Effects of colchicine on pericardial diseases: a review of the literature and current evidence

Occurrence and predictors of pericardial effusion requiring invasive treatment following heart valve surgery

OBJECTIVES

To describe the occurrence of significant pericardial effusion, and to investigate characteristics associated with pericardial effusion within three months following heart valve surgery.

METHODS

A retrospective, observational cohort study including adult patients undergoing heart valve surgery at Odense University Hospital from August 2013 to November 2017. Data were gathered from The Western Denmark Heart Registry and electronic patient records.Cox proportional hazard models were used to investigate the associations between characteristics associated with significant pericardial effusion during index admission and within 3 months. Results are presented as HR with 95% CI.

RESULTS

In total, 1460 patients were included (70% men, median age 71 years (IQR 63-76)) and of those, n=230 patients (16%) developed significant pericardial effusion.EuroScore II was significantly associated with an increased risk of pericardial effusion during index admission and associated with a lower risk following discharge (index admission HR 1.05, 95% CI 1.02 to 1.08, after discharge HR 0.80, 95% CI 0.69 to 0.92). Increasing age (HR 0.97, 95% CI 0.95 to 0.98 per year) and concomitant coronary artery bypass grafting versus isolated valve surgery (HR 0.58, 95% CI 0.35 to 0.97) were significantly associated with a reduced risk of pericardial effusions in both periods. Being a man (HR 2.30, 95% CI 1.32 to 4.01) and aortic valve disease versus mitral valve disease (HR 2.16, 95% CI 1.20 to 3.90) were significantly associated with an increased risk after discharge.

CONCLUSION

Significant pericardial effusions requiring drainage were present in 16% of cases following heart valve surgery, and different clinical characteristics were associated with the development of effusion.

Design and discovery of new antiproliferative 1,2,4-triazin-3(2H)-ones as tubulin polymerization inhibitors targeting colchicine binding site

Thirty-five new colchicine binding site inhibitors have been designed and synthesized based on the 1,2,4-triazin-3(2H)-one nucleus. Such molecules were synthesized through a cascade reaction between readily accessible α-amino ketones and phenyl carbazate as a masked N-isocyanate precursor. The synthesized derivatives are cisoid restricted combretastatin A4 analogues containing 1,2,4-triazin-3(2H)-one in place of the olefinic bond, and they have the same essential pharmacophoric features of colchicine binding site inhibitors. The synthesized compounds were evaluated in vitro for their antiproliferative activities against a panel of three human cancer cell lines (MCF-7, HepG-2, and HCT-116), using colchicine as a positive control. Among them, two compounds 5i and 6i demonstrated a significant antiproliferative effect against all cell lines with IC₅₀ ranging from 8.2 - 18.2 µM. Further investigation was carried out for the most active cytotoxic agents as tubulin polymerization inhibitors. Compounds 5i and 6i effectively inhibited microtubule assembly with IC₅₀ values ranging from 3.9 to 7.8 µM. Tubulin polymerization assay results were found to be comparable with the cytotoxicity results. The cell cycle analysis revealed significant G2/M cell cycle arrest of the analogue 5i in HepG-2 cells. The most active compounds 4i, 4j, 5 g, 5i and 6i did not induce significant cell death in normal human lung cells Wl-38, suggesting their selectivity against cancer cells. Also, These compounds upregulated the level of active caspase-3 and boosted the levels of the pro-apoptotic protein Bax by five to seven folds in comparison to the control. Moreover, apoptosis analyses were conducted for compound 5i to evaluate its apoptotic potential. Finally, in silico studies were conducted to reveal the probable interaction with the colchicine binding site. ADME prediction study of the designed compounds showed that they are not only with promising tubulin polymerization inhibitory activity but also with favorable pharmacokinetic and drug-likeness properties.

Using left ventricular assist devices in advanced heart failure patients

Advanced Heart Failure (AHF) is a complex syndrome that affects the physiology of the heart to maintain efficient blood circulation resulting in multiorgan failure and, eventually, death. Left Ventricular Assist Devices (LVADs) have become the cornerstone therapy for AHF patients, both as a bridge to transplantation and as a decisive therapy. Recently the results of the MOMENTUM 3 Trial were published. The trial compared HeartMate 3 LVAD with HeartMate II LVAD in a randomized trial in The Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy with HeartMate 3 (MOMENTUM 3). Of 366 patients, 190 were assigned to the centrifugal-flow pump group (HeartMate 3) and 176 to the axial-flow (HeartMate II) pump group. In the intention-to-treat population, the primary end point occurred in 151 patients (79.5%) in the centrifugal-flow pump group, as compared with 106 (60.2%) in the axial-flow pump group (P < 0.001 for noninferiority). Reoperation for pump malfunction was less frequent in the centrifugal-flow pump group than in the axial-flow pump group (P < 0.001).The results of the MOMENTUM 3 Trial are a big achievement in the cardiovascular world. Any improvement in LVADs that reduces the risk of stroke, perhaps the most feared complication of these devices, would be meaningful. Besides, given the observed lower rate of pump thrombosis and reoperation for pump malfunction, it already seems likely that the HeartMate 3 will supplant the HeartMate II in clinical practice. In addition, the risks that are associated with reoperation undoubtedly counterbalanced any unintentional bias in performing that intervention.

A closer look at heart failure in patients with concurrent diabetes mellitus using glucose lowering drugs

INTRODUCTION

Type 2 diabetes (T2D) is an independent risk factor for heart failure (HF). With concomitant T2D and HF, recent data suggests an incremental risk of cardiovascular death and hospitalization for HF, as compared to patients with HF without T2D. Areas covered: Management of these two diseases has been a challenge for physicians. The treatment goals for HF patients in T2D are very important. They serve as the endpoint in using a specific treatment for management and treatment of T2D patients hence, decreasing mortality rates. In this review, we examine the effects of oral antidiabetic drugs on HF patients, discussing current evidence-based up-to-date management strategies and guidelines in the general population with HF and T2D. Expert commentary: Future in the management of T2D in HF patients looks bright. Augmenting data on potential cardiovascular side effects of antidiabetic drugs is valuable since millions of people are treated over many years. Newer novel drugs targeting specific signaling pathways are approaching the stages of clinical investigation. They have been a highly attractive concept for the future in the management of these patients. However, while advances in technology elucidated many aspects of these diseases, many mysteries still remain.

Management of atrial fibrillation-flutter: uptodate guideline paper on the current evidence

The term 'flutter' and 'fibrillation' were first coined to differentiate the differences between fast, regular contractions in Atrial Flutter (AFLUT) with irregular, vermiform contractions of Atrial Fibrillation (AFIB). Management of these two diseases has been a challenge for physicians. Rate control (along with rhythm control) is the first line of management for symptomatic AFIB/AFLUT with Rapid Ventricular Rate (RVR). In some situations, atrial rhythms may not be well controlled by these anti-arrhythmic drugs, making cardioversion to sinus rhythm necessary. Anti-coagulation therapy in both the disease population is essential. Catheter ablation is an effective treatment option in certain patients that have AFIB/AFLUT refractory to medical management. Newer techniques like left atrial appendage (LAA) has been developed and is a highly attractive concept for the future in the management of AFIB/AFLUT. Newer novel drugs targeting specific ion channels are approaching the stages of clinical investigation. However, while advances in technologies have helped elucidate many aspects of these diseases, many mysteries still remain. This literature review serves as one of the guideline papers for current up-to-date management on both AFIB and AFLUT.

Atrial fibrillation and heart failure- results of the CASTLE-AF trial

Congestive Heart Failure (HF) and Atrial Fibrillation (AFIB) often coexist. Catheter ablation is a well-established option for symptomatic AFIB that is resistant to drug therapy in patients with otherwise normal cardiac function. This has been seen in various studies where catheter ablation was associated with positive outcomes in patients with HF. Recently, the study results from the Catheter Ablation versus Standard Conventional Therapy in Patients with Left Ventricular Dysfunction and Atrial Fibrillation (CASTLE-AF) trial were published. After a median follow-up of more than 3 years, patients getting catheter ablation for AFIB had significantly fewer hospital admissions as well as death from worsening HF. In addition, 63% of patients in the ablation group were in sinus rhythm, as compared with 22% of those in the medical-therapy group (P < 0.001). This trial may represent a significant additional therapeutic tool in the clinical prevention and management of cardiovascular mortality and morbidity. While catheter ablation does not eliminate the AFIB per se, it can limit the ventricular rate by eliminating triggers and altering electrophysiological connections in the heart in a similar fashion to rate control anti-arrhythmic drugs. Longer-duration normal sinus rhythm may improve outcomes by means of a number of mechanisms, including greater atrial emptying, all of which translate into improved cardiac output. A better understanding is needed as to why a decrease in density, but not complete elimination of atrial fibrillation, is sufficient for reverse remodelling. It is anticipated that the results of the CASTLE-AF trial will soon be implemented in international guidelines.

Right ventricular dysplasia: management and treatment in light of current evidence

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare cardiovascular disease that predisposes to ventricular arrhythmias potentially leading to sudden cardiac death (SCD). ARVC varies considerably with multiple clinical presentations, ranging from no symptoms to cardiac arrhythmias to SCD. ARVC prevalence is not well known, but the estimated prevalence in the general population is 1:5000. Diagnosis of ARVC can be made by using the Revised European Society of Cardiology criteria for ARVC that includes ventricular structural and functional changes, ECG abnormalities, arrhythmias, family and genetic factors. The management of ARVC is focused on prevention of lethal events such as SCD. Implantable cardioverter defibrillator placement is the only proven mortality benefit in treatment of ARVC. Other treatment strategies include medications such as beta blockers and antiarrhythmics, radiofrequency ablation, surgery, cardiac transplantation, and lifestyle changes. All these interventions help in symptomatic treatment but none of them have proved to decrease mortality rates. ARVC is a progressive disease that leads to SCD if not treated appropriately. Management of these diseases has been a challenge for physicians. With the advent of technology and many new drugs/devices under clinical investigation, this might change in the future. However, while advances in technologies have helped elucidate many aspects of these diseases, many mysteries still remain of this unique disease. With continued research, we can expect more cost-effective and patient-friendly drug therapies and ablation techniques to be developed in the near future.

Long QT Syndrome: A Comprehensive Review of the Literature and Current Evidence

Long QT syndrome (LQT) represents a heterogeneous family of cardiac electrophysiologic disorders characterized by QT prolongation and T-wave abnormalities on the electrocardiogram. It is commonly associated with syncope, however, sudden cardiac death can occur due to torsades de pointes. LQT is a clinical diagnosis and should be suspected in individuals on the basis of clinical presentation, family history and ECG characteristics. Management is focused on the prevention of syncope and ultimately sudden death. Complete cessation of symptoms is the goal. Life-style modification, beta blockers and ICD implantation are the most important therapeutic modalities in proper management of patients with LQT. Awareness should be raised regarding possible circumstances that could increase the risk of QT prolongation. Advanced age, hypokalemia, a history of heart failure, and structural heart disease are often mentioned in this context. Prudent consideration is needed before making a decision to recommend an ICD implantation in a young, active patient. Medical and/or device therapy still represent important therapeutic modalities in the management of patients with LQT with careful clinical judgement for the substrate of patients who will benefit. Insights from benchside to bedside have facilitated progress toward better therapeutic strategies, there also remains a need for tailoring management toward individuals in a mechanism-specific manner to optimize care. In addition, continued progress toward fundamental understanding of mechanisms of ion channel function and drug-channel interaction will guide the development of more effective, mechanism-based molecular agents in the treatment of LQT.

Topical vasodilator response in skeletonized internal mammary artery: Is there really a difference?

Aim of the Study:

Coronary artery bypass graft surgery is the gold standard for the treatment of multivessel and left main coronary artery disease. However, there is considerable debate that whether left internal mammary artery (IMA) should be taken as pedicled or skeletonized. This study was conducted to assess the difference in blood flow after the application of topical vasodilator in skeletonized and pedicled IMA.

Materials and Methods:

In this study, each patient underwent either skeletonized (n = 25) or pedicled IMA harvesting (n = 25). The type of graft on each individual patient was decided randomly. Intraoperative variables such as conduit length and blood flow were measured by the surgeon himself. The length of the grafted IMA was carefully determined in vivo, with the proximal and distal ends attached, from the first rib to IMA divergence. The IMA flow was measured on two separate occasions, before and after application of topical vasodilator. Known cases of subclavian artery stenosis and previous sternal radiation were excluded from the study.

Results:

The blood flow before the application of topical vasodilator was similar in both the groups (P = 0.227). However, the flow was significantly less in pedicled than skeletonized IMA after application of vasodilator (P < 0.0001). Similarly, the length of skeletonized graft was significantly higher than the length of pedicled graft (P < 0.0001).

Conclusion:

Our study signifies that skeletonization of IMA results in increased graft length and blood flow after the application of topical vasodilator. However, we recommend that long-term clinical trials should be conducted to fully determine long-term patency rates of skeletonized IMA.