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Spiller KL, Vunjak-Novakovic G. Clinical translation of controlled protein delivery systems for tissue engineering. Drug Deliv Transl Res 2016; 5:101-15. [PMID: 25787736 DOI: 10.1007/s13346-013-0135-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Strategies that utilize controlled release of drugs and proteins for tissue engineering have enormous potential to regenerate damaged organs and tissues. The multiple advantages of controlled release strategies merit overcoming the significant challenges to translation, including high costs and long, difficult regulatory pathways. This review highlights the potential of controlled release of proteins for tissue engineering and regenerative medicine. We specifically discuss treatment modalities that have reached preclinical and clinical trials, with emphasis on controlled release systems for bone tissue engineering, the most advanced application with several products already in clinic. Possible strategies to address translational and regulatory concerns are also discussed.
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Affiliation(s)
- Kara L Spiller
- Department of Biomedical Engineering, Columbia University, 622 West 168th Street Vanderbilt Clinic 12-234, New York, NY, 10032, USA
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Picichè M. Noncoronary Collateral Myocardial Blood Flow: The Human Heart's Forgotten Blood Supply. Open Cardiovasc Med J 2015; 9:105-13. [PMID: 27006713 PMCID: PMC4768666 DOI: 10.2174/1874192401509010105] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 03/20/2015] [Accepted: 04/22/2015] [Indexed: 11/22/2022] Open
Abstract
The “noncoronary collateral circulation” (NCCC) or “noncoronary collateral myocardial blood flow”
(NCCMBF), reaches the heart through a micro-vascular network arising from the bronchial, esophageal, pericardial,
diaphragmatic, and aortic arteries. The left and right internal thoracic arteries (ITAs) along with their collateral branches
also serve as a source of NCCMBF-a feature seen in other mammals. Under certain circumstances the ITAs have a high
potential for developing collateral branches. In the case of severe Leriche syndrome or with chronic obstruction of the
abdominal aorta, the ITAs can serve as the main or even sole source of blood supply to the lower limbs. It is also possible
for the ITAs to develop angiographically visible branches that directly connect with the coronary arteries. In ischemic
conditions there is a functional, ischemia-reducing extracardiac coronary artery supply via natural ipsilateral ITA
anastomosis. To date we know little about NCCMBF and its potential benefits in clinical applications, which makes this a
challenging and intriguing field of research. This paper reviews all available data on noncoronary collateral blood supply
to the human heart.
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Affiliation(s)
- Marco Picichè
- Cardiac Surgery Department, San Filippo Neri Hospital, Via Martinotti 20, 00135, Rome, Italy
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Briones E, Lacalle JR, Marin‐Leon I, Rueda J. Transmyocardial laser revascularization versus medical therapy for refractory angina. Cochrane Database Syst Rev 2015; 2015:CD003712. [PMID: 25721946 PMCID: PMC7154377 DOI: 10.1002/14651858.cd003712.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND This is an update of a review previously published in 2009. Chronic angina and advanced forms of coronary disease are increasingly more frequent. In spite of the improvement in the efficacy of available revascularization treatments, a subgroup of patients continue suffering from refractory angina. Transmyocardial laser revascularization (TMLR) has been proposed to improve the clinical situation of these patients. OBJECTIVES To assess the effects (both benefits and harms) of TMLR versus optimal medical treatment in people with refractory angina who are not candidates for percutaneous coronary angioplasty or coronary artery bypass graft, in alleviating angina severity, reducing mortality and improving ejection fraction. SEARCH METHODS We searched the following resources up to June 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the metaRegister of Controlled Trials database, ClinicalTrials.gov, and the WHO International Clinical Trials Registry. We applied no languages restrictions. We also checked reference lists of relevant papers. SELECTION CRITERIA We selected studies if they fulfilled the following criteria: randomized controlled trials (RCTs) of TMLR, by thoracotomy, in patients with Canadian Cardiovascular Society or New York Heart Association angina grade III-IV who were excluded from other revascularization procedures. DATA COLLECTION AND ANALYSIS Three authors independently extracted data for each trial about the population and interventions compared and assessed the risk of bias of the studies, evaluating randomisation sequence generation, allocation concealment, blinding (of participants, personnel and outcome assessors), incomplete outcome data, selective outcome reporting, and other potential sources of bias. MAIN RESULTS From a total of 502 references, we retrieved 47 papers for more detailed evaluation. We selected 20 papers, reporting data from seven studies, which included 1137 participants, of which 559 were randomized to TMLR. Participants and professionals were not blinded, which suggests high risk of performance bias. Overall, 43.8% of participants in the treatment group decreased two angina classes, as compared with 14.8% in the control group: odds ratio (OR) 4.63, 95% confidence interval (CI) 3.43 to 6.25), and heterogeneity was present. Mortality by intention-to-treat analysis was similar in both groups at 30 days (4.0% in the TMLR group and 3.5% in the control group), and one year (12.2% in the TMLR group and 11.9% in the control group). However, the 30-day mortality as-treated was 6.8% in the TMLR group and 0.8% in the control group (pooled OR was 3.76, 95% CI 1.63 to 8.66), mainly due to a higher mortality in participants crossing from standard treatment to TMLR. The assessment of subjective outcomes, such as improvement in angina, was affected by a high risk of bias and this may explain the differences found. Other adverse events such as myocardial infarction, arrhythmias or heart failure, were not considered in this review, as they were not predefined outcomes in trials design and they show a high inconsistency across studies. No new trials on transmyocardial laser revascularization have been published in the last ten years and it is very unlikely that new research will be undertaken in this field. AUTHORS' CONCLUSIONS This review shows that risks associated with TMLR outweigh the potential clinical benefits. Subjective outcomes are subject to high risk of bias and no differences were found in survival, but a significant increase in postoperative mortality and other safety outcomes suggests that the procedure may pose unacceptable risks.
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Affiliation(s)
- Eduardo Briones
- Primary Care District. IBIS‐CIBERESPPublic Health UnitAvda Jerez s/nAntiguo Hospital MilitarSevillaSevillaSpain41014
| | - Juan Ramon Lacalle
- Universidad de SevillaPreventive Medicine and Public HealthAvenida Sanchez PizjuanSevillaSpain41009
| | - Ignacio Marin‐Leon
- Hospital Universitario Virgen del Rocio, IBIS‐CIBERESPDepartment of Internal MedicineManuel Siurot, Office 2nd floorSevillaSpain41013
| | - José‐Ramón Rueda
- University of the Basque CountryDepartment of Preventive Medicine and Public HealthBarrio SarrienaS.N.LeioaBizkaiaSpainE‐48080
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Wang LW, Fahim MA, Hayen A, Mitchell RL, Baines L, Lord S, Craig JC, Webster AC. Cardiac testing for coronary artery disease in potential kidney transplant recipients. Cochrane Database Syst Rev 2011; 2011:CD008691. [PMID: 22161434 PMCID: PMC7177243 DOI: 10.1002/14651858.cd008691.pub2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) are at increased risk of coronary artery disease (CAD) and adverse cardiac events. Screening for CAD is therefore an important part of preoperative evaluation for kidney transplant candidates. There is significant interest in the role of non-invasive cardiac investigations and their ability to identify patients at high risk of CAD. OBJECTIVES We investigated the accuracy of non-invasive cardiac screening tests compared with coronary angiography to detect CAD in patients who are potential kidney transplant recipients. SEARCH METHODS MEDLINE and EMBASE searches (inception to November 2010) were performed to identify studies that assessed the diagnostic accuracy of non-invasive screening tests, using coronary angiography as the reference standard. We also conducted citation tracking via Web of Science and handsearched reference lists of identified primary studies and review articles. SELECTION CRITERIA We included in this review all diagnostic cross sectional, cohort and randomised studies of test accuracy that compared the results of any cardiac test with coronary angiography (the reference standard) relating to patients considered as potential candidates for kidney transplantation or kidney-pancreas transplantation at the time diagnostic tests were performed. DATA COLLECTION AND ANALYSIS We used a hierarchical modelling strategy to produce summary receiver operating characteristic (SROC) curves, and pooled estimates of sensitivity and specificity. Sensitivity analyses to determine test accuracy were performed if only studies that had full verification or applied a threshold of ≥ 70% stenosis on coronary angiography for the diagnosis of significant CAD were included. MAIN RESULTS The following screening investigations included in the meta-analysis were: dobutamine stress echocardiography (DSE) (13 studies), myocardial perfusion scintigraphy (MPS) (nine studies), echocardiography (three studies), exercise stress electrocardiography (two studies), resting electrocardiography (three studies), and one study each of electron beam computed tomography (EBCT), exercise ventriculography, carotid intimal media thickness (CIMT) and digital subtraction fluorography (DSF). Sufficient studies were present to allow hierarchical summary receiver operating characteristic (HSROC) analysis for DSE and MPS. When including all available studies, both DSE and MPS had moderate sensitivity and specificity in detecting coronary artery stenosis in patients who are kidney transplant candidates [DSE (13 studies) - pooled sensitivity 0.79 (95% CI 0.67 to 0.88), pooled specificity 0.89 (95% CI 0.81 to 0.94); MPS (nine studies) - pooled sensitivity 0.74 (95% CI 0.54 to 0.87), pooled specificity 0.70 (95% CI 0.51 to 0.84)]. When limiting to studies which defined coronary artery stenosis using a reference threshold of ≥ 70% stenosis on coronary angiography, there was little change in these pooled estimates of accuracy [DSE (9 studies) - pooled sensitivity 0.76 (95% CI 0.60 to 0.87), specificity 0.88 (95% CI 0.78 to 0.94); MPS (7 studies) - pooled sensitivity 0.67 (95% CI 0.48 to 0.82), pooled specificity 0.77 (95% CI 0.61 to 0.88)]. There was evidence that DSE had improved accuracy over MPS (P = 0.02) when all studies were included in the analysis, but this was not significant when we excluded studies which did not avoid partial verification or use a reference standard threshold of ≥70% stenosis (P = 0.09). AUTHORS' CONCLUSIONS DSE may perform better than MPS but additional studies directly comparing these cardiac screening tests are needed. Absence of significant CAD may not necessarily correlate with cardiac-event free survival following transplantation. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.
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Affiliation(s)
- Louis W Wang
- St Vincent's HospitalDepartment of CardiologyDarlinghurstNSWAustralia2010
- University of SydneySydney School of Public HealthSydneyNSWAustralia
| | - Magid A Fahim
- Princess Alexandra HospitalDepartment of NephrologyBrisbaneQLDAustralia4102
| | - Andrew Hayen
- University of SydneyScreening and Test Evaluation Program (STEP), Sydney School of Public HealthA27 ‐ Edward Ford BuildingSydneyNSWAustralia2006
| | - Ruth L Mitchell
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Laura Baines
- Newcastle upon Tyne Hospitals NHSRenal ServicesFreeman RdNewcastle upon TyneUKNE7 DN
| | - Stephen Lord
- Newcastle upon Tyne Hospitals NHSCardiology ServicesNewcastle upon TyneUKNE7 7DN
| | - Jonathan C Craig
- University of SydneySydney School of Public HealthSydneyNSWAustralia
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Angela C Webster
- University of SydneySydney School of Public HealthSydneyNSWAustralia
- The Children's Hospital at WestmeadCochrane Renal Group, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
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Wang LW, Fahim MA, Hayen A, Mitchell RL, Lord SW, Baines LA, Craig JC, Webster AC. Cardiac testing for coronary artery disease in potential kidney transplant recipients: a systematic review of test accuracy studies. Am J Kidney Dis 2011; 57:476-87. [PMID: 21257239 DOI: 10.1053/j.ajkd.2010.11.018] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 11/08/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiovascular disease is the leading cause of death after kidney transplant. Screening for coronary artery disease is integral to pretransplant evaluation, although the relative performance of different tests is uncertain. STUDY DESIGN Systematic review of diagnostic test accuracy studies using hierarchical summary receiver operating characteristic analysis. SETTING & POPULATION Kidney transplant candidates undergoing pretransplant assessment. SELECTION CRITERIA OF STUDIES: Studies evaluating the accuracy of screening tests for detecting coronary artery disease. INDEX TESTS Any non- or minimally invasive test used to diagnose coronary artery disease. REFERENCE TEST Coronary angiography. RESULTS 11 studies (690 participants) evaluated dobutamine stress echocardiography; 7 (317 participants), myocardial perfusion scintigraphy; 2 (129 participants), exercise stress electrocardiography; and 2 (121 participants), other tests. Dobutamine stress echocardiography had pooled sensitivity of 0.80 (95% CI, 0.64-0.90) and specificity of 0.89 (95% CI, 0.79-0.94). Myocardial perfusion scintigraphy had pooled sensitivity of 0.69 (95% CI, 0.48-0.85) and specificity of 0.77 (95% CI, 0.59-0.89). Head-to-head comparison of dobutamine stress echocardiography and myocardial perfusion scintigraphy (2 studies; 116 participants) showed that dobutamine stress echocardiography had higher specificity and at least equivalent or higher sensitivity. Indirect comparison suggested dobutamine stress echocardiography may have improved accuracy over myocardial perfusion scintigraphy (P = 0.07). LIMITATIONS Power to detect differences in accuracy between tests is limited due to sparse data. Absence of significant coronary artery disease may not necessarily correlate with cardiac event-free survival after transplant. CONCLUSIONS Dobutamine stress echocardiography may perform better than myocardial perfusion scintigraphy; however, additional studies directly comparing dobutamine stress echocardiography and myocardial perfusion scintigraphy are needed. Further research should focus on assessing the ability of functional tests to predict postoperative outcome.
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Affiliation(s)
- Louis W Wang
- Sydney School of Public Health, University of Sydney, Sydney, Australia
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Diastolic stress echocardiography detects coronary artery disease in patients with asymptomatic type II diabetes. Coron Artery Dis 2010; 21:104-12. [DOI: 10.1097/mca.0b013e328335a05d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Briones E, Lacalle JR, Marin I. Transmyocardial laser revascularization versus medical therapy for refractory angina. Cochrane Database Syst Rev 2009:CD003712. [PMID: 19160223 DOI: 10.1002/14651858.cd003712.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chronic angina and advanced forms of coronary disease are increasingly more frequent. Although the improved efficacy of available revascularization treatments, a subgroup of patients present with refractory angina. Transmyocardial laser revascularization (TMLR) has been proposed to improve the clinical situation of these patients. OBJECTIVES To assess the efficacy and safety of TMLR versus optimal medical treatment in patients with refractory angina in alleviating the severity of angina and improving survivorship and heart function. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 2 2007), MEDLINE (January 2006 to June 2007), EMBASE ( 2004 to June 2007) and ongoing studies were sought using the metaRegister of Controlled Trials database (mRCT) and ClinicalTrials.gov databases. No languages restrictions were applied. Reference lists of relevant papers were also checked. SELECTION CRITERIA Studies were selected if they fulfilled the following criteria: randomized controlled trials of TMLR, by thoracotomy, in patients with angina grade III-IV who were excluded from other revascularization procedures. From a total of 181 references, 20 papers were selected, reporting data from seven studies. DATA COLLECTION AND ANALYSIS Two reviewers abstracted data from selected papers; . The reviewers performed independently both quality assessment and data extraction. Selected studies present methodological weaknesses. None of them fulfilled all the quality criteria. MAIN RESULTS Seven studies (1137 participants of which 559 randomized to TMLR) were included. Overall, 43.8 % of patients in the treatment group decreased two angina classes as compared with 14.8 % in the control group, odds ratio (OR) of 4.63 (95% confidence interval (CI) 3.43 to 6.25), and heterogeneity was statistically significant. Mortality by intention-to-treat analysis at both 30 days (4.0 % in the TMLR group and 3.5 % in the control group) and 1 year (12.2 % in the TMLR group and 11.9 % in the control group) was similar in both groups. The 30-days mortality as treated was 6.8% in TMLR group and 0.8% in the control group, showing a statistically significant difference. The pooled OR was 3.76 (95% CI 1.63 to 8.66), because of the higher mortality in patients crossing from standard treatment to TMLR. AUTHORS' CONCLUSIONS There is insufficient evidence to conclude that the clinical benefits of TMLR outweigh the potential risks. The procedure is associated with a significant early mortality.
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Affiliation(s)
- Eduardo Briones
- Quality and Health Information , Valme University Hospital, Avda Bellavista s.n., Sevilla, Spain, 41014.
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Khan SN, McNab DC, Sharples LD, Freeman CJ, Hardy I, Stone DL, Schofield PM. A study to assess changes in myocardial perfusion after treatment with spinal cord stimulation and percutaneous myocardial laser revascularisation; data from a randomised trial. Trials 2008; 9:9. [PMID: 18304366 PMCID: PMC2266700 DOI: 10.1186/1745-6215-9-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 02/28/2008] [Indexed: 11/30/2022] Open
Abstract
Background Spinal cord stimulation (SCS) and percutaneous myocardial laser revascularisation (PMR) are treatment modalities used to treat refractory angina pectoris, with the major aim of such treatment being the relief of disabling symptoms. This study compared the change in myocardial perfusion following SCS and PMR treatment. Methods Subjects with Canadian Cardiovascular Society class 3/4 angina and reversible perfusion defects as assessed by single-photon emission computed tomographic myocardial perfusion scintigraphy were randomised to SCS (34) or PMR (34). 28 subjects in each group underwent repeat myocardial perfusion imaging 12 months post intervention. Visual scoring of perfusion images was performed using a 20-segment model and a scale of 0 to 4. Results The mean (standard deviation) baseline summed rest score (SRS) and stress scores (SSS) were 4.6 (5.7) and 13.6 (9.0) in the PMR group and 6.1 (7.4) and 16.8 (11.6) in the SCS group. At 12 months, SRS was 5.5 (6.0) and SSS 15.3 (11.3) in the PMR group and 6.9 (8.2) and 15.1 (10.9) in the SCS group. There was no significant difference between the two treatment groups adjusted for baseline (p = 1.0 for SRS, p = 0.29 for SSS). Conclusion There was no significant difference in myocardial perfusion one year post treatment with SCS or PMR.
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Affiliation(s)
- Sadia N Khan
- Department of Cardiology, Papworth Hospital, Papworth Everard, Cambridge, UK.
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Stewart DJ, Hilton JD, Arnold JMO, Gregoire J, Rivard A, Archer SL, Charbonneau F, Cohen E, Curtis M, Buller CE, Mendelsohn FO, Dib N, Page P, Ducas J, Plante S, Sullivan J, Macko J, Rasmussen C, Kessler PD, Rasmussen HS. Angiogenic gene therapy in patients with nonrevascularizable ischemic heart disease: a phase 2 randomized, controlled trial of AdVEGF121 (AdVEGF121) versus maximum medical treatment. Gene Ther 2006; 13:1503-11. [PMID: 16791287 DOI: 10.1038/sj.gt.3302802] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The demonstration that angiogenic growth factors can stimulate new blood vessel growth and restore perfusion in animal models of myocardial ischemia has led to the development of strategies designed for the local production of angiogenic growth factors in patients who are not candidates for conventional revascularization. The results of recent clinical trials of proangiogenesis gene therapy have been disappointing; however, significant limitations in experimental design, in particular in gene transfer strategies, preclude drawing definitive conclusions. In the REVASC study cardiac gene transfer was optimized by direct intramyocardial delivery of a replication-deficient adenovirus-containing vascular endothelial growth factor (AdVEGF121, 4 x 10(10) particle units (p.u.)). Sixty-seven patients with severe angina due to coronary artery disease and no conventional options for revascularization were randomized to AdVEGF121 gene transfer via mini-thoracotomy or continuation of maximal medical treatment. Exercise time to 1 mm ST-segment depression, the predefined primary end-point analysis, was significantly increased in the AdVEGF121 group compared to control at 26 weeks (P=0.026), but not at 12 weeks. As well, total exercise duration and time to moderate angina at weeks 12 and 26, and in angina symptoms as measured by the Canadian Cardiovascular Society Angina Class and Seattle Angina Questionnaire were all improved by VEGF gene transfer (all P-values at 12 and 26 weeks < or =0.001). However, if anything the results of nuclear perfusion imaging favored the control group, although the AdVEGF121 group achieved higher workloads. Overall there was no significant difference in adverse events between the two groups, despite the fact that procedure-related events were seen only in the thoracotomy group. Therefore, administration of AdVEGF121 by direct intramyocardial injections resulted in objective improvement in exercise-induced ischemia in patients with refractory ischemic heart disease.
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Affiliation(s)
- D J Stewart
- Division of Cardiology, St Michael's Hospital, 30 Bond Street, Rm. 6050 Queen Wing, Toronto, Ontario, Canada.
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Gersh BJ, Simari RD. Cardiac cell-repair therapy: clinical issues. ACTA ACUST UNITED AC 2006; 3 Suppl 1:S105-9. [PMID: 16501615 DOI: 10.1038/ncpcardio0400] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2005] [Accepted: 10/11/2005] [Indexed: 11/08/2022]
Abstract
The possibility that cardiac cell-repair therapy might become a clinical reality is a challenge worthy of the current state of technological and scientific expertise at the start of the 21(st) century. The success of preclinical and early clinical studies is a strong inducement to move ahead with larger clinical trials, but caution is warranted given our lack of understanding of the potential mechanisms by which cell-repair therapy exerts a benefit on ventricular function, perfusion, and infarct size, irrespective of the type of cell, method, site, and disease entity. There are multiple clinical, mechanistic, and safety questions requiring answers, and these will be forthcoming only if the design of clinical trials is carefully tailored to answer specific questions. These questions, in turn, will require the use of different and multiple end points, depending on the specific issue and study. Accordingly, this review addresses the limitations of current clinical studies, the design of future trials, and the concept of a hierarchical series of end points that might provide answers to a host of different questions. Clinical and basic scientists need to approach the next generation of trials in partnership.
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Affiliation(s)
- Bernard J Gersh
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
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Gyöngyösi M, Khorsand A, Zamini S, Sperker W, Strehblow C, Kastrup J, Jorgensen E, Hesse B, Tägil K, Bøtker HE, Ruzyllo W, Teresiñska A, Dudek D, Hubalewska A, Rück A, Nielsen SS, Graf S, Mundigler G, Novak J, Sochor H, Maurer G, Glogar D, Sylven C. NOGA-guided analysis of regional myocardial perfusion abnormalities treated with intramyocardial injections of plasmid encoding vascular endothelial growth factor A-165 in patients with chronic myocardial ischemia: subanalysis of the EUROINJECT-ONE multicenter double-blind randomized study. Circulation 2006; 112:I157-65. [PMID: 16159809 DOI: 10.1161/01.circulationaha.105.525782] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this substudy of the EUROINJECT-ONE double-blind randomized trial was to analyze changes in myocardial perfusion in NOGA-defined regions with intramyocardial injections of plasmid encoding plasmid human (ph)VEGF-A(165) using an elaborated transformation algorithm. METHODS AND RESULTS After randomization, 80 no-option patients received either active, phVEGF-A165 (n=40), or placebo plasmid (n=40) percutaneously via NOGA-Myostar injections. The injected area (region of interest, ROI) was delineated as a best polygon by connecting of the injection points marked on NOGA polar maps. The ROI was projected onto the baseline and follow-up rest and stress polar maps of the 99m-Tc-sestamibi/tetrofosmin single-photon emission computed tomography scintigraphy calculating the extent and severity (expressed as the mean normalized tracer uptake) of the ROI automatically. The extents of the ROI were similar in the VEGF and placebo groups (19.4+/-4.2% versus 21.5+/-5.4% of entire myocardium). No differences were found between VEGF and placebo groups at baseline with regard to the perfusion defect severity (rest: 69+/-11.7% versus 68.7+/-13.3%; stress: 63+/-13.3% versus 62.6+/-13.6%; and reversibility: 6.0+/-7.7% versus 6.7+/-9.0%). At follow-up, a trend toward improvement in perfusion defect severity at stress was observed in VEGF group as compared with placebo (68.5+/-11.9% versus 62.5+/-13.5%, P=0.072) without reaching normal values. The reversibility of the ROI decreased significantly at follow-up in VEGF group as compared with the placebo group (1.2+/-9.0% versus 7.1+/-9.0%, P=0.016). Twenty-one patients in VEGF and 8 patients in placebo group (P<0.01) exhibited an improvement in tracer uptake during stress, defined as a >or =5% increase in the normalized tracer uptake of the ROI. CONCLUSIONS Projection of the NOGA-guided injection area onto the single-photon emission computed tomography polar maps permits quantitative evaluation of myocardial perfusion in regions treated with angiogenic substances. Injections of phVEGF A165 plasmid improve, but do not normalize, the stress-induced perfusion abnormalities.
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Affiliation(s)
- Mariann Gyöngyösi
- Division of Cardiology, Department of Internal Medicine II, University of Vienna, Wahringer Gürtel 18-20, A-1090 Vienna, Austria.
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Affiliation(s)
- Michael Simons
- Angiogenesis Research Center and Section of Cardiology, Department of Medicine, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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Dziuk MA, Canizales A, Ali N, El-Deeb H, Britton KE, Dymond DS, Edmondson SJ. The prospective clinical and scintigraphic assessment of patients with preserved left ventricular systolic function after transmyocardial laser revascularisation. Int J Cardiovasc Imaging 2005; 21:405-12. [PMID: 16047122 DOI: 10.1007/s10554-004-7987-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2004] [Accepted: 12/21/2004] [Indexed: 10/25/2022]
Abstract
AIM To analyse the clinical outcome and myocardial perfusion and function after transmyocardial revascularisation (TMR) in patients with normal left ventricular function and multivessel coronary artery disease non-amenable for standard revascularisation. METHOD AND RESULTS Twenty three severely symptomatic patients (CCS score median 4) with normal left ventricular systolic function but coronaries non-amenable for either PTCA or CABG were subjected to TMR. The angina score, left ventricular systolic and diastolic function in radionuclide ventriculography at rest, exercise tolerance and myocardial perfusion--Thallium-201 SPECT (adenosine stress 74 and 37 MBq under nitrate cover) were evaluated before and 3, 6, 12 months post-operatively. After an average of 40 +/- 12 (range 14-56) TMR channels angina score decreased significantly (p< 0.0001) and the exercise tolerance increased (from 6.0 +/- 4.5 to 9.1 +/- 4.6 after 6 months, p< 0.05) in 21 patients. During the follow up period two patients had a myocardial infarction and one committed suicide after 6 months. Ejection fraction dropped significantly only after 1 year post-TMR from 70 +/- 13 to 63 +/- 0.13%, p < 0.05. The overall perfusion improved initially in 14 patients with subsequent deterioration in time. The changes in segmental perfusion were not associated with the symptomatic improvement. CONCLUSION Transmyocardial revascularisation in patients with normal ejection fraction may improve the angina class, exercise tolerance and overall but not segmental perfusion and does not show any immediate effect on left ventricular function.
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Affiliation(s)
- Miroslaw A Dziuk
- Department of Nuclear Medicine, St. Bartholomev's Hospital, London, UK.
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Patel AD, Iskandrian AE. Role of single photon emission computed tomography imaging in the evaluation of therapy for angina pectoris. Am Heart J 2003; 145:952-61. [PMID: 12796749 DOI: 10.1016/s0002-8703(03)00088-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Amar D Patel
- Division of Cardiovascular Diseases, Department of Medicine, University of Alabama at Birmingham, USA
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Szatkowski A, Ndubuka-Irobunda C, Oesterle SN, Burkhoff D. Transmyocardial laser revascularization: a review of basic and clinical aspects. Am J Cardiovasc Drugs 2002; 2:255-66. [PMID: 14727971 DOI: 10.2165/00129784-200202040-00005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Transmyocardial laser revascularization (TMR or TMLR) is a surgical therapy developed to treat patients with debilitating, medically refractory angina pectoris due to epicardial coronary artery disease that is not amenable to treatment using the traditional methods of percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). This technique can also be applied percutaneously [percutaneous myocardial revascularization (PMR) or direct myocardial revascularization (DMR)]. The original hypotheses which motivated development of TMR were that: (i) oxygenated blood could flow directly from the left ventricle and perfuse the myocardium; and (ii) such artificially created channels would remain patent. However, experimental data have refuted both hypotheses. In the face of early reports of marked clinical benefits in terms of relief of anginal symptoms, alternate hypotheses to explain the mechanism have been pursued, including TMR-associated neoangiogenesis and cardiac denervation. Clinically, numerous reports of reduction in frequency and severity of anginal symptoms, improved exercise tolerance and improved quality of life have appeared from nonblind registry-type studies as well as nonblind randomized clinical trials of TMR or PMR versus continued medical therapy. TMR was not associated with a significant improvement in survival compared with medical therapy alone in randomized trials. For example, the prospective, randomized Angina Treatments-Lasers and Normal Therapies in Comparison (ATLANTIC) trial found a 1-year mortality of 5% in 92 TMR-treated patients and 10% in 90 patients treated with medication only. No proof of improved myocardial blood flow in hearts of treated patients is currently available. The first randomized study of PMR was the Potential Angina Class Improvement From Intramyocardial Channels (PACIFIC) trial which found significantly greater improvements in anginal symptoms and exercise tolerance with PMR plus medical therapy, compared with medical therapy alone. The preliminary results of two double-blind studies with PMR/DMR have been presented but have not yet been published in full. Whereas PMR-treated patients did significantly better than sham-treated control groups after 6 months in the Blinded Evaluation of Laser Intervention Electively For angina pectoris (BELIEF) trial, there was no difference after 1 year between DMR-treated patients and those treated with medication only in the DMR In Regeneration of Endomyocardial Channels Trial (DIRECT). Different devices used for revascularization in these two trials may explain the disparity in the results, and therefore the efficacy and tolerability of each device should be judged upon data collected with that particular device.
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Affiliation(s)
- Arie Szatkowski
- Department of Medicine, Division of Circulatory Physiology, Columbia University, New York, New York 10032, USA
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