Piper tectoniifolium Kunth: A New Natural Source of the Bioactive Neolignan (-)-Grandisin

The Piper species are a recognized botanical source of a broad structural diversity of lignans and its derivatives. For the first time, Piper tectoniifolium Kunth is presented as a promising natural source of the bioactive (−)-grandisin. Phytochemical analyses of extracts from its leaves, branches and inflorescences showed the presence of the target compound in large amounts, with leaf extracts found to contain up to 52.78% in its composition. A new HPLC-DAD-UV method was developed and validated to be selective for the identification of (−)-grandisin being sensitive, linear, precise, exact, robust and with a recovery above 90%. The absolute configuration of the molecule was determined by X-ray diffraction. Despite the identification of several enantiomers in plant extracts, the major isolated substance was characterized to be the (−)-grandisin enantiomer. In vascular reactivity tests, it was shown that the grandisin purified from botanical extracts presented an endothelium-dependent vasorelaxant effect with an IC₅₀ of 9.8 ± 1.22 μM and around 80% relaxation at 30 μM. These results suggest that P. tectoniifolium has the potential to serve as a renewable source of grandisin on a large scale and the potential to serve as template for development of new drugs for vascular diseases with emphasis on disorders related to endothelial disfunction.

In Vitro Phenotypic Activity and In Silico Analysis of Natural Products from Brazilian Biodiversity on Trypanosoma cruzi

Chagas disease (CD) affects more than 6 million people worldwide. The available treatment is far from ideal, creating a demand for new alternative therapies. Botanical diversity provides a wide range of novel potential therapeutic scaffolds. Presently, our aim was to evaluate the mammalian host toxicity and anti-Trypanosoma cruzi activity of botanic natural products including extracts, fractions and purified compounds obtained from Brazilian flora. In this study, 36 samples of extracts and fractions and eight pure compounds obtained from seven plant species were evaluated. The fraction dichloromethane from Aureliana fasciculata var. fasciculata (AFfPD) and the crude extract of Piper tectoniifolium (PTFrE) showed promising trypanosomicidal activity. AFfPD and PTFrE presented EC₅₀ values 10.7 ± 2.8 μg/mL and 12.85 ± 1.52 μg/mL against intracellular forms (Tulahuen strain), respectively. Additionally, both were active upon bloodstream trypomastigotes (Y strain), exhibiting EC₅₀ 2.2 ± 1.0 μg/mL and 38.8 ± 2.1 μg/mL for AFfPD and PTFrE, respectively. Importantly, AFfPD is about five-fold more potent than Benznidazole (Bz), the reference drug for CD, also reaching lower EC₉₀ value (7.92 ± 2.2 μg/mL) as compared to Bz (23.3 ± 0.6 μg/mL). Besides, anti-parasitic effect of eight purified botanic substances was also investigated. Aurelianolide A and B (compounds 1 and 2) from A. fasciculata and compound 8 from P. tuberculatum displayed the best trypanosomicidal effect. Compounds 1, 2 and 8 showed EC₅₀ of 4.6 ± 1.3 μM, 1.6 ± 0.4 μM and 8.1 ± 0.9 μM, respectively against intracellular forms. In addition, in silico analysis of these three biomolecules was performed to predict parameters of absorption, distribution, metabolism and excretion. The studied compounds presented similar ADMET profile as Bz, without presenting mutagenicity and hepatotoxicity aspects as predicted for Bz. Our findings indicate that these natural products have promising anti-T. cruzi effect and may represent new scaffolds for future lead optimization.

Medicinal Plants as Efficacious Agents for Diabetic Foot Ulcers: A Systematic Review of Clinical Studies

A diabetic foot ulcer (DFU) is a chronic, nonhealing wound that occurs in approximately 15% to 25% of patients with diabetes, and amputation is necessary in approximately 5% to 24% of these patients. Medicinal plants have demonstrated promising wound healing activities in animal models of DFUs as well as in clinical studies. These plants, which are described as medicinal in different regions of the world, are not considered to be standard medicinal treatments in Western medicine at this time. Some medicinal products, such as bromelain-an herbal protease currently used for enzymatic debridement of wounds-have been obtained from plants, showing the important role of these natural products as sources of wound healing agents. This paper aims to review clinical studies on the effects of medicinal plants in patients with DFUs based on the improvement of local and systemic parameters related to wound healing. Electronic databases including PubMed, Scopus, and Cochrane Library were searched for studies from inception through May 2019 using the keywords "diabetic foot ulcer" and "plant," "phytochemical," "extract," or "herb." Inclusion criteria were controlled or before-after clinical studies with English-language full-text in which topical or systemic herbal preparations for DFUs were evaluated by considering outcomes such as reduction of wound healing time and wound area, markers of inflammation and oxidative stress, and number of cases requiring amputation. Studies on non-herbal materials and human studies other than clinical trials were excluded. Fourteen studies were included in the present review. Herbal medicines were administered as add-on therapy to standard wound care in the form of topical (cream, gel, oil) or systemic (capsule, decoction, injection) preparations. Parameters such as ulcer width and depth, phagocytic function, tumor necrosis factor α level, epithelialization, vascularization, and wound closure were evaluated in clinical trials, several of which were significantly improved in patients compared with their baseline values or control group. Per the studies included in this review, medicinal plants can be recommended as promising adjuvant therapies to conventional wound care to accelerate wound healing in patients with DFUs.

Microvascular Effects of Echinodorus grandiflorus on Cardiovascular Disorders

Echinodorus grandiflorus is a semiaquatic plant native to Brazil and belongs to the Alismataceae family. Infusion preparations of the leaves of this plant are often used due to its diuretic, blood pressure lowering, and anti-inflammatory properties. Our aim was to investigate the effects of chronic treatment with the crude hydroalcoholic extract of E. grandiflorus on central and peripheral microvascular changes induced in a model of hypertension and diabetes. The hemodynamic and microvascular effects of E. grandiflorus extract (50, 100, or 200 mg/kg/day for 28 days) or the isolated major diterpene from E. grandiflorus (3 to 10 mg/kg i. v.) were evaluated in spontaneously hypertensive rats using tail plethysmography and intravital fluorescence videomicroscopy, respectively, and were compared to vehicle-treated normotensive Wistar-Kyoto rats. We also investigated the protective effects of chronic treatment with E. grandiflorus (100 mg/kg/day) in brain capillary density and leukocyte-endothelium interactions on the brain vessels of DM-spontaneously (DM: diabetes mellitus) hypertensive rats. Chronically treating spontaneously hypertensive rats with increasing doses of crude hydroalcoholic E. grandiflorus extract resulted in significant dose-dependent reductions in systolic blood pressure and an anti-inflammatory effect on the brain microcirculation of DM-spontaneously hypertensive rat animals. Using laser speckle contrast imaging, we observed that intravenous administration of the major isolated clerodane diterpene metabolite (1 - 10 mg/kg) increased microvascular blood flow by 25% in spontaneously hypertensive rat skeletal muscle. The results of this study show that E. grandiflorus extracts can be useful in the prevention and reduction of microcirculatory damage in arterial hypertension and other diseases that involve microvascular dysfunction.

Natural polyphenols for the prevention of irritable bowel syndrome: molecular mechanisms and targets; a comprehensive review

Irritable bowel syndrome (IBS) is a well diagnosed disease, thoroughly attributed to series of symptoms criteria that embrace a broad range of abdominal complainers. Such criteria help to diagnosis the disease and can guide controlled clinical trials to seek new therapeutic agents. Accordingly, a verity of mechanisms and pathophysiological conditions including inflammation, oxidative stress, lipid peroxidation and different life styles are involved in IBS. Predictably, diverse therapeutic approaches are available and prescribed by clinicians due to major manifestations (i.e., diarrhea-predominance, constipation-predominance, abdominal pain and visceral hypersensitivity), psychological disturbances, and patient preferences between herbal treatments versus pharmacological therapies, dietary or microbiological approaches. Herein, we gathered the latest scientific data between 1973 and 2019 from databases such as PubMed, Google Scholar, Scopus and Cochrane library on relevant studies concerning beneficial effects of herbal treatments for IBS, in particular polyphenols. This is concluded that polyphenols might be applicable for preventing IBS and improving the IBS symptoms, mainly through suppressing the inflammatory signaling pathways, which nowadays are known as novel platform for the IBS management. Graphical abstract.

A systematic review of nano formulation of natural products for the treatment of inflammatory bowel disease: drug delivery and pharmacological targets

Inflammatory bowel diseases (IBD), which is classified into Crohn's disease and ulcerative colitis, are among chronic gastrointestinal diseases with unknown pathogenesis. Diverse strategies have been applied for the treatment of this chronic disease. However, selective and site-specific routes of drug delivery to the inflamed location of the colon remain of high importance. Consequently, the application and effects of natural products in the form of nanoformulation and stimuli responsive nanoparticles as a novel strategy for the treatment of IBD are discussed in this review article. This approach may potentially overcome some complications that are associated with conventional means of colon drug delivery. Meanwhile, in vitro and in vivo studies pave the way for understanding of the mechanism that lies behind this chronic relapsing disease and potentially more effective treatment. Graphical abstract ᅟ.

Correction to: A systematic review of nano formulation of natural products for the treatment of inflammatory bowel disease: drug delivery and pharmacological targets

The corresponding author, Mohammad Hosein Farzaei, affiliation is Pharmaceutical Sciences Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran. The correct spelling of the 7th author surname is Iranpanah.

Aloysia citrodora Paláu (Lemon verbena): A review of phytochemistry and pharmacology

ETHNOPHARMACOLOGICAL RELEVANCE

Aloysia citrodora Paláu (Lippia citriodora Kunth), commonly known as "lemon verbena" is a medicinal plant native to South America, North Africa, and South of Europe which is used by native people for several indications such as diarrhea, flatulence, insomnia, and rheumatism.

AIM OF THE REVIEW

Despite the wide biological activities of lemon verbena, there is no current review summarizing medicinal properties of the plant; thus, this paper aims to discuss current state of the art regarding the phytochemistry, pharmacology, and therapeutic applications of A. citrodora considering in vitro, in vivo, and clinical studies.

MATERIALS AND METHODS

Electronic databases including PubMed, Scifinder, Cochrane library, Scopus, and Science direct were searched with the scientific name of the plant and its synonyms, as well as the common name. All studies on the ethnobotany, phytochemistry, pharmacology, and clinical application of the plant until October 2017 were included in this review.

RESULTS

Despite the few number of studies on the ethnopharmacology of the plant, A. citrodora is widely assessed regarding its phytochemistry and biological activities. Neral and geranial are the main ingredients of the essential oil; whereas verbascoside is the most significant component of the extract. Biological activities such as antioxidant, anxiolytic, neuroprotective, anticancer, anesthetic, antimicrobial, and sedative effects are proved in cell cultures, as well as animal studies.

CONCLUSIONS

Several pharmacological activities have been reported for A. citrodora; however, the plant is not fully assessed regarding its safety and efficacy in human. Future well-designed human studies are essential to confirm the therapeutic benefits of this plant in clinical settings.

Topological bound states in interacting Su-Schrieffer-Heeger rings

We study two-particle states in a Su-Schrieffer-Heeger (SSH) chain with periodic boundary conditions and nearest-neighbor (NN) interactions. The system is mapped into a problem of a single particle in a two-dimensional (2D) SSH lattice with potential walls along specific edges. The 2D SSH model has a trivial Chern number but a non-trivial Zak's phase, the one-dimensional (1D) topological invariant, along specific directions of the lattice, which allow for the presence of topological edge states. Using center-of-mass and relative coordinates, we calculate the energy spectrum of these two-body states for strong interactions and find that, aside from the expected appearance of doublon bands, two extra in-gap bands are present. These are identified as bands of topological states localized at the edges of the internal coordinate, the relative distance between the two particles. As such, the topological states reported here are intrinsically many-body in what concerns their real space manifestation, having no counterpart in single-particle states derived from effective models. Finally, we compare the effect of Hubbard interactions with that of NN interactions to show how the presence of the topological bound states is specific to the latter case.

Local Anesthetic Activity from Extracts, Fractions and Pure Compounds from the Roots of Ottonia anisum Spreng. (Piperaceae)

Piperaceae species can be found worldwide in tropical and subtropical areas and many of them have been used for centuries in traditional folk medicine and in culinary. In Brazil, species of Piperaceae are commonly used in some communities as local anesthetic and analgesic. Countrified communities have known some species of the genus Ottonia as "anestesia" and it is a common habit of chewing leaves and roots of Ottonia species to relief toothache. The purpose of this study is to report our findings on new molecules entities obtained from the roots of Ottonia anisum Spreng, in which local anesthetic activity (sensory blockage) is demonstrated for the first time in vivo guinea pig model. Phytochemical investigation led to the isolation of three amides (pipercallosidine, piperine and valeramide) and in an enriched mixture of seven amides (valeramide, 4,5-dihydropiperlonguminine, N-isobutil-6-piperonil-2-hexenamide, piperovatine, dihydropipercallosidine, pipercallosidine and pipercallpsine). Our findings demonstrated the anesthetic potential for the methanolic extract from roots, its n-hexane partition and amides from O. anisum and it is in agreement with ethnobotanical survey.

HSCCC separation and enantiomeric distribution of key volatile constituents of Piper claussenianum (Miq.) C. DC. (Piperaceae)

High Speed Countercurrent Chromatography (HSCCC) technique was used for the preparative isolation of the major leishmanicidal compounds from the essential oils of Piper claussenianum species in Brazil. The essential oils from inflorescences of P. claussenianum were analyzed by GC-FID and GC-MS. The enantiomeric ratio of the major constituents of the P. claussenianum essential oils were determined using a Rt-DEXsm chiral capillary column by GC-FID analysis. It was found an enantiomeric excess of (+)-(E)-nerolidol in the leaves, and (+)-linalool and (+)-(E)-nerolidol in the inflorescences essential oil. The major volatile terpenes alcohols were isolated in preparative scale from inflorescences: linalool (320.0 mg) and nerolidol (95.0 mg) in high purity level. The HSCCC, a support-free liquid-liquid partition chromatographic technique, proved to be an effective and useful method for fast isolation and purification of hydrophobic and similarly structured bioactive components from essential oils of Piper species.

Echinodorus grandiflorus: Ethnobotanical, phytochemical and pharmacological overview of a medicinal plant used in Brazil

Echinodorus grandiflorus (Cham. & Schltdl.) Micheli is a native Brazilian species used in traditional practices for the treatment of several conditions such as inflammatory diseases, arthritis and hypertension. Through a systematic review of the accumulated knowledge about the species E. grandiflorus, the botanical, phytochemistry, ethnobotanical and pharmacological properties of this medicinal plant demonstrates its potential to naturally provide anti-inflammatory and anti-oxidant with a special emphasis on anti-hypertensive and cardioprotective effects. The body of literature reports that the chemical composition of crude E. grandiflorus extracts are notably composed of diterpenoids and flavonoids metabolites. Pharmacological studies have shown that oral treatments using the hydroalcoholic extracts of leaves from this plant has a significant anti-inflammatory, anti-hypertensive, diuretic and cardioprotective effects in rats with no toxicity. The holistic activities of complex extracts are corroborated by the individuals mechanisms of action, as well as, synergistic benefits attributed to the isolated chemical major constituents in this species. In light of the serious health concerns ascribed, it is important to investigate medicinal plant species with histories of traditional use for circulatory problems to meet the growing demands by scientifically validating their use and safety.

Larvicidal activity of Ottonia anisum metabolites against Aedes aegypti: A potential natural alternative source for mosquito vector control in Brazil

BACKGROUND & OBJECTIVES

Aedes aegypti mosquito is the principal vector of the viruses responsible for urban yellow fever, dengue, dengue haemorrhagic fever, as well as Zika and chikungunya in Brazil. The present study was aimed to investigate the insecticidal potential of the extract and fractions of Ottonia anisum, along with special metabolites isolated from it, as natural alternatives against larvae (L3) of Ae. aegypti, vector of potentially deadly tropical infections in Brazil.

METHODS

The plant species O. anisum was collected in March 2015, at Xerιm area, in Rio de Janeiro City, Brazil. Crude extracts and the isolated pure compounds were screened for toxicity against Ae. aegypti larvae (L3). Bioassays were performed on 20 larvae (L3) of Ae. aegypti in triplicate. The samples were dissolved in a mixture of acetone and DMSO at final concentrations of 1-200 μg/ml. The toxicity of the solutions was evaluated towards the growth and development of Ae. aegypti larvae till emergence of adults.

RESULTS

The crude hexane extract showed 100% larval mortality 24 h after treatment at a concentration of 200 μg/ml. The bioassays using 1-butyl-3,4-methylenedioxybenzene revealed 100% mortality among L3 larvae, 24 h afterthe treatment at a concentration of 30 μg/ml, the LC recorded was 1.6 μg/ml. At concentration of 10 μg/ml, the L3 larval mortality recorded was 92%.

INTERPRETATION & CONCLUSION

The metabolite 1-butyl-3,4-methylenedioxybenzene showed potent toxicity against Ae. aegypti larvae. This arylbutanoid agent could be used as a natural alternative adjuvant pesticide, in new compositions that would be environmentally safer.

Hypoglycemic Effect of the Methanol flower Extract of Piper Claussenianum and the Major Constituent 2',6'-dihydroxy-4'-methoxychalcone in Streptozotocin Diabetic Rats

Piper claussenianum inflorescences crude methanol extract was tested for hypoglycemic effect in streptozotocin-induced diabetic rats. The blood glucose levels of rats treated with methanol extract were reduced from 318.4±28.1 mg/dl before treatment to 174.2±38.3 mg/dl after 12 days of treatment (P<0.05). Phytochemical studies were carried out on inflorescences methanol crude extract in order to investigate the possible metabolites responsible for the pharmacological properties of the extract. After chromatographic procedures, three flavonoids were isolated and characterized. The major compound 2’,6’-dihydroxy-4’-methoxychalcone was also tested. Rats that received the chalcone content also displayed a reduction in blood glucose levels from 277.4±7.7 mg/dl before treatment to 158.8±9.2 mg/dl after 12 days of treatment (P<0.05). The results suggest this chalcone is one of the metabolite responsible for the blood glucose levels reduction in rats with streptozotocin-induced diabetes. The inflorescence crude extract of P. claussenianum was found to be composed mainly by flavonoids and may be a potential natural source of compounds with hypoglycemic properties.

A novel nerolidol-rich essential oil from Piper claussenianum modulates Candida albicans biofilm

Candidiasis is a major opportunistic fungal infection in humans, and its incidence has increased steadily over the last two decades. Candida albicans, the main species of the genus, has a large arsenal of virulence attributes that contribute to successful infections, such as dimorphism and biofilm formation. The adverse effects of eukaryotic antimicrobial therapies associated with an increase in resistance to the compounds presently available have boosted efforts to improve the therapeutic arsenal against candidiasis with a newer and cheaper range of drugs. In this study, a novel nerolidol-rich essential oil (EO) derived from Piper claussenianum (Miq.) C. DC., Piperaceae, was tested on the growth, transition (yeast to hyphae), formation and stability of biofilms produced by C. albicans. Both inflorescence and leaf EOs were evaluated and revealed MIC values ranging from 0.04 to 0.1 % and 0.2 to 1.26 %, respectively. Furthermore, leaf EO managed to downregulate the yeast-to-hyphae transition by 81 %, as well as reducing biofilm formation by about 30 and 50 % after incubation for 24 and 48 h, respectively. The EO was also able to reduce the viability of pre-formed biofilm by 63.9 %. Finally, the association between the leaf EO and fluconazole was evaluated and revealed an interesting synergistic effect. Taken together, these results demonstrate that this novel compound could be a promising agent and could reinforce the arsenal of therapeutic alternatives for the treatment of candidiasis. Furthermore, it may represent a novel and natural source of nerolidol, which could be of interest pharmaceutically.

3-Ishwarone, a rare ishwarane sesquiterpene from Peperomia scandens Ruiz & Pavon: structural elucidation through a joint experimental and theoretical study

3-Ishwarone, (1), a sesquiterpene with a rare ishwarane skeleton, was isolated from Peperomia scandens Ruiz & Pavon (Piperaceae). Its structure was unambiguously determined by 1D- and 2D-NMR and infrared analyses, as well as by comparative theoretical studies which involved calculations of 13C-NMR chemical shifts, using the Density Functional Theory (DFT) with the mPW1PW91 hybrid functional and Pople's 6-31G(d) basis set, and of vibrational frequencies, using the B3LYP hybrid functional and triple ζ Dunning's correlation consistent basis set (cc-pVTZ), of (1) and three of its possible diastereomers, compounds 2-4.

Aristolactams from roots of Ottonia anisum (Piperaceae)

The Piperaceae species are known worldwide for its medicinal properties and its chemical compounds. In Brazil, many species of this family are distributed mainly in Amazon Region and in the Atlantic Forest. The genus Ottonia is known as source of amides, flavonoids, arilpropanoids and terpenes with record biological activities. Six aristolactams, including, aristolactam BII, piperolactam C, goniothalactam, stigmalactam, aristolactam AII and aristolactam BIII were isolated from roots of this species. GC-MS, 1H NMR and NOESY techniques were used to characterize these compounds. This is the first report about the occurrence of aristolactams in the Ottonia anisum Sprengel.

Aristolactams from roots of Ottonia Anisum (Piperaceae)

The Piperaceae species are known worldwide for its medicinal properties and its chemical compounds. In Brazil, many species of this family are distributed mainly in Amazon Region and in the Atlantic Forest. The genus Ottonia is known as source of amides, flavonoids, arylpropanoids and terpenes with record biological activities. Six aristolactams, including, aristolactam BII, piperolactam C, goniothalactam, stigmalactam, aristolactam AII and aristolactam BIII were isolated from roots of this species. GC-MS, 1H NMR and NOESY techniques were used to characterize these compounds. This is the first report about the occurrence of aristolactams in the Ottonia anisum Sprengel.

Chemistry and biological activity of essential oils from Piper claussenianum (Piperaceae)

Analyses of essential oils obtained from fresh and dried leaves and inflorescences of Piper clausenianum were performed using GC-FID, GC-MS and NMR techniques. Forty compounds were detected for these four oils with the total of identified constituents ranging from 88.7% for the dried inflorescences to 97.7% for the dried leaves. Sesquiterpenes were the main constituents in the volatile fraction from leaves with a high percentage of (E)-nerolidol (up to 83%). However, monoterpenes were identified in greater amount in the inflorescences, with linalool percentages from 50% up. The essential oils from fresh leaves and inflorescences were submitted to anti-parasitic activity against a strain of Leishmania amazonensis. Both samples showed biological activity, but the essential oil from P. claussenianum fresh leaves, which was rich in (E)-nerolidol, showed effective growth inhibition of L. amazonensis due to the high percentage of this metabolite in the mixture.

Chemistry and Biological Activity of Essential Oils from Piper Claussenianum (Piperaceae)

Analyses of essential oils obtained from fresh and dried leaves and inflorescences of Piper clausenianum were performed using GC-FID, GC-MS and NMR techniques. Forty compounds were detected for these four oils with the total of identified constituents ranging from 88.7% for the dried inflorescences to 97.7% for the dried leaves. Sesquiterpenes were the main constituents in the volatile fraction from leaves with a high percentage of ( E)-nerolidol (up to 83%). However, monoterpenes were identified in greater amount in the inflorescences, with linalool percentages from 50% up. The essential oils from fresh leaves and inflorescences were submitted to anti-parasitic activity against a strain of Leishmania amazonensis. Both samples showed biological activity, but the essential oil from P. claussenianum fresh leaves, which was rich in ( E)-nerolidol, showed effective growth inhibition of L. amazonensis due to the high percentage of this metabolite in the mixture.

Personal computer software evaluation in interactive generation of pig liver three-dimensional anatomical images

The efficiency of software for a personal computer in the interactive generation of three-dimensional (3D) images from computer tomography was studied in six pig livers after hepatic resection and catheterization of the hepatic and portal veins. After perfusion the livers were submitted to computed tomography angiography, volumetric measurement by water displacement, and production of an acrylic model of the veins by the injection and corrosion method, by which the lengths of the hepatic and portal veins were measured. From the angiogram, the software generated a 3D image that allowed measurement of the vein lengths. The identified branches of the hepatic and portal veins were correlated with the hepatic sectors and segments, respectively. The virtual measures from the 3D images were compared with the real measures. There were no significant differences between the topography and the vessel length. The mean difference between the volumes calculated from software and those measured by water displacement corresponded to 1.2%, and between the vessel lengths, 0.2%. In conclusion, the software for personal computer (named LIVER3D) is efficient, allowing interactive inspection of 3D images. All virtual measurements of liver vessel length and partial/total liver volume were similar to the actual ones.

[Adjuvant therapy with a glycoprotein IIb-IIa inhibitor (abciximab) in coronary angioplasties with a high thrombotic risk]

INTRODUCTION

We retrospectively studied our experience with adjunctive therapy with glycoprotein IIb-IIIa inhibitor (abciximab) on patients with a high risk of thrombotic complications during coronary angioplasty (PTCA).

PATIENTS AND METHODS

From September 1996 to November 1997, we performed PTCA in 210 patients, and abciximab was given to 38 (18%) of them. The interventions were urgent (primary PTCA in acute myocardial infarction) in 55% of the cases. The mean age of patients was 68.6 +/- 12 years and 71% were male. The reasons for coronary intervention were: acute myocardial infarction in 21 patients (55.3%), unstable angina in 9 (23.7%) and stable angina in 8 (21%). Coronary stents were implanted in 13 patients (34%) and an intra aortic balloon pump was used in 4 (11%). The reasons for using abciximab were: thrombus containing lesion: 22 (57.9%); other type B2/C lesion characteristics: 6 (15.9%); acute closure post balloon PTCA: 9 (23.7%), sub-acute stent thrombosis: 1 (2.6%). Oral acetilsalicilic acid and intravenous heparin were given to all patients at the beginning of the intervention. The mean APTT was 124 +/- 32 seconds at the end of the procedure.

RESULTS

The arterial sheaths (8 French) were removed six hours after procedure, according to the normalisation of APTT values. Angiographic success in this group of patients was 100%. One patient died during hospitalisation due to left ventricular failure. There was no need for repeated angioplasty or coronary bypass grafting during hospital stay. The main complications related to the use of abciximab were: bleeding (requiring transfusion) in four patients 10.5%); severe thrombocytopenia (< 50,000 platelets/mm3): 1 (2.6%): cardiac tamponade (requiring pericardiocentesis): 1 (2.6%) and pseudo-aneurysm of femoral artery (requiring vascular surgery): 1 (2.6%).

CONCLUSIONS

The use of abciximab as adjunctive therapy in this small group of patients undergoing coronary interventions with high risk of thrombotic complications is associated with high procedural success, but at the expense of high rates of bleeding complications. Therefore, special care must be applied during and after the procedure to enhance the safety of the patients treated with this drug.

[Traumatic aortic valve insufficiency]

The traumatic aortic valvular insufficiency (TAVI), through less frequent after a non-penetrating thoracic traumatism, is a serious entity with a very reserved prognosis. So it must be suspected in every patients with signs or symptoms of de novo heart failure post-traumatism. The transthoracic echocardiography and eventually transesophageal echocardiography have a fundamental role in the confirmation of the diagnosis. The clinical picture of traumatic aortic regurgitation is quickly evolutionary and the non efficacy of medical therapy has placed the valvular substitution surgery as the best succeeded treatment. With the advent of the aortic valve repairing surgery some TAVI cases has been submitted to this procedure. Nevertheless, the development of residual aortic regurgitation in these situations, usually requiring later valvular replacement surgery, make the aortic valvuloplasty a controversial surgical technique. The AA describe a recent clinical case of aortic regurgitation after a non-penetrant thoracic traumatism, discussing the aspects connected with physiopathology, diagnosis and therapy. The singularity of this case was based on the fact that the initial clinical diagnosis had been prejudiced by the context of a polytraumatism and there had been a time free of symptoms between the traumatism and the beginning of the symptomatology of left ventricular failure. Even though the identification of the problem allowed an intensive treatment of this serious situation that ended with the replacement of the aortic valve by mechanical aortic prosthesis, with the patient's total recovery.

[Pacemaker implantation in a patient with persistent left superior vena cava and atresia of the right superior vena cava]

Persistent left superior vena cava with absence or atresia of right superior vena cava is a congenital abnormality of systemic venous return to the heart which may complicate the insertion of a pacemaker electrode. We present a case report of a patient with conduction system disturbances in whom this abnormality was diagnosed during pacemaker implantation, with the possibility of using a transvenous electrode without active fixation system.

[Primary tricuspid valve insufficiency. Report of 2 clinical cases]

Two case reports of primary tricuspid regurgitation are presented which diagnoses were made in mean adult life after a long period of few symptoms. The clinical outcome of the two cases was uneven in the sense that only one of them could be corrected with single surgical procedures. Despite relatively rare, this pathology could probably be turned more frequent with a complete and systematic echocardiographic approach. In connection with the reported cases, a review is made of the main etiologies and of some published reports.

[Main left coronary artery disease. Aspects of its diagnosis and treatment]

The Left Main Disease (LMD) assumes a special particularity within the coronary pathology, because of its seriousness and of its urgent need of surgical treatment. The lesion is associated mainly with clinical situations of unstable angina, and who's diagnose by non-invasive methods is extremely difficult; among these methods the echocardiography and specially the stress test still remain of most value in this diagnosis. Coronary arteriography remains the standard exam and is indispensable for a positive confirmation of diagnosis. However, the risk involved here is significantly higher than in other coronary pathologies especially if the lesion of LMD is localized in the proximal region or is ostium level. Therefore, in this review, the need of special care is emphasized before, during and after catheterization, in patients with sunpect of LMD or in those in which the diagnosis was placed during the angiographic examination. Finally, it is very important to recognize the most dangerous situations in order to rightly identify those who need urgent surgical treatment.

[Myocardial infarct in a young man with normal coronary vessels: apropos of a clinical case treated with streptokinase]

The authors report a case of a 31 year old young man who suffered acute myocardial infarction and was subjected to early treatment with streptokinase. The immediate follow-up showed a complete recanalization of the infarct-related vessel, without any identifiable obstructive lesion on coronary arteriography. Related to this angiographic finding, common in myocardial infarction in the young adult, the authors debate the implicated mechanisms, focusing essentially in the relation endothelium-platelets-vasomotricity. The issue of cigarette smoking as a risk factor and its possible pathogenic implication, even in the absence of atherosclerotic plaque, is also approached.