not observed (age and sex adjusted, P = .066).

CONCLUSIONS

This study did not show significant additional value of biomarkers to BNP for risk stratification, except sST2 in patients with preserved ejection fraction.

Upgrade of cardiac resynchronization therapy by utilizing additional His-bundle pacing in patients with inotrope-dependent end-stage heart failure: a case series

Background

His-bundle pacing (HBP) alone may become an alternative to conventional cardiac resynchronization therapy (CRT) utilizing right ventricular apical (RVA) and left ventricular (LV) pacing (BiV_RVA+LV) in selected patients, but the effects of CRT utilizing HBP and LV pacing (BiV_HB+LV) on cardiac resynchronization and heart failure (HF) are unclear.

Case summary

We presented two patients with inotrope-dependent end-stage HF in whom the upgrade from conventional BiV_RVA+LV to BiV_HB+LV pacing by the addition of a lead for HBP improved their HF status. Patient 1 was a 32-year-old man with lamin A/C cardiomyopathy, atrial fibrillation, and complete atrioventricular (AV) block. Patient 2 was a 70-year-old man with ischaemic cardiomyopathy complicated by AV block and worsening of HF resulting from ablation for ventricular tachycardia storm. The HF status of both patients improved dramatically following the upgrade from BiV_RVA+LV to BiV_HB+LV pacing.

Discussion

End-stage HF patients suffer from diffuse intraventricular conduction defect not only in the LV but also in the right ventricle (RV). The resulting dyssynchrony may not be sufficiently corrected by conventional BiV_RVA+LV pacing or HBP alone. Right ventricular apical pacing itself may also impair RV synchrony. An upgrade to BiV_HB+LV pacing could be beneficial in patients who become non-responsive to conventional BiV pacing as the His–Purkinje conduction defect progresses.

A simple pacing maneuver to unmask an epicardial connection involving the right-sided pulmonary veins

INTRODUCTION

An epicardial connection (EC) between the right-sided pulmonary venous (PV) carina and right atrium (RA) is one of the mechanisms for which carinal ablation is required for right-sided PV isolation. The purpose of the study was to devise a simple pacing maneuver to differentiate an EC from a residual conduction gap on the antral ablation line during radiofrequency catheter ablation.

METHODS AND RESULTS

This study included 133 consecutive patients. After one round of ablation, electrograms at the posterior antrum outside the ablation line were recorded during sinus rhythm (SR) and coronary sinus (CS) pacing, and intervals between the antral and PV potentials were measured in each rhythm. The Δinterval_SR-CS was calculated as the difference between the interval during SR and that during CS pacing. Presence of an EC was confirmed by observation of a RA posterior wall breakthrough during right-sided PV pacing, which was then targeted for ablation. Patients with nonachievement of first-pass isolation (N = 35) and with PV reconnection during the procedure (N = 9) were classified into the EC-group (N = 20) and gap-group (N=24), respectively. The prevalence of carina breakthrough during SR was higher in the EC-group than the gap-group (18 [95%] vs. 1 [4%] patients, p < .0001). The Δinterval_SR-CS was larger in the EC-group versus gap-group (71 [interquartile range, 57-97] vs. 6 [2-9] ms, p < .0001). In all patients with an EC, RA ablation resulted in delay (32 [20-40] ms) (N = 15) or elimination of PV potentials (N = 5).

CONCLUSION

An EC can be efficiently discriminated from a conduction gap by a simple pacing maneuver.

Predictors of Recurrence after Catheter Ablation of Paroxysmal Atrial Fibrillation in Different Follow-Up Periods

Background and objectives: Pulmonary vein (PV) reconnection is a major reason for recurrence after catheter ablation of paroxysmal atrial fibrillation (PAF). However, the timing of the recurrence varies between patients, and recurrence >1 year after ablation is not uncommon. We sought to elucidate the characteristics of atrial fibrillation (AF) that recurred in different follow-up periods. Materials and Methods: Study subjects comprised 151 consecutive patients undergoing initial catheter ablation of PAF. Left atrial volume index (LAVi) and atrial/brain natriuretic peptide (ANP/BNP) levels were systematically measured annually over 3 years until AF recurred. Results: Study subjects were classified into four groups: non-recurrence group (n = 84), and short-term- (within 1 year) (n = 30), mid-term- (1–3 years) (n = 26), and long-term-recurrence group (>3 years) (n = 11). The short-term-recurrence group was characterized by a higher prevalence of diabetes mellitus (hazard ratio 2.639 (95% confidence interval, 1.174–5.932), p = 0.019 by the Cox method), frequent AF episodes (≥1/week) before ablation (4.038 (1.545–10.557), p = 0.004), and higher BNP level at baseline (per 10 pg/mL) (1.054 (1.029–1.081), p < 0.0001). The mid-term-recurrence group was associated with higher BNP level (1.163 (1.070–1.265), p = 0.0004), larger LAVi (mL/m²) (1.033 (1.007–1.060), p = 0.013), and longer AF cycle length at baseline (per 10 ms) (1.194 (1.058–1.348), p = 0.004). In the long-term-recurrence group, the ANP and BNP levels were low throughout follow-up, as with those in the non-recurrence group, and AF cycle length was shorter (0.694 (0.522–0.924), p = 0.012) than those in the other recurrence groups. Conclusions: Distinct characteristics of AF were found according to the time to first recurrence after PAF ablation. The presence of secondary factors beyond PV reconnections could be considered as mechanisms for the recurrence of PAF in each follow-up period.

Interatrial distance predicts the necessity of additional carina ablation to isolate the right-sided pulmonary veins

Background

Ablation of the pulmonary vein (PV) carina is occasionally required for PV isolation (PVI). Marshall bundle and epicardial connections between the right-sided PV (RtPV) carina and right atrium (RA) may be one of the mechanisms that necessitates carina ablation.

Objective

We sought to clarify anatomical characteristics predictive of the necessity of carina ablation.

Methods

Forty-five consecutive patients undergoing radiofrequency catheter ablation of atrial fibrillation were prospectively included in this study. Left atrial (LA) and PV size and morphology, and interatrial distance in the posterior aspect, were measured on cardiac computed tomography (CT) images.

Results

For right-sided PVI, the patients were divided into 2 groups based on the necessity of RtPV carina ablation, Carina-ABL group (n = 21) and Non-Carina-ABL group (n = 24). The distance between the anterior portion of the RtPV carina and RA was shorter in the Carina-ABL group vs in the Non-Carina-ABL group (7.7 ± 1.7 mm/m² vs 9.5 ± 2.3 mm/m²; P = .005), whereas other anatomical parameters (LA and RA volumes, right inferior PV angle, and ostial diameters of the RtPVs) did not differ between the groups. For left-sided PVI, the ostial diameter and circumference of the left superior PV were smaller in the Carina-ABL group (n = 13) vs the Non-Carina-ABL group (n = 32) (8.6 ± 2.1 mm/m² vs 7.3 ± 1.5 mm/m²; P = .044, and 34.9 ± 6.0 mm/m² vs 30.1 ± 5.1 mm/m²; P = .017, respectively).

Conclusions

A shorter interatrial distance for right-sided PVI and a smaller PV ostium for left-sided PVI were associated with the necessity of additional carina ablation. The presence and location of the epicardial fibers may be affected by the atrial and PV geometry.

P1444 Occurrence and predictors of right ventricular dysfunction after pericardiocentesis

Background—The changes in cardiac function that occur after pericardiocentesis are unclear.Purpose—This study was performed to assess right ventricular (RV) and left ventricular (LV) function with echocardiography before and after pericardiocentesis.

Method and Results—In total, 19 consecutive patients who underwent pericardiocentesis for more than moderate pericardial effusion were prospectively enrolled from August 2015 to October 2017. Comprehensive transthoracic echocardiography was performed before, immediately after (within 3 hours), and 1 day after pericardiocentesis to investigate the changes in RV and LV function. RV dysfunction is defined as meeting three of the four criteria: a TAPSE of &lt;17 mm, an S’ of &lt;9.5 cm, an FAC of &lt;35%, and an RV free wall longitudinal strain &gt;−20%. The mean age of all patients was 72.6 ± 12.2 years. The changes of echocardiographic parameters related to RV function are shown in Table. After pericardiocentesis, RV inflow and outflow diameters increased and the parameters of RV function significantly decreased. These abnormal values or RV dysfunction remained at 1 day after pericardiocentesis. Conversely, no parameters of LV function parameters changed after pericardiocentesis. Of 19 patients, 13 patients showed RV dysfunction immediately after pericardiocentesis and 6 patients did not. RV free wall longitudinal strain before pericardiocentesis was higher in patients with post-procedural RV dysfunction (−18.9 ± 3.6%) than in those without (−28.4 ± 6.3%). ROC analysis revealed that a RV free wall longitudinal strain cut-off value of −23.0% had a sensitivity of 100% and a specificity of 83.3% for predicting the occurrence of RV dysfunction after pericardiocentesis (AUC = 0.910).

Conclusions—The occurrence of RV dysfunction after pericardiocentesis should be given more attention. Pre-existing RV dysfunction maybe related to the occurrence of RV dysfunction after pericardiocentesis.

Changes in RV function before and after Before Immediately after One day after P−value Basal right ventricular linear dimension (mm) 32.8 ± 5.0 37.1 ± 4.4† 33.6 ± 5.4 0.028 Mid-cavity right ventricular linear dimension (mm) 34.5 ± 4.6 38.8 ± 5.3† 37.0 ± 5.6 0.0504 Proximal right ventricular outflow diameter (mm) 30.2 ± 4.0 33.9 ± 3.5† 31.4 ± 3.9 0.014 TAPSE (mm) 20.0 ± 4.2 13.6 ± 4.3* 14.7 ± 3.9 &lt;0.001 S" (cm/s) 12.6 ± 3.3 8.7 ± 2.4* 9.1 ± 2.4 &lt;0.001 Fractional area change (%) 48.3 ± 5.9 37.8 ± 8.0* 40.0 ± 9.0 &lt;0.001 Right ventricular free wall strain (%) −21.3 ± 6.3 −15.8 ± 6.7* −16.9 ± 5.2 0.036 Tricuspid regurgitation velocity peak (m/s) 2.41 ± 0.29 2.43 ± 0.25 2.34 ± 0.32 0.37

Clinical Applications of Natriuretic Peptides in Heart Failure and Atrial Fibrillation

Natriuretic peptides (NPs) have become important diagnostic and prognostic biomarkers in cardiovascular diseases, particularly in heart failure (HF). Diagnosis and management of coronary artery disease and atrial fibrillation (AF) can also be guided by NP levels. When interpreting NP levels, however, the caveat is that age, sex, body mass index, renal dysfunction, and race affect the clearance of NPs, resulting in different cut-off values in clinical practice. In AF, NP levels have been associated with incident AF in the general population, recurrences after catheter ablation, prediction of clinical prognosis, and the risk of stroke. In this article, we first review and summarize the current evidence and the roles of B-type NP and atrial NP in HF and coronary artery disease and then focus on the increasing utility of NPs in the diagnosis and management of and the research into AF.

Anatomical total shoulder arthroplasty in young patients with osteoarthritis: all-polyethylene versus metal-backed glenoid

Aims

Controversy about the use of an anatomical total shoulder arthroplasty (aTSA) in young arthritic patients relates to which is the ideal form of fixation for the glenoid component: cemented or cementless. This study aimed to evaluate implant survival of aTSA when used in patients aged < 60 years with primary glenohumeral osteoarthritis (OA), and to compare the survival of cemented all-polyethylene and cementless metal-backed glenoid components.

Materials and Methods

A total of 69 consecutive aTSAs were performed in 67 patients aged < 60 years with primary glenohumeral OA. Their mean age at the time of surgery was 54 years (35 to 60). Of these aTSAs, 46 were undertaken using a cemented polyethylene component and 23 were undertaken using a cementless metal-backed component. The age, gender, preoperative function, mobility, premorbid glenoid erosion, and length of follow-up were comparable in the two groups. The patients were reviewed clinically and radiographically at a mean of 10.3 years (5 to 12, sd 26) postoperatively. Kaplan-Meier survivorship analysis was performed with revision as the endpoint.

Results

A total of 26 shoulders (38%) underwent revision surgery: ten (22%) in the polyethylene group and 16 (70%) in the metal-backed group (p < 0.0001). At 12 years' follow-up, the rate of implant survival was 74% (sd 0.09) for polyethylene components and 24% (sd 0.10) for metal-backed components (p < 0.0002). Glenoid loosening or failure was the indication for revision in the polyethylene group, whereas polyethylene wear with metal-on-metal contact, instability, and insufficiency of the rotator cuff were the indications for revision in the metal-backed group. Preoperative posterior subluxation of the humeral head with a biconcave/retroverted glenoid (Walch B2) had an adverse effect on the survival of a metal-backed component.

Conclusion

The survival of a cemented polyethylene glenoid component is three times higher than that of a cementless metal-backed glenoid component ten years after aTSA in patients aged < 60 years with primary glenohumeral OA. Patients with a biconcave (B2) glenoid have the highest risk of failure. Cite this article: Bone Joint J 2018;100-B:485-92.

Abstract P4-08-07: PIK3CA mutation, reduced AKT serine 473 phosphorylation, and increased ERα serine 167 phosphorylation are positive prognostic indicators in postmenopausal estrogen receptor-positive, HER2-negative early breast cancer

Background: Endocrine therapy is the most important treatment option for women with estrogen receptor (ER)-positive breast cancer. We recently reported that approximately two-thirds of patients who relapsed within 5 years had received anthracyclins and/or taxanes as adjuvant or neoadjuvant chemotherapy in addition to adjuvant endocrine therapy. New strategies, such as signal transduction inhibitors together with endocrine therapy are required to improve survival. PIK3CA mutations are detected in almost 40% of early ER-positive breast cancers, and are therefore the most frequent genetic alterations in this subtype. PIK3CA mutation status is reported to affect activation of AKT and ERα. Moreover, recent studies demonstrate that patients had a better prognosis when tumors expressed ER, androgen receptor (AR), and vitamin D receptor (VDR).

Methods: Expression of AR and VDR, phosphorylation of AKT serine (Ser) 473 (AKT phospho-Ser473) and ERα Ser167 (ERα phospho-Ser167) were examined by immunohistochemistry in ER-positive, HER2-negative early breast cancer tissues. Seventeen mutations in exons 1, 4, 7, 9, and 20 of the PIK3CA gene were detected in genomic DNA extracted from formalin-fixed paraffin-embedded tumor blocks. Correlations between these biological markers and clinicopathological factors and prognosis were analyzed separately in pre- and postmenopausal women.

Results: Levels of AKT phospho-Ser473 were significantly higher in premenopausal women (n = 62) than in postmenopausal women (n = 152) (P &lt; 0.0001 and P = 0.014, respectively). In contrast, expression levels of AR were significantly higher in postmenopausal women than in premenopausal women (P &lt; 0.0001). In premenopausal women, 26 tumors (43%) had a single mutation of PIK3CA gene, and 3 tumors (5%) had mutations at two sites. In postmenopausal women, 64 tumors (44%) had a single PIK3CA mutation, 6 tumors (4%) had mutations at two sites, and one tumor (1%) had mutations at three sites. In premenopausal women, wild type PIK3CA was associated with smaller tumor size, higher ER expression levels, and lower AR expression levels when compared with women in the same cohort with PIK3CA mutant tumors. In postmenopausal women, patients with PIK3CA wild-type tumors had higher Ki67 labeling index, higher AKT phospho-Ser473, and lower ERα phospho-Ser167 when compared to patients with PIK3CA mutant tumors. Postmenopausal women with PIK3CA wild-type tumors had significantly worse disease-free survival than patients with PIK3CA mutant tumors (P = 0.007). In contrast, PIK3CA mutation status was not correlated with survival in premenopausal women. Low levels of AKT phospho-Ser473 and high levels of ERα phospho-Ser167 were strongly associated with increased disease-free survival in postmenopausal women (P = 0.016 and P = 0.0016, respectively).

Conclusion: ERα activation, in addition to PIK3CA mutation, may be biomarkers for highly endocrine-responsive tumors. This would facilitate the selection of postmenopausal ER-positive breast cancer patients who are likely to benefit from endocrine therapy alone from those who are not.

Citation Format: Ishida N, Hatanaka Y, Baba M, Hagio K, Okada H, Hatanaka KC, Matsuno Y, Yamashita H. PIK3CA mutation, reduced AKT serine 473 phosphorylation, and increased ERα serine 167 phosphorylation are positive prognostic indicators in postmenopausal estrogen receptor-positive, HER2-negative early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-08-07.

Quality of life following esophagectomy with three-field lymphadenectomy for carcinoma, focusing on its relationship to vocal cord palsy

To clarify the quality of life of patients who underwent esophagectomy for carcinoma by right thoracotomy, laparotomy and cervical anastomosis, 116 patients who were cancer free at the time of mailing a questionnaire were analyzed. A significant decrease in vital capacity for 3 years postoperatively, as well as in the percentage of ideal body weight, between 3 and 5 years were observed in 57 patients with three-field lymphadenectomy. Patients' quality of life undergoing three-field dissection was worse than those with less radical lymphadenectomy (59 cases) in terms of the performance status and difficulty in talking at 60 months or more postoperatively. Around 20% of all patients reported severe hoarseness due to permanent recurrent nerve paralysis, resulting in poor quantity of food intake at 24 months or less postoperatively and restricted daily activity and difficulty in talking at 60 months or more after the operation. When a patient suffers from vocal cord insufficiency caused by permanent paralysis of the recurrent nerve, early treatment before discharge from the hospital should be performed to improve the quality of life of such a patient.

Abstract P2-01-31: Validation of novel diagnostic kits using the semi-dry dot-blot method for detecting metastatic lymph nodes in breast cancer; distinguishing macrometastases and micrometastases

Background: The semi-dry dot-blot (SDB) method is a diagnostic procedure for detecting lymph node (LN) metastases. Metastases are confirmed by the presence of cytokeratin (CK) in lavage fluid of sectioned LNs that contain anti-pancytokeratin antibody, based on the theory that epithelial components such as CK are not found in normal LNs. We evaluated two novel SDB kits that use the newly developed anti-CK19 antibody for diagnosing LN metastases in breast cancer.

Methods: We obtained 159 LNs dissected from 93 breast cancer patients from July 2013 to December 2015 at Nagasaki University Hospital, including 38 dissected axillary LNs and 121 sentinel LNs, sliced at 2-mm intervals and washed with phosphate-buffered saline. The suspended cells in the lavage fluid of sliced LNs were centrifuged and lysed to extract protein. This extracted protein was used with a low-power and a high-power kit to diagnose LN metastasis. The washed LNs were blindly diagnosed by pathologists using hematoxylin and eosin (H&E) stain. Diagnoses based on the kit were compared with their H&E counterparts.

Results: Of the 159 LNs, 68 were assessed as positive and 91 as negative by permanent pathological examination with H&E. Sensitivity, specificity, and accuracy of the low-power kit for detecting LN metastases was 83.8%, 100%, and 93.1%, respectively. In 11 false-negative cases, there were nine micrometastases, producing a sensitivity of 96.4% for detecting macrometastases. Sensitivity, specificity, and accuracy of the high-power kit for detecting LN metastases was 92.6%, 92.3%, and 92.5%, respectively. Combining the low- and high-power kit results, sensitivity, specificity and accuracy for distinguishing macrometastases from micrometastases was 94.5%, 95.2%, and 95.0%, respectively. Diagnosis was achieved in approximately 20 min using the kits, at a cost of less than 25 USD.

Conclusions: The kits in our study were accurate, quick, and cost-effective in diagnosing LN metastases without the loss of LN tissue. The kits' ability to distinguish macrometastases from micrometastases was excellent, which is important, clinically.

Citation Format: Otsubo R, Hirakawa H, Oikawa M, Inamasu E, Baba M, Matsumoto M, Yano H, Kinoshita N, Abe K, Fukuoka J, Nagayasu T. Validation of novel diagnostic kits using the semi-dry dot-blot method for detecting metastatic lymph nodes in breast cancer; distinguishing macrometastases and micrometastases [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-31.

Abstract P4-21-03: A randomized phase II study of Ki-67 response-guided preoperative chemotherapy for HER2-positive breast cancer

As for the HER2-positive breast cancer, there are many cases to be effective for neoadjuvant chemotherapy in comparison with other intrinsic subtypes. However, pCR is not provided by neoadjuvant chemotherapy in all cases. [Aim] This study evaluated the effectiveness of a therapeutic strategy that switches chemotherapy, based on Ki-67 tumor expression after initial therapy, relative to that of standard chemotherapy in patients with HER2-positive breast cancer. [patients and methods] Patients were randomly assigned to the control arm or the Ki-67 response-guided arm (Ki-67 arm). Primary tumor biopsies were obtained before treatment, and after three once-weekly doses of paclitaxel and trastuzumab to assess the interim Ki-67 index. In the control arm, paclitaxel and trastuzumab was continued for a total of 12 doses, regardless of the interim Ki-67 index. In the Ki-67 arm, subsequent treatment was based on the interim Ki-67 index. Early Ki-67 responders continued to received paclitaxel plus trastuzumab for a total of 12 doses, while early Ki-67 non-responders were switched to epirubicin plus cyclophosphamide every 3 weeks for three cycles with once-weekly trastuzumab for a total of 12 doses. The primary endpoint was the pathological complete response (pCR) rate. [Results] When 237 patients were enrolled, an interim analysis was conducted in 200 patients. There was almost linear correlation between the Ki-67 reduction rate at interim assessment and the pCR rate. The pCR rate in Ki-67 early non-responders in the Ki-67 arm (23.6%; 95% CI, 12.4 to 34.9) was inferior to that in the control arm (44.1%; 31.4 to 56.7; p=0.025). A strong correlation was not found between the Ki-67 reduction rate and the clinical response rate (Spearman's correlation coefficient 0.22).

pCR rate among Ki-67 early non-responders and responders TotalpCR nn%95%CIKi-67 early non responderControl arm59264431.4-56.7 Ki-67 response guided arm55132312.4-34.9Ki-67 early responderControl arm21104726.3-69.0 Ki-67 response guided arm2084018.5-61.5

Conclusions: The pCR rate in the Ki-67 arm was inferior to that in the control arm. A therapeutic strategy that switches chemotherapy, based on Ki-67 tumor expression after initial therapy, was not effective. The standard chemotherapy protocol remains as the recommended strategy for patients with HER2-positive breast cancer.

Citation Format: Takahashi M, Nishiyama Y, Hara F, Naito Y, Baba M, Sasaki M, Sato M, Watanabe K, Uemura Y, Yamaguchi T, Mukai H. A randomized phase II study of Ki-67 response-guided preoperative chemotherapy for HER2-positive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-03.

Patient-specific glenoid guides provide accuracy and reproducibility in total shoulder arthroplasty

AIMS

Patient-specific glenoid guides (PSGs) claim an improvement in accuracy and reproducibility of the positioning of components in total shoulder arthroplasty (TSA). The results have not yet been confirmed in a prospective clinical trial. Our aim was to assess whether the use of PSGs in patients with osteoarthritis of the shoulder would allow accurate and reliable implantation of the glenoid component.

PATIENTS AND METHODS

A total of 17 patients (three men and 14 women) with a mean age of 71 years (53 to 81) awaiting TSA were enrolled in the study. Pre- and post-operative version and inclination of the glenoid were measured on CT scans, using 3D planning automatic software. During surgery, a congruent 3D-printed PSG was applied onto the glenoid surface, thus determining the entry point and orientation of the central guide wire used for reaming the glenoid and the introduction of the component. Manual segmentation was performed on post-operative CT scans to compare the planned and the actual position of the entry point (mm) and orientation of the component (°).

RESULTS

The mean error in the accuracy of the entry point was -0.1 mm (standard deviation (sd) 1.4) in the horizontal plane, and 0.8 mm (sd 1.3) in the vertical plane. The mean error in the orientation of the glenoid component was 3.4° (sd 5.1°) for version and 1.8° (sd 5.3°) for inclination.

CONCLUSION

Pre-operative planning with automatic software and the use of PSGs provides accurate and reproducible positioning and orientation of the glenoid component in anatomical TSA. Cite this article: Bone Joint J 2016;98-B:1080-5.

Allosteric Inhibitors against HIV-1 Reverse Transcriptase: Design and Synthesis of MKC-442 Analogues Having an Ω-Functionalized Acyclic Structure

Based on X-ray crystallographic analysis of MKC-442/human immunodeficiency virus type 1 reverse transcriptase (HIV-1 RT) complex, analogues in which the N1-substituent is replaced with ω-functionalized alkyl groups were designed to improve the affinity for the enzyme. Synthesis of these compounds was carried out starting from MKC-442 by a sequence of reactions (N3-protection, removal of N1-ethoxymethyl group, alkylation, and N3-deprotection). The compounds were evaluated for anti-HIV activity. Structure–activity relationships are discussed in terms of the possible interaction with the enzyme.

Activation cross sections of proton and deuteron induced nuclear reactions on holmium and erbium, related to the production of (161)Er and (160)Er medical isotopes

Experimental excitation functions for long-lived products in proton induced reactions were measured with the activation method in the 37-65MeV energy range on natural holmium. Stacked foil irradiation technique and high resolution gamma spectrometry were used in order to measure cross-section data for the production of (161)Er, (160)Er and (1)(59,157)Dy. For comparison of the production routes of medically related (161)Er and (160)Er radioisotopes new experimental cross section data were deduced for the (162)Er(p,x)(161,160)Er and (162)Er(d,x)(161,160)Er reactions by re-evaluating gamma-ray spectra from earlier measurements. No earlier data were found in the literature for these reactions. The experimental data are compared with results of TALYS theoretical code reported in TENDL-2015.

Naphthalenesulphonic Acid Derivatives as Potential anti-HIV-1 Agents. Chemistry, Biology and Molecular Modelling of Their Inhibition of Reverse Transcriptase

Activity against human immunodeficiency virus (HIV) in the naphthalenesulphonic acid series is most pronounced in the disulphonic acid series. In this class of compounds, N-acyl derivatives of 4-amino-5-hydroxy-2,7-naphthalenedisulphonic acid demonstrate significant anti-HIV activity at non-toxic doses. The most potent compounds in this group of agents are bis naphthalenedisulphonic acids. A bis derivative containing a decamethylene spacer demonstrated activity against HIV-1, HIV-2 giant cell formation and reverse transcriptase (RT). This compound also demonstrated an in vitro therapeutic index (ratio of 50% cytotoxic concentration to 50% inhibitory antiviral concentration) of 10.6. Molecular modelling analyses of this agent, suramin, and several suramin analogues were undertaken to explain the potent anti-HIV-1 RT activity. These studies were carried out using the molecular decomposition/recomposition strategy, conformational searching, energy minimization and molecular dynamics (MD) simulation. The bis naphthalenedisulphonic acid derivative compound 1, having a flexible decamethylene spacer, was shown to be able to mimic the helical twist of the B-DNA backbone as a low energy conformer state.

Sulphated Polymers are Potent and Selective Inhibitors of Various Enveloped Viruses, Including Herpes Simplex Virus, Cytomegalovirus, Vesicular Stomatitis Virus, Respiratory Syncytial Virus, and Toga-, Arena- and Retroviruses

The sulphated polymers, such as polyvinylalcohol sulphate (PVAS) and its co-polymer with acrylic acid (PAVAS), have proved to be potent inhibitors for herpes simplex virus, human cytomegalovirus, vesicular stomatitis virus, respiratory syncytial virus, Sindbis virus, Semliki Forest virus, Junin virus, Tacaribe virus, murine sarcoma virus and human immunodeficiency virus. They are not inhibitory to non-enveloped viruses, such as poliovirus and reovirus. The broad-spectrum antiviral effects of these compounds depend on their molecular weight and degree of sulphation. Pharmacokinetic studies in rabbits have indicated that after intravenous bolus injection the serum concentrations of these compounds decay biphasically, with an initial half-life of approximately 90–120 min.

Antiviral Activity of a Sulphated Polysaccharide Extracted from the Marine Pseudomonas and Marine Plant Dinoflagellata against Human Immunodeficiency Viruses and other Enveloped Viruses

A natural sulphated mucopolysaccharide (OKU40), extracted from a marine plant Dinoflagellata, and an artificial sulphated polysaccharide (OKU41), prepared from a marine Pseudomonas, displayed antiviral activities against several enveloped viruses. OKU40 and OKU41 were found to be homogenous in electrophoresis and sedimation velocity and had a molecular weight of 8.0 × 1065.0 × 105respectively. The sulphation rate of OKU40 and OKU41 was 8.9% and 5.4%, respectively. Each OKU40 and OKU41 inhibited the cytopathic effect of human immunodeficiency virus type 1 (HIV-1), type 2 (HIV-2) and zidovudineresistant HIV-1 in MT-4 cells at similar concentrations to those of dextran sulphate (molecular weight: 5000) (50% inhibitory concentrations: 0.86-1.95 μg mL−1), whereas these compounds did not affect the growth and viability of mock-infected MT-4 cells at concentrations up to 500 μg mL−1. These compounds proved inhibitory not only to HIV-1 and HIV-2 but also to other enveloped viruses, i.e. herpes simplex virus type 1, influenza virus A and B, respiratory syncytial virus and measles virus. OKU40 and OKU41 suppressed syncytium formation induced by cocultivation of MOLT-4/IIIb and MOLT-4 cells at concentrations higher than 20 μg mL−1. Although OKU41 inhibited the binding of HIV-1 to the host cells and the binding of anti-gp120 monoclonal antibody to HIV-1 gp120, OKU40 did not inhibit these bindings, suggesting that the mechanism of anti-HIV activity of OKU40 and OKU41 may be primarily due to the inhibition of virus-cell fusion and viral adsorption to the host cells, respectively. Furthermore, these compounds did not inhibit to the blood coagulation process at a concentration that was significantly inhibitory to HIV replication. The compounds appear to have an interesting potential as virucidal agents.

Inhibitory Effect of Pyridobenzoazoles on Orthomyxo-and Paramyxovirus Replication in vitro

Among thirteen newly synthesized pyridobenzoazole derivatives which have been examined for anti-myxovirus and antiherpesvirus activities, three benzimidazoles emerged as potent anti-orthomyxo- or paramyxovirus compounds. 4-Cyano-2-benzamide-1-oxo-1,5-dihydropyrido[1,2a]benzimidazole (CBO-PB) showed broad antiviral activities against paramyxo-and orthomyxoviruses with EC50 of 0.1–2.0 μg ml−1, and 2-cyano-1-amino derivatives of CBO-PB (CCI-PB) were inhibitory to paramyxoviruses at 1.4–8.5 (μg ml−1 by a plaque reduction method. The third compound, 2-ethoxycarbonyl derivatives of CCI-PB was inhibitory only to respiratory syncytial virus (RSV) at 15–28 μg ml−1. Selectivity indexes of these 3 compounds for RSV in HeLa cells were 60, 86, and >13, respectively. All three compounds inhibited syncytium formation of RSV and Parainfluenzavirus (PFLUV) type 3 at comparable concentrations with EC50 for plaque formation. They inhibited antigen production of RSV and PFLUV at the concentrations that were 4 to 20-fold higher than those needed for plaque reduction, but they did not inhibit adsorption of virus to cells at all. All three compounds inhibited the growth of RSV in HeLa cells at 4-fold higher concentrations than their EC50 for plaque reduction.

Potent and Selective Activity of Dextrin Sulphate against Human Immunodeficiency Virus Type 1 in vitro

Several dextrin sulphate derivatives were prepared and investigated for their activity against human immunodeficiency virus type 1 (HIV-1) in vitro. These compounds have proved to be potent and selective inhibitors of HIV-1. One of the compounds, termed FG-752 [molecular weight (MW) 3000], was the most active, and its 50% antiviral effective concentration was 2.1 μg ml−1 (0.7 μm) in MT-4 cells. No toxicity for the cells was observed at a concentration of 500 μg ml−1. The compounds were also inhibitory to HIV-1-induced giant cell (syncytium) formation. These results suggest that dextrin sulphate may be useful for the chemotherapy of HIV-1 infections.

In vitro Antimyxovirus and Anti-Human Immunodeficiency Virus Activities of Polyoxometalates

Polyoxometalates have been shown to inhibit the replication of retro-, toga-, paramyxo- and herpesviruses. The primary mechanism of the anti-human immunodeficiency virus type 1 (HIV-1) action of polyoxometalates seems to be inhibition of binding of virus to cells and inhibition of syncytium formation. Since myxoviruses and HIV-1 are known to interact with the cytoplasmic membrane by adsorption and penetration of virus and by fusion of infected and uninfected cells, 25 polyoxometalates were examined for anti-ortho-, anti-paramyxovirus and anti-HIV-1 activity in vitro. Of the 25 compounds evaluated, 24 showed antiviral effects against influenza virus A, 11 showed activity against respiratory syncytial virus, six showed activity against measles virus, and 23 were considered effective against HIV-1 at a lower concentration than that producing cytotoxicity. Four polyoxotungstates which had potent inhibitory effects were examined for inhibitory effects against additional ortho- and paramyxoviruses, and proved to have a broad spectrum of antimyxoviral activity. HS-058, the Keggin sandwich compound K10Fe4(H2O)2(PW9O34)2·nH2O, was inhibitory against influenza viruses A and B, respiratory syncytial virus, measles virus, and parainfluenza virus 2, with median effective concentrations of 1.4, 21.8, 7.4, 0.8 and 0.32 μ,M, respectively. However, HS-058 had no effect on parainfluenza virus 3 or mumps virus. The median cytotoxic concentration of HS-058 for Madin-Darby canine kidney (MDCK) and HEp-2 cells was more than 200 μM and that for HMV-2 and Vero cells was about 50 μM. When HS-058 was added at different times after influenza A and respiratory syncytial virus infection, it inhibited binding of the latter but not of the former to cells. However, at higher concentrations, HS-054 and HS-058 inhibited haemolysis of chick erythrocytes by influenza virus and syncytium formation involving respiratory syncytial virus-infected cells and uninfected cells. Four times the median effective antiviral concentration of HS-058 completely inhibited the growth of influenza virus A in MDCK cells when compound was added before virus adsorption. Furthermore, when HS-058 was added after virus adsorption, it inhibited the yield of virus in MDCK cells infected at low but not at high multiplicity of infection.

Antiviral Activities of Mizoribine and other Inosine Monophosphate Dehydrogenase Inhibitors against Several Ortho- and Paramyxoviruses

Mizoribine (4-carbamoyl-1-β-D-ribofuranosylimidazo-lelium-5-olate), EICAR (5-ethynyl-1-β-D-ribofuranosylimi-dazole-4-carboxamide), mycophenolic acid and ribavirin are antiviral agents targeted for inosine monophosphate (IMP) dehydrogenase. These compounds have been examined for their activities against orthomyxoviruses [influenza viruses (FluV)] and paramyxoviruses [parainfluenza viruses (PFIuV), mumps virus, measles virus (MLSV) and respiratory syncytial virus (RSV)] in vitro. Mizoribine was 1- to 9-fold more active than ribavirin against RSV, PFIuV and MLSV. EICAR and mycophenolic acid showed higher potency than mizoribine and ribavirin against all myxoviruses examined. None of the four compounds examined proved cytotoxic to stationary host cells (HeLa, Vero and MDCK) at a concentration of 200 μg ml−1 or more. On the other hand, EICAR and mycophenolic acid were toxic to rapidly growing cells at concentrations of 2.2-9 and 0.1-1.1 μg ml−1, respectively. Mizoribine and ribavirin showed cytotoxicity to the growing cells at higher concentrations (12-51 μg ml−1). The antiviral activities of mizoribine against FluV and RSV were reversed by 25-100 μm of each of guanosine and guanosine monophosphate (GMP). The antiviral activity of ribavirin against FluV was reversed by 25 μg of each of guanosine and GMP, while its activity against RSV was reversed by ≥ 100 μm of each of these compounds. Neither xanthosine nor xanthosine monophosphate (XMP) reversed the antiviral effects of mizoribine and ribavirin at concentrations of 300 μM. Concentrations 9 times higher than the median effective doses (EC50) of mizoribine and ribavirin inhibited the growth of RSV in HeLa cells as determined in an assay of infectious virus yield. Mizoribin should be further pursued as a candidate drug for the treatment of ortho- and paramyxovirus infections.

Isolation and Characterization of Human Immunodeficiency Virus Type-1 Mutants Resistant to the Non-Nucleotide Reverse Transcriptase Inhibitor MKC-442

MKC-442, 6-benzy 1-1-ethoxymethyl-5-isopropyIuraciI (l-EBU), is a potent and selective non-nucleoside inhibitor of human immunodeficiency virus type-1 (HIV-1) reverse transcriptase (RT). Nevirapine, another non-nucleoside RT inhibitor (NNRTI), is associated with rapid emergence of drug-resistant variants during in vitro passages of HIV-1. The emergence of resistant viruses to MKC-442 or nevirapine was examined in vitro. MT-4 cells infected with a clinical isolate (HE) of HIV-1 were cultivated in medium containing excess concentrations of these drugs, and the drug susceptibilities of the breakthrough viruses recovered from the medium were measured. Although nevirapine lost its antiviral activity after six passages, a delay in the emergence of fully resistant viruses was observed for MKC-442. Two resistant clones for each drug were isolated and nucleotide sequences within the RT region were analysed. An amino acid substitution at position 181 (Tyr to Cys) was found, with additional substitutions at positions 103 (Lys to Arg) and 108 (Val to lle) in the MKC-442-resistant viruses. These clones showed various susceptibilities to MKC-442, and cross-resistance to other NNRTIs but not to AZT. These results suggest that the major binding site of MKC-442 on the HIV-1 RT is the tyrosine residue common to these NNRTIs, and that drug resistance to NNRTIs is dependent on both the quality and the quantity of mutations within the HIV-1 RT gene.

Inhibition of HIV-1-Induced Cytopathogenicity, Syncytium Formation, and Virus-Cell Binding by Naphthalenedisulphonic Acids through Interaction with the Viral Envelope gp120 Glycoprotein

Bis-naphthalenedisulphonic acid derivatives with a biphenyl spacer, 4,4′-[4,4′-biphenyldiylbis(sulphonyl-amino)]bis(5-hydroxy-2,7-naphthalenedisulphonic acid) and 3,3′-[4,4′-biphenyldiylbis(sulphonyl-amino)]bis(1,5-naphthalenedisulphonic acid), have previously been reported as potent and selective inhibitors of human immunodeficiency virus type 1 (HIV-1) replication in cell culture. These compounds have also proved inhibitory to syncytium formation in cocultures of MOLT-4 cells with HIV-1-infected HUT-78 cells. They also inhibit the binding of HIV-1 virions to MT-4 cells as determined by a flow cytometric (FACS) method. Further studies on their mechanism of action by the FACS have revealed that the compounds inhibit the binding of anti-gp120 monoclonal antibody to the viral envelope glycoprotein gp120. Binding of OKT4A/Leu3a monoclonal antibody to the cellular CD4 receptor is not affected by the compounds. These results suggest that the anti-HIV-1 activity of the naphthalenedisulphonic acid derivatives can be attributed to inhibition of the gp120-CD4 interaction through binding of the compounds to the viral gp120 antigen.