A phase II of gemcitabine combined with pazopanib followed by pazopanib maintenance, as second-line treatment in patients with advanced leiomyosarcomas: A unicancer French Sarcoma Group study (LMS03 study)

BACKGROUND

Options in second-line therapy after doxorubicin-based chemotherapy for metastatic/advanced leiomyosarcoma include gemcitabine (G), trabectedin and pazopanib (P) monotherapy. Currently, no combination therapy is better than monotherapy. LMS03 is an open-label multicentre single-group phase II study designed to assess the efficacy and tolerance of G + P in the second-line setting.

PATIENTS AND METHODS

Patients (pts), ECOG ≤2, with metastatic leiomyosarcomas (LMS) after first-line doxorubicin chemotherapy failure were eligible. Pts were treated with G 1000 mg/m² on days 1 and 8 of each 21 days (maximum eight cycles), in combination with oral daily P (800 mg), until disease progression/toxicity. 9-month progression-free survival (PFS) rate was the primary endpoint. Inacceptable and promising 9-month PFS rates were defined, in the intent-to-treat population, as 32% and 44%.

RESULTS

106 pts were included with a mean age of 59.8 years and an ECOG 0 in 63.5%; the primary tumour site was uterus in 61%. Pts were treated with P + G for a median of 3.8 mo, and P for a median of 4.2 mo. The 9-month PFS rate was 32.1% (95% CI 23.1-41.1). After a median follow-up of 14.2 months, the PFS was 6.5 months (95% CI 5.6-8.2), and the overall survival was 22.4 months (95% CI 16.9-26.5). The best response was 23.8%. The most frequent reported grade 3-4 adverse events were haematological.

CONCLUSIONS

LMS03 failed to show that second-line therapy, with gemcitabine combined with pazopanib, followed by pazopanib alone, was beneficial for advanced LMS patients. Eudract N°2011-001308-36 and NCT01442662.

Thiopurine S-methyltransferase gene polymorphism is predictive of azathioprine-induced myelosuppression in heart transplant recipients

Azathioprine (AZA) is metabolized via the cytosolic enzyme thiopurine S-methyltransferase (TPMT). TPMT activity exhibits genetic polymorphism with four prevalent (75%) mutant alleles TPMT*2 (G238C) and TPMT*3 (A719G and/or G460A) and a wild-type allele TPMT*1. To test the hypothesis that presence of these mutations is associated with greater toxicity of AZA in heart transplant recipients, 30 consecutive patients treated with AZA were followed up for the first month after heart transplant. Mutation of TPMT gene (mutation-specific polymerase chain reaction-based methods) was observed in four patients (A719G: n = 2; A719G plus G460: n = 2). Agranulocytosis did not occur in patients with the wild genotype. It occurred in the two patients with mutation A719G and there was a 40% drop in neutrophils in the two other patients. Discontinuation of AZA in the four mutant patients corrected for the drop. Presence of TPMT mutations is associated with a greater likelihood of agranulocytosis. Determination of these mutations could reduce the risk for hematological side-effects.

A critical appraisal of the quality of the management of infective endocarditis

OBJECTIVES

The purpose of this study was to assess the quality of the management of infective endocarditis.

BACKGROUND

Although many guidelines on the management of infective endocarditis exist, the quality of this management has not been evaluated.

METHODS

We collected data on all patients (116) hospitalized with infective endocarditis over 1 year in all hospitals in the Rhône-Alpes region (France).

RESULTS

Prophylactic antibiotics were not given before infective endocarditis to 8/11 cardiac patients at risk and who underwent an at risk procedure. Among the 55 cardiac patients at risk and with fever and who consulted a physician, blood cultures were not performed before antibiotic therapy was initiated for 32 patients. In-hospital antibiotic therapy was incorrect for 23 patients. The portal of entry was not treated for 16/61 patients with an accessible portal of entry. Among the 19 patients who had severe heart failure or fever persisting more than 2 weeks in spite of antibiotic therapy and who could have undergone early surgery, surgery was delayed for five, and not performed for three. Overall, the average score was 15/20.

CONCLUSIONS

More information on the management of infective endocarditis should be widely disseminated to the physicians' and the dentists' communities and to the patients at risk.

Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study

BACKGROUND

The Lyon Diet Heart Study is a randomized secondary prevention trial aimed at testing whether a Mediterranean-type diet may reduce the rate of recurrence after a first myocardial infarction. An intermediate analysis showed a striking protective effect after 27 months of follow-up. This report presents results of an extended follow-up (with a mean of 46 months per patient) and deals with the relationships of dietary patterns and traditional risk factors with recurrence.

METHODS AND RESULTS

Three composite outcomes (COs) combining either cardiac death and nonfatal myocardial infarction (CO 1), or the preceding plus major secondary end points (unstable angina, stroke, heart failure, pulmonary or peripheral embolism) (CO 2), or the preceding plus minor events requiring hospital admission (CO 3) were studied. In the Mediterranean diet group, CO 1 was reduced (14 events versus 44 in the prudent Western-type diet group, P=0.0001), as were CO 2 (27 events versus 90, P=0.0001) and CO 3 (95 events versus 180, P=0. 0002). Adjusted risk ratios ranged from 0.28 to 0.53. Among the traditional risk factors, total cholesterol (1 mmol/L being associated with an increased risk of 18% to 28%), systolic blood pressure (1 mm Hg being associated with an increased risk of 1% to 2%), leukocyte count (adjusted risk ratios ranging from 1.64 to 2.86 with count >9x10(9)/L), female sex (adjusted risk ratios, 0.27 to 0. 46), and aspirin use (adjusted risk ratios, 0.59 to 0.82) were each significantly and independently associated with recurrence.

CONCLUSIONS

The protective effect of the Mediterranean dietary pattern was maintained up to 4 years after the first infarction, confirming previous intermediate analyses. Major traditional risk factors, such as high blood cholesterol and blood pressure, were shown to be independent and joint predictors of recurrence, indicating that the Mediterranean dietary pattern did not alter, at least qualitatively, the usual relationships between major risk factors and recurrence. Thus, a comprehensive strategy to decrease cardiovascular morbidity and mortality should include primarily a cardioprotective diet. It should be associated with other (pharmacological?) means aimed at reducing modifiable risk factors. Further trials combining the 2 approaches are warranted.

Liver transplantation resolves the hyperdynamic circulation in hereditary hemorrhagic telangiectasia with hepatic involvement

BACKGROUND & AIMS

Hepatic involvement in hereditary hemorrhagic telangiectasia is common but often asymptomatic. However, in some cases, the vascular lesions that involve the liver may lead to high-output cardiac failure and pulmonary hypertension that is predominant over hepatobiliary manifestations. Liver transplantation and treatment of these complications are described and discussed in this article.

METHODS

Three patients with hereditary hemorrhagic telangiectasia and hepatic involvement received transplants. They had pulmonary hypertension and chronic right-sided heart failure caused by disseminated intrahepatic telangiectasias with shunts between the hepatic artery and hepatic veins or portal vein. Left-to-right intrahepatic shunt output was estimated to range between 51% and 57.5% of cardiac output.

RESULTS

Hyperdynamic circulation disappeared after liver transplantation in all patients. Results of computed tomography and right-sided heart catheterization performed 6 months later were normal. Follow-up periods currently are 65, 53, and 29 months, and each patient continues to be asymptomatic.

CONCLUSIONS

This report suggests that liver transplantation can be considered as an alternative and successful curative treatment that may prevent the irreversible evolution of cardiopulmonary disease.

Effect of dietary cholesterol on low density lipoprotein-receptor, 3-hydroxy-3-methylglutaryl-CoA reductase, and low density lipoprotein receptor-related protein mRNA expression in healthy humans

We investigated the possibility that dietary cholesterol downregulates the expression of low density lipoprotein (LDL) receptor and 3-hydroxy-3-methylglutaryl (HMG)-CoA reductase genes of circulating mononuclear cells in vivo in healthy humans. We also studied the variations of the LDL receptor-related protein (LRP) gene in the same conditions. Dieters (n = 5) were submitted to a 4-d fat restriction (mean cholesterol intake: 6+/-4 mg/d), followed by a 7-d cholesterol (a mean of 791+/-150 mg/d) supplementation. Controls (n = 3) did not change their diet. During fat restriction, serum total and LDL cholesterol decreased significantly (P < 0.05), and LDL receptor and HMG-CoA reductase mRNA copy numbers in mononuclear cells increased by 57 and 147%, respectively (P < 0.05). After reintroducing cholesterol, serum cholesterol was stable whereas LDL receptor and HMG-CoA reductase mRNA decreased by 46 and 72% (P < 0.05) and LRP mRNA increased by 59% (P < 0.005). The changes in LDL receptor and HMG-CoA reductase mRNA abundance were correlated (r = +0.79, P = 0.02) during cholesterol reintroduction as were LDL receptor and LRP mRNA levels, but negatively (r = -0.70, P = 0.05). Also, 70% of the variability in LRP mRNA (P < 0.005) was explained by dietary cholesterol. Thus, the basic mechanisms regulating cellular cholesterol content, the coordinate feedback repression of genes governing the synthesis and uptake of cholesterol, are operating in vivo in humans. However, serum cholesterol did not increase in response to dietary cholesterol, suggesting that these mechanisms may not play as predominant a role as previously believed in the short-term control of serum cholesterol in vivo in humans. A new finding is that LRP gene is also sensitive to dietary cholesterol, suggesting that it may participate in the control of serum cholesterol. Further in vivo studies in humans are warranted to explore the molecular mechanisms of the physiological response to dietary cholesterol in humans.

Improved myocardial tolerance to ischaemia in the diabetic rabbit

Because cardiac complications after myocardial infarction are more frequent in diabetics, we tested whether experimentally-induced diabetes may increase ischaemic myocardial injury in 23 rabbits. Diabetes was induced in randomized rabbits with the alloxan method. After 2 months, diabetic rabbits underwent a 30-min coronary occlusion followed by 3-h reperfusion and were compared with controls. Collateral flow was measured by the radioactive microsphere technique and infarct size by tetrazolium staining. Infarct size represented 28.6+/-4% of area-at-risk in controls and 16.5+/-3% in diabetics (P<0.05). Collateral flow (0.06+/-0.03 ml/min/g in controls and 0.014+/-0.004 ml/min/g in diabetics) and area-at-risk (50.2+/-4.2% of left ventricle in controls and 53.9+/-5. 4% in diabetics) were similar in both groups. There was a significant positive correlation between area-at-risk and infarct size in both groups (r=0.60 and 0.70, respectively) and for a given area-at-risk, diabetic rabbits developed smaller myocardial infarction than controls (covariance analysis, P<0.01). In additional experiments, hyperglycemia induced by intravenous glucose infusion in non-diabetic rabbits did not protect the ischaemic myocardium (infarct size: 37.9+/-12.5%). In conclusion, diabetes in the rabbit induces a chronic and metabolic form of preconditioning. Further studies are needed to explore the mechanism and time course of this protection.

Effect of chronic severe diabetes on myocardial stunning in the dog

In this study, we examined whether chronic severe diabetes may affect ischaemic and post-ischaemic regional myocardial dysfunction in vivo in the dog. Diabetes was chemically induced in randomized animals and major metabolic alterations were observed confirming the severity and chronicity of the diabetes. After 70 days, halothane-anaesthetized dogs underwent a 20-min coronary occlusion, followed by reperfusion. During ischaemia, global left ventricle function (dP/dtmax) was more altered (P<0.005) in diabetics ( n=10) than in controls (n=10), whereas area-at-risk (29+/-2.5% of the left ventricle in diabetics v 32.4+/-1.9% in controls) and ischaemic subendocardial myocardial blood flow (radioactive microsphere technique, 0.11+/-0.02 v 0.10+/-0.03 ml/min/g) were similar. During reperfusion, both groups developed significant (P<0.05) regional myocardial dysfunction (somomicrometry, 41+/-14% of baseline in controls and 66+/-8% in diabetics), whereas the difference between groups was not significant. No dog of either group developed myocardial cell necrosis on tissue histology. Multivariate analyses, including the severity of prior ischaemia and the occurrence of ventricular fibrillation as covariables, confirmed that myocardial stunning was not increased in diabetics, although ischaemia was clearly less-well-tolerated in diabetic dogs as global (dP/dtmax) as well as regional myocardial function were significantly (P<0.05) more altered in diabetics during ischaemia. Whilst alteration of arachidonate and cholesterol metabolism may partly explain this apparent paradox, further studies are required to resolve this issue.

Ticlopidine increases nitric oxide generation in heart-transplant recipients: a possible novel property of ticlopidine

The objective of this study was to evaluate the effects of ticlopidine on the generation of eicosanoids and nitric oxide in heart-transplant recipients. In a randomized double-blind study, we studied the urinary excretion of the stable metabolites of thromboxane, prostacyclin, and nitric oxide before and after ticlopidine (250 mg/day). Platelet aggregation was significantly reduced in ticlopidine-treated patients [from 40.2 +/- 24.2% of maximal aggregation to 14.7 +/- 8.2% in response to adenosine diphosphate (ADP); p < 0.001] but not in the placebo group, confirming the efficacy of the drug with that dosage in these specific patients. The 24-h urinary excretion of prostacyclin metabolites was not modified by ticlopidine (1,865 +/- 833 ng/24 h at day 14 and 1,664 +/- 425 ng/24 h at day 0), whereas the excretion of thromboxane B2 tended to increase in the ticlopidine group (from 3,854 +/- 1,163 ng/24 h at day 0 to 5,014 +/- 2,914 ng/24 h at day 14), although not significantly. The excretion of nitric oxide metabolites (although not different from that of healthy nonimmunosuppressed subjects) was significantly (p < 0.005) increased in the ticlopidine group (from 3,082 +/- 1,683 micromol/24 h at day 0 to 4,133 +/- 2,262 micromol/24 h at day 14), but not in controls. Thus ticlopidine does not reduce prostacyclin but increases the systemic generation of nitric oxide, both substances having major antiplatelet and vasodilator properties. Further studies are warranted to examine whether ticlopidine could reduce the incidence of thromboembolic complications in these patients and whether this possible novel property of ticlopidine is restricted to immunosuppressed heart-transplant recipients.

[Treatment with angiotension converting enzyme inhibitors]

Eight randomised clinical trials of angiotensin converting enzyme (ACE) inhibitors versus placebo in myocardial infarction have been published in three years, including over 100,000 patients. High risk myocardial infarction carries a poor prognosis with a 25% death rate at 42 months in SAVE, 23% at 15 months in AIRE and 42% at 37 months in TRACE. This form of myocardial infarction benefits the most from treatment with ACE inhibitors: the relative reductions in risk for the previously mentioned trials were 19%, 27% and 22% respectively, and the absolute reductions in risk of death were 4% at 42 months, 6% at 15 months and 8% at 37 months, respectively. Studies including all forms of myocardial infarction involve populations at lower risk. The effects of ACE inhibitors on mortality are then less obvious: from 7.7% to 7.2% at 5 weeks in ISIS-4, from 7.1% to 6.3% at 6 weeks in GISSI-3, from 9.6% to 9.0% at 4 weeks in CCS-1, corresponding to relative reductions in the risk of death of 7%, 12% and 3% respectively and absolute reductions of the risk of death of 0.5% at 5 weeks, 0.8% at 6 weeks and 0.6% at 4 weeks, respectively. Who should be treated? All patients for 4 to 6 weeks or only high risk patients. When should treatment be started? Some investigators institute treatment from the first day but others think it prudent to wait until the second day. For how long? Four to 6 weeks would be sufficient to counteract ventricular remodelling while the benefits are sustained in the long term. But treatment should be continued long term in high risk patients. Which molecule, which dose and how many times, should it be taken per day? The logical answer is molecules with proven efficacy at the dose given in the clinical trials respecting the number of times indicated per day.

A drug interaction study between ticlopidine and cyclosporin in heart transplant recipients

OBJECTIVES

Previous uncontrolled studies have suggested an interaction between ticlopidine, a major antiplatelet agent, and cyclosporin in heart- and kidney-transplant recipients. The aims of this study were to examine in a randomised, double-blind fashion, the possible interaction between cyclosporin A and ticlopidine (250 mg per day) and the tolerability of this combination in heart-transplant recipients.

METHODS

Twenty heart-transplant recipients were randomised into either a treated or a placebo group. Blood samples were drawn for time-course evaluation of cyclosporin blood levels over a period of 12 h, following the morning intake of cyclosporin and, for platelet aggregation studies, before and after 14 days of ticlopidine administration. Twenty four-hour urine samples were collected for 6-beta-hydroxycortisol measurements, before and after 14 days of ticlopidine.

RESULTS

Although given at half the recommended daily dosage, ticlopidine significantly reduced platelet aggregation. Pharmacokinetic parameters indicate that the bioavailability of cyclosporin A was not significantly modified by ticlopidine. However, one patient in the ticlopidine group was withdrawn because of a major fall in cyclosporin blood level within 3 days of treatment. Urinary excretion of 6-beta-hydroxycortisol was augmented after treatment in the ticlopidine group compared with the placebo group, suggesting that induction of drug metabolism might have occurred. Data also show quite a large intra-individual variability in cyclosporin bioavailability in the placebo group, suggesting that poor absorption of the drug formulation and/or poor compliance might have contributed to the decreased cyclosporin blood levels in the patient withdrawn from this study and in previous uncontrolled studies.

CONCLUSION

Cyclosporin bioavailability was not clearly modified by a half dosage of ticlopidine in this study. We, however, recommend closely monitoring cyclosporin blood levels when prescribing ticlopidine. Further studies will be needed with new formulations of cyclosporin or when using the full dosage of ticlopidine.

Effect of chronic oral supplementation with alpha-tocopherol on myocardial stunning in the dog

Recent clinical and experimental studies have suggested that antioxidant supplements might actually have harmful as well as beneficial effects in the setting of cardiovascular disease. The mechanisms underlying the beneficial effects of the various antioxidants are poorly understood in humans. Reperfusion-associated myocardial injury, and particularly the phenomenon of stunning, is important because it occurs in clinical settings and may condition the prognosis after short ischemic insult. We studied the effects of chronic (3 months) alpha-tocopherol supplementation with a large oral dose (500 mg daily) on myocardial contractility (stunning) and ventricular arrhythmias in a dog model of short ischemia followed by reperfusion. Twenty dogs were randomized to either an alpha-tocopherol supplemented or a control group. After 3 months, dogs were anesthetized and underwent a 20-min coronary artery occlusion followed by reperfusion. Myocardial regional blood flow was measured by the radioactive microsphere technique and myocardial contractility by sonomicrometry. Plasma alpha-tocopherol was measured by high-performance liquid chromatography in all dogs. Twelve dogs (seven supplemented and five controls) developed ventricular fibrillation at reperfusion, showing no difference between groups. Hemodynamic parameters, blood flow in the ischemic area (collateral flow), and area at risk were similar in the two groups. Regional systolic segment shortening in the ischemic area was similar during ischemia and reperfusion in both groups, representing 41 +/- 15% (mean +/- SEM) of baseline contractility in controls and 51 +/- 8% in supplemented dogs after 150 min of reperfusion. Plasma alpha-tocopherol level was higher in supplemented than in controls (19.1 +/- 1.6 and 6.9 +/- 0.6 mg/L; p < 0.001). Thus a long-term large dose of alpha-tocopherol had no significant effect on postischaemic ventricular arrhythmias and dysfunction (myocardial stunning) in this canine model. These data suggest that if alpha-tocopherol supplementation might be useful to improve the prognosis of coronary patients, it is likely not by interfering with the stunning phenomenon.

The 'diet heart' hypothesis in secondary prevention of coronary heart disease

From this detailed analysis of the main dietary trials conducted over the last 30 years in the secondary prevention of coronary heart disease, it can be said that the older trials were conducted on low risk patients and used high fat diets (about 40% of energy as lipids), comprising low saturated fat and cholesterol intake but very high (15 to 20% of energy) polyunsaturated fat intake, particularly from the omega-6 fatty acid family. These experimental diets were designed to reduce blood cholesterol and failed to improve prognosis. By contrast, recent trials were not primarily designed to reduce cholesterol, were conducted in medium- and high-risk patients and used low fat diets supplemented by omega-3 fatty acids from various sources. In two of these trials, the consumption of natural antioxidants, oligoelements and vegetable proteins was increased. Recurrence rate was reduced in the range of 30 to 70%. One conclusion from these well-conducted recent experiments on more than 3000 patients is that new and more specific dietary recommendations are clearly warranted in secondary prevention of coronary heart disease. They should be more specific and more clearly defined and therefore different from those generally provided in the U.S.A. and Europe at present. In a recent Consensus Panel statement, authors wrote less than one line to describe a cardioprotective diet in patients with coronary heart disease, summarized as < or = 30% fat, < 7% saturated fat, < 200 mg.day-1 cholesterol. This is both too much (too restrictive to hope that white European and American patients will adhere in the long-term) and insufficient because dietary counselling cannot be restricted to three factors. Ulbricht and Southgate recently emphasized that the relationship between diet and coronary heart disease is more complex than the current cholesterol hypothesis. They identified at least seven major dietary factors, including fibres, although the evidence of an effect on coronary heart disease is weak. However, they did not mention vegetable and fish proteins which are rich in arginine and L-glutamine, major regulators of cardiovascular function. Thus, new dietary advice should include: reduce intake of total (not more than 30% of energy) and saturated (less than 10%) fats maintain intake at least minimally, of the essential omega-6 fatty acids augment consumption of oleic acid and moderately increase consumption of omega-3 fatty acids augment intake of natural antioxidants and oligo-elements maintain sufficient intake of vegetable proteins As conceptualized in the 'Mediterranean' and 'Asian-vegetarian' types of diet, it is very important that a healthy diet should be thought of as a whole rather than as a recitation of good and bad components. Although these protective dietary modifications should probably all be used in each patient to obtain maximal efficacy, these scientifically quantitated principles should be adapted to the culture, ethnic origin and 'image of the world' of each patient in order to create an environment favourable to the perception of positive associations between various foods and healthy habits.

[Fibrous aortic valve tumor (Lambl's excrescence) trapped in the right coronary artery. Apropos of a case]

Lambl's excrescences are filliform aortic or mitral valve tumours. They do not usually cause any clinical problems and are autopsy findings. The authors report a case of a 64 year old female with an invalidating angina in whom echo and angiographic investigations suggested obstruction of the right coronary ostium by a valvular tumour. This was confirmed at surgery and tumorectomy was followed by regression of the anginal syndrome.

[Diagnostic value of echocardiography under dobutamine in everyday practice]

In order to evaluate the place of dobutamine echocardiography in everyday practice, this test and a stress ECG were performed in 34 patients referred for diagnostic or assessment coronary angiography. Dobutamine, administered in 3-minute stages from 5 to 30 micrograms/kg/min, was well tolerated. The anti-ischaemic treatment was continued in 26 patients before dobutamine echocardiography and in 15 patients before the stress ECG. The electrocardiographic, echocardiographic and angiographic documents were each analysed by 2 independent observers. Dobutamine echocardiography was considered to be positive in the presence of the development of a new abnormality of segmental kinetics or when abnormality of segmental kinetics was identified outside of the territory of infarction. With reference to coronary angiography, the sensitivity of stress ECG and dobutamine echocardiography was 46% and 42%, respectively, and the specificity was 75% and 88%, respectively; the sensitivity of each test was low, probably because of fake tests. The combination of the two tests improved the sensitivity (69%) without altering the specificity (75%). Dobutamine echocardiography could usefully complete a negative stress ICG whenever a false-negative result is suspected to avoir wrongly reassuring some patients and to allow appropriate management.

Effect of a mediterranean type of diet on the rate of cardiovascular complications in patients with coronary artery disease. Insights into the cardioprotective effect of certain nutriments

OBJECTIVES

We sought to describe the various cardiovascular complications that occurred in the Lyon Diet Heart Study (a secondary prevention trial testing the protective effects of a Mediterranean type of diet), to analyze their relations with the associated drug treatments and to gain insights into the possible mechanisms underlying the beneficial effects of certain nutriments.

BACKGROUND

Dietary habits are implicated in coronary heart disease, and the traditional Mediterranean diet is thought to be cardioprotective. However, the exact mechanisms of this protection are unknown.

METHODS

A total of 605 patients (303 control subjects and 302 study patients) were studied over a mean period of 27 months. Major primary end points (cardiovascular death and nonfatal acute myocardial infarction), secondary end points (including unstable angina, stroke, heart failure and embolisms) and minor end points (stable angina, need for myocardial revascularization, postangioplasty restenosis and thrombophlebitis) were analyzed separately and in combination.

RESULTS

When major primary and secondary end points were combined, there were 59 events in control subjects and 14 events in the study patients, showing a risk reduction of 76% (p < 0.0001). When these end points were combined with the minor end points, there were 104 events in control subjects and 68 events in the study patients, giving a risk reduction of 37% (p < 0.005). By observational analysis, only aspirin among the medications appeared to be significantly protective (risk ratio after adjustment for prognosis factors 0.45; 95% confidence interval 0.25 to 0.80).

CONCLUSIONS

These data show a protective effect of the Mediterranean diet. However, the risk reduction varied depending on the type of end point considered. Our hypothesis is that different pathogenetic mechanisms were responsible for the development of the various complications. It is likely that certain nutriments characteristic of the Mediterranean diet (omega-3 fatty acids, oleic acid antioxidant vitamins) have specific cardioprotective effects.

[Value of coronary angiography in the diagnosis of coronary artery disease of the transplanted heart. Coronary angiography and arteriosclerosis of the graft]

The diagnostic value of coronary angiography, a widespread method of detection of transplant coronary artery disease, was studied in 17 cardiac transplant patients with reference to histological examination. In the 6 coronary segments studied, the only significant but weak correlation that was found was for the distal left anterior descending artery: the correlations were not statistically significant in the other 5 segments. Coronary angiography underestimated lesions and false negative results were frequently reported (66 and 27% respectively). The limitations of coronary angiography may be explained by the technical artefacts related to both methods of evaluation and the anatomically diffuse and distal nature of transplant coronary artery atherosclerosis. A more reliable diagnostic method would seem to be required in view of the clinical importance of this pathology.

Cretan Mediterranean diet for prevention of coronary heart disease

As a result of the Seven Countries Study, the Mediterranean diet has been popularized as a healthy diet. Nevertheless, it has not replaced the prudent diet commonly prescribed to coronary patients. Recently, we completed a secondary, randomized, prospective prevention trial in 605 patients recovering from myocardial infarction in which we compared an adaptation of the Cretan Mediterranean diet with the usual prescribed diet. After a mean follow-up period of 27 mo, recurrent myocardial infarction, all cardiovascular events, and cardiac and total death were significantly decreased by > 70% in the group consuming the Mediterranean diet. These protective effects were not related to serum concentrations of total, low-density-lipoprotein (LDL), or high-density-lipoprotein (HDL) cholesterol. In contrast, protective effects were related to changes observed in plasma fatty acids: an increase in n-3 fatty acids and oleic acid and a decrease in linoleic acid that resulted from higher intakes of linolenic and oleic acids, but lower intakes of saturated fatty acids and linoleic acid. In addition, higher plasma concentrations of antioxidant vitamins C and E were observed. We conclude that a Cretan Mediterranean diet adapted to a Western population protected against coronary heart disease much more efficiently than did the prudent diet. Thus, it appears that the favorable life expectancy of the Cretans could be largely due to their diet.

The long term prognosis of infective endocarditis

Three problems hamper the prognosis of patients who survive the initial phase of infective endocarditis (IE): the rate of IE recurrence is 0.3-2.5/100 patient years, about 60% of patients will have to be operated on at some time, 20-30% during the initial stay, 30-40% during the following 5-8 years; five-year survival after the hospital phase is about 75% in previous reports and 85% in more recent papers. Death is mainly due to heart failure. We looked at the long-term survival of 330 patients with IE who were hospitalized in our institution in 1970-1982, and at the potential influence of 10 factors: age, gender, previous heart disease, microorganism, location of IE, onset of IE, congestive heart failure (CHF) at onset, CHF during the first year, persistent fever, surgery at the acute phase. Global survival was 75% at 6 months, and 57% at 5 years. The only non-significant factor was IE location. The annual instantaneous risk of death was 0.55 at 6 months, 0.18 at 1 year, then 0.03. After one year, the only prognostic factor was age. The relative risk of dying among patients with IE who survived the first year, as compared to the risk of dying among the general population, was 3.27. The IE prognosis is not uniform. Mortality is high during the initial phase, but after one year the risk of dying is low, although still above that of the general population. Part of the risk is probably the direct consequence of IE, but part is due to the course of the underlying heart disease.

Effects of dietary supplementation with alpha-tocopherol on myocardial infarct size and ventricular arrhythmias in a dog model of ischemia-reperfusion

OBJECTIVES

We investigated whether dietary supplementation with the antioxidant vitamin alpha-tocopherol (500 mg daily) might reduce lethal ventricular arrhythmias and infarct size.

BACKGROUND

Previous studies suggested that dietary supplementation with alpha-tocopherol may be associated with a reduced risk of ischemic heart disease. However, the mechanism of this protection remains unknown.

METHODS

Beagle dogs were randomized to either a supplemented or a control group. Because of the low mortality rate in the supplemented group, five dogs were added to the control group. After 2 months, dogs were anesthetized and underwent a 2-h coronary artery occlusion and 6-h reperfusion. Plasma vitamin E, retinol and malondialdehyde concentrations were assessed in all dogs.

RESULTS

Fourteen dogs (11 of 25 control vs. 3 of 19 supplemented dogs, p < 0.05) developed ventricular fibrillation during either ischemia or reperfusion. Malondialdehyde concentrations were higher in dogs that subsequently developed arrhythmias (2.7 +/- 0.2 mumol/liter, mean +/- SEM) compared with dogs that did not (2.1 +/- 0.2 mumol/liter, p = 0.03). Among survivors with significant ischemia, infarct size was larger in supplemented (n = 12, 58.5 +/- 3.3% of area at risk) than in control (n = 11, 41.9 +/- 6.5%, p < 0.04) dogs. In addition, for a given collateral flow, supplemented dogs (n = 16) developed larger infarct size than control dogs (n = 15, p < 0.001, analysis of covariance).

CONCLUSIONS

The data suggest that dietary alpha-tocopherol supplementation prevented lethal ventricular arrhythmias associated with ischemia and reperfusion. However, its influence on infarct size and long-term prognosis warrants further investigation.

Effect of experimental non-insulin requiring diabetes on myocardial microcirculation during ischaemia in dogs

To examine whether chronic high blood glucose may influence myocardial microcirculation during acute myocardial ischaemia in the dog, a noninsulin-requiring diabetes was induced by the streptozotocin-alloxan method. Seventy-five days later, myocardial ischaemia was provoked by occluding the left anterior descending coronary artery for 2 h and microcirculation regulation was assessed in the ischaemic and non-ischaemic myocardium by the radioactive microsphere method. Diabetic dogs were compared with normal dogs. Diabetic dogs had higher blood glycated haemoglobin (2.66 +/- 0.4%) and fructosamine (397 +/- 62 mumol l-1) than control dogs (0.66 +/- 0.2, P < 0.004 and 229 +/- 13, P < 0.03, respectively). Haemodynamic data in the two groups were not different at any time. The size of the ischaemic zone was similar in both groups. During the 2 h ischaemia in the ischaemic zone subendocardial (P = 0.22) and subepicardial (P < 0.05) blood flow slightly increased in control dogs whereas there was a 63% (P < 0.02) and 35% (P = 0.06) reduction respectively in diabetic dogs. In the non-ischaemic zone, blood flow of controls tended to increase (P < 0.006 in the subepicardium and P < 0.06 in the subendocardium) whereas in diabetic dogs blood flow tended to decrease (P = 0.03 in the subendocardium and in the subepicardium). This first investigation on myocardial microcirculation in diabetic dogs during ischaemia suggests that one of the possible causes of increased mortality rate from ischaemic cardiac disease in diabetics might be related to a paradoxical and unfavourable pattern of myocardial blood flow during ischaemia.

Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease

In a prospective, randomised single-blinded secondary prevention trial we compared the effect of a Mediterranean alpha-linolenic acid-rich diet to the usual post-infarct prudent diet. After a first myocardial infarction, patients were randomly assigned to the experimental (n = 302) or control group (n = 303). Patients were seen again 8 weeks after randomisation, and each year for 5 years. The experimental group consumed significantly less lipids, saturated fat, cholesterol, and linoleic acid but more oleic and alpha-linolenic acids confirmed by measurements in plasma. Serum lipids, blood pressure, and body mass index remained similar in the 2 groups. In the experimental group, plasma levels of albumin, vitamin E, and vitamin C were increased, and granulocyte count decreased. After a mean follow up of 27 months, there were 16 cardiac deaths in the control and 3 in the experimental group; 17 non-fatal myocardial infarction in the control and 5 in the experimental groups: a risk ratio for these two main endpoints combined of 0.27 (95% CI 0.12-0.59, p = 0.001) after adjustment for prognostic variables. Overall mortality was 20 in the control, 8 in the experimental group, an adjusted risk ratio of 0.30 (95% CI 0.11-0.82, p = 0.02). An alpha-linolenic acid-rich Mediterranean diet seems to be more efficient than presently used diets in the secondary prevention of coronary events and death.

Postoperative and long-term prognosis of myotomy-myomectomy for obstructive hypertrophic cardiomyopathy: influence of associated mitral valve replacement

Several surgical techniques have been proposed for obstructive hypertrophic cardiomyopathy (OHCM): myotomy, mitral valve replacement (MVR), or myotomy-myomectomy (MM). We reviewed our series of 47 patients who had undergone surgery in order to determine their prognosis and to know whether MVR+MM was better than MM only. Left intraventricular gradient decreased from 86 +/- 34 mmHg to 15 +/- 20 mmHg (P < 0.0001). Postoperatively, three patients died from low cardiac output (6.4%); five died later. Annual mortality (including postoperative deaths) was 3.0%. Follow-up was 5.7 +/- 0.7 years. Survival was 87 +/- 11% at 12 years. After operation, 91% had NYHA class I or II dyspnoea (before surgery this had been 28%); chest pain was CCS class I in 88% (vs 47%); 12% had had syncope since operation (vs 53%). The gradient decrease was larger in the MM+MVR group (P < 0.05). Survival and functional improvement were similar in the two groups. Mitral regurgitation decreased from 2.7 to 0 in the MM+MVR group (P < 0.0001), whereas it decreased from 1.5 to 1.2 in the MM group (ns). MM appears to be the procedure of choice. When mitral regurgitation is important or when an intrinsic disease of the mitral valve exists, the addition of MVR should be considered.

[Myocardial infarction beyond the 48 first hours: treatment with calcium channel antagonists]

Calcium channel blocking agents prevent calcium entering cardiac and smooth muscle cells. With reduction of the blood pressure, heart rate and myocardial contractility, they reduce myocardial oxygen demand. By relieving spasm and coronary constriction, and dilating the collateral coronary vessels, they improve perfusion of the ischemic zones. The results in experimental infarction are contradictory: the reduction in the infarct size and ischaemia is not constant. In the Myocardial Infarction Study, a trial of lidoflazine in 1792 subjects followed up for an average of 5 years, there was no significant difference between the mortality rates of the two groups. In the Danish Verapamil Infarction Trial I, which included 436 subjects receiving 360 mg/day of verapamil or placebo, the 6 months mortality was less (NS) in the verapamil group (12.8%) than in the placebo group (13.9%) as was the reinfarction rate (7.8% versus 9.2%; NS). In the DAVIT II trial of 1775 subjects, treatment was introduced 9 +/- 2.7 days after admission. Mortality was lower (NS) in the verapamil group (11.1%) than in the placebo group (13.8%) and the recurrences were less common (p = 0.04) in the treatment group (11.0%) than with placebo (13.2%). The Secondary Prevention Reinfarction Israeli Nifedipine Trial is a comparison of Nifedipine 30 mg/day and placebo introduced 7-21 days after infarction in 2276 subjects. After 10 months, the mortality and reinfarction rate were similar in both groups, as in the SPRINT II trial (60 mg/day of nifedipine or placebo) at 6 months. In the Multicenter Diltiazem Postinfarction Trial of 2466 patients, Diltiazem 240 mg/day or placebo was administered 3 to 15 days after infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary accelerated arteriosclerosis and vasospasm in the transplanted heart]

Accelerated atherosclerosis of cardiac grafts is one of the factors limiting long-term survival after cardiac transplantation. The authors report the case of a patient who had a cardiac arrest associated with severe atherosclerosis 18 months after transplantation. The severity of the coronary lesions was underestimated by coronary angiography. An ergometrine test induced coronary spasm, a phenomenon which has only rarely been observed in transplanted hearts. The patient died one month later despite calcium inhibitor therapy. Autopsy revealed very severe triple vessel disease. This case illustrates the possible rapid evolution of coronary artery disease in cardiac transplant recipients, the difficulty in evaluating the severity of the lesions by coronary angiography and the additional possibility of observing coronary spasm in these cases.

[Myxoma of the right atrium. Apropos of 10 surgically treated cases]

In a series of 100 patients with intracardiac myxoma, the lesion was in the right atrium in 10 cases. The authors attempt to define the particular features of right atrial myxoma in terms of clinical aspects, outcome and pathology. The diagnostic difficulty raised by complex clinical pictures (including right ventricular failure, pseudopericardial forms and forms with a predominance of systemic problems) has now been resolved by imaging and, above all echocardiography. Consequences for the right side of the heart may involve the pulmonary artery with myxomatous emboli causing multiple fusiform aneurysms and pulmonary hypertension, or, more rarely, the tricuspid (with need for valve replacement), vena cava (Budd-Chiari syndrome) or atrial septum (right/left shunt). Alongside systemic problems due to interleukin 6, erythrocyte abnormalities are a new feature. Frequent etiological inclusion in a Carney complex explains recurrences and multi-cavity forms. The dominant pathological feature is tumor calcifications, no doubt as a result of the long presymptomatic phase of myxoma.

Importance of the flow perfusion deficit in the response to captopril in experimental myocardial infarction

Previous results on the effects of angiotensin-converting enzyme (ACE) inhibition in myocardial ischemia are conflicting. To determine whether acute ACE inhibition may influence myocardial perfusion deficit during ischemia and reduce ischemia-reperfusion injury, anesthetized open-chest dogs underwent 2-h left anterior descending coronary artery (LAD) occlusion followed by 6-h reperfusion. After 1-h coronary occlusion, each dog was randomized to receive either captopril [5 mg/kg intravenous (i.v.) bolus and 0.25/kg/h infusion for 7 h] or saline. Whereas arterial pressure was reduced (p = 0.001), captopril did not influence myocardial perfusion deficit: Blood flow in the central ischemic zone represented 17.1 +/- 2.8% of the flow in the nonischemic zone versus 20.5 +/- 3.8% before treatment (NS). The values of the control group were 17.8 +/- 2.5 and 16.7 +/- 2.4%, respectively. In addition, there was no difference in infarct size: 35.9 +/- 3.3% of the area at risk in captopril-treated dogs versus 40.0 +/- 3.6% in controls. Analysis of subgroups based on the level of the collateral flow indicated, however, that ACE inhibition had an adverse effect on infarct size in dogs with high collateral flow: 31.9 +/- 4.6% in captopril dogs versus 17.6 +/- 4.7 (p = 0.048). This effect was related to a decrease in collateral flow because animals exhibiting the highest increase in perfusion deficit presented the greatest increase in infarct size (r = -0.92, p = 0.003). Although in dogs with low collateral flow, ACE inhibition appeared to exert a slight beneficial effect on infarct size, we conclude that at least in this dog model, acute ACE inhibition could exacerbate myocardial injury.

[Long-term surgical prognosis of aortic valve diseases with pulmonary hypertension. Apropos of 34 cases]

Thirty-four patients underwent isolated aortic valve replacement with mean pulmonary artery pressures greater than 40 mmHg between 1972 and 1988. The aortic valve disease was stenotic in 10 cases, regurgitant in 14 cases and mixed in 10 cases. Thirty patients (88%) had invalidating cardiac failure (NYHA Classes III and IV). The mean preoperative ejection fraction was 44 +/- 15%. The hospital mortality was 17.6%. Ten patients died secondarily, five with terminal cardiac failure. The 5 year actuarial survival was 70 +/- 16%; the 10 year survival was 60 +/- 18% with an average follow-up of 115 +/- 61 months. None of the patients was lost to follow-up. Fifteen of the 18 survivors (83%) are asymptomatic or pauci-symptomatic after a follow-up of 126 +/- 62 months. Doppler echocardiography (n = 12) showed normal prosthetic valve function in 11 cases and aortic regurgitation in 1 case. Eight patients had tricuspid regurgitation with pulmonary artery systolic pressures less than 30 mmHg in 6 cases and between 30 and 40 mmHg in 2 cases. Severe pulmonary hypertension is therefore a poor early postoperative prognostic factor in aortic valve replacement surgery due to the associated left ventricular dysfunction. However, the long-term results are satisfactory: clinical improvement is usually related to a reduction of pulmonary hypertension.

Quantitation of reperfused myocardial infarction by Gd-DOTA-enhanced magnetic resonance imaging. An experimental study

Because there is evidence that myocardial infarct size is modified by coronary artery reperfusion, an ex vivo experimental model of myocardial infarction was developed to determine the influence of the timing of gadolinium-tetraazacyclododecane tetraacetic acid (Gd-DOTA)-enhanced magnetic resonance imaging (MRI) on the accuracy of infarct size quantitation. Eighteen dogs underwent a 2-hour coronary occlusion followed by 1 (n = 6), 6 (n = 6), or 48 (n = 6) hours of reperfusion. Gd-DOTA was injected 10 minutes before the dogs were killed. T1 (SE 250/26) and T2 (SE 1500/78) weighted images were performed on excised hearts. Gd-DOTA concentration was measured in myocardium by atomic emission spectrometry, and correlated with myocardial blood flow evaluated by radioactive microspheres. All dogs presented with myocardial infarction (mean size 20.4% +/- 3.1% of the left ventricle), and a corresponding area of increased signal intensity on T1-weighted MR images. In none of the three groups did the area of high signal intensity correlate with the ischemic area. By contrast, after 6 and 48 hours of reperfusion, the high signal intensity area (17.9% +/- 2.4%) closely matched the area of nonreversible jeopardized tissue (16.4% +/- 2.5%), as determined on tetrazolium-stained heart slices. Although a noreflow phenomenon was observed in the jeopardized tissue, Gd-DOTA concentration was higher in the subendocardial central ischemic zone than in normally perfused myocardium. Gd-DOTA imaging enhancement seems to be the consequence of a delayed clearance of the agent from the injured tissue. Gd-DOTA-enhanced MRI accurately quantitates the size of reperfused myocardial infarction on the ex vivo heart for more than 6 hours after the beginning of reperfusion. It remains to be determined whether the in vitro results obtained here can be applied to assess the myocardial infarct size in vivo.

[Mitral valve replacement in severe pulmonary hypertension. Long-term results]

Between 1972 and 1987, 43 patients underwent isolated mitral valve replacement with mean pulmonary arterial pressures greater than 50 mmHg. The valve disease was stenosis in 13 cases, regurgitation in 15 cases and mixed mitral valve disease in 15 cases. Forty-one patients (95 %) had invalidating cardiac failure (Stages III and IV of the NYHA Classification). The hospital mortality was 2.3%. Thirteen patients died during follow-up, 8 of cardiac failure, 3 of sudden death and 2 died of non-cardiac causes. The 8 year actuarial survival was 82 +/- 7% with an average postoperative follow-up of 96 +/- 41 months. No patients were lost to follow-up. Eighty six per cent of survivors (25/29) are asymptomatic or paucisymptomatic. Doppler studies were performed in 22 patients, showing normal prosthetic function in 18 cases and an obstructive prosthesis in 4 cases. Seventeen patients had tricuspid regurgitation showing normal pulmonary artery systolic pressures in 9 cases and less than 55 mmHg in 5 cases. On average, systolic pulmonary artery pressure fell from 88 +/- 11 mmHg before to 33 +/- 9 mmHg after surgery (p = 0.01). These results show that severe pulmonary hypertension is not prohibitive for mitral valve replacement. The long-term results are good with functional improvement and reduction of pulmonary hypertension.

U74006F, a novel 21-aminosteroid, inhibits in vivo lipid peroxidation but fails to limit infarct size in a canine model of myocardial ischemia reperfusion

Peroxidation of membrane lipids has been suggested to play a role in the pathogenesis of myocardial ischemia/reperfusion injury. We therefore assessed the efficacy of U74006F, a potent in vitro vitamin E-like inhibitor of lipid peroxidation, in limiting infarct size in a canine model of transient coronary artery occlusion. Twenty dogs underwent 2 hours of occlusion of the left anterior descending coronary artery and 6 hours of reperfusion. U74006F or saline solution was administered continuously from 1 hour of occlusion to the end of the experiment. U74006F blunted any increase in production of conjugated dienes (an index of lipid peroxidation) at both 30 minutes (1.73 +/- 0.16 mol/L x 10(-4) vs 2.62 +/- 0.22 in control dogs, p less than 0.05) and 6 hours (1.39 +/- 0.22 vs 2.06 +/- 0.18 in control dogs, p less than 0.05) after reperfusion. Furthermore, 6 hours after reflow vitamin E levels tended to be lower than baseline values in control dogs and higher than baseline values in dogs treated with U74006F. However, analysis of infarct size indicated no statistically significant difference between the two groups when expressed either as a percentage of the left ventricle (10.4 +/- 1.8% in U74006F vs 15.2 +/- 2.4% in control dogs) or as a percentage of the area at risk (33.0 +/- 5.5% in U74006F vs 37.8 +/- 4.5% in control dogs). Although U74006F appeared to be a potent in vivo inhibitor of lipid peroxidation, it failed to limit infarct size after 2 hours of occlusion and 6 hours of reperfusion in this canine model.

Influence of associated valvular lesions on long-term prognosis of mitral stenosis. A 20-year follow-up of 202 patients

Other valvular lesions associated with pure MS were studied in 202 consecutive patients whose mean age was 43.4 +/- 12.7 years; 76.7% were females. MS was isolated in 63.4%, associated with aortic regurgitation (AR) in 27.7%, aortic stenosis in 1.0%, tricuspid stenosis (+aortic valve lesion) in 1.0%. In isolated MS, 42.4% were NYHA class III or IV, compared with 49.0% in MS + aortic valve lesion. One hundred and sixty-nine (85.4%) patients were operated on; 23.1% had mitral valve replacement, 76.9% had closed (31.4%) or open (45.6%) mitral commissurotomy; 7.1% had associated aortic valve replacement. There were perioperative complications in 20.4%, and the perioperative death rate was 4.1%. Two patients were reoperated in the postoperative course, and 28 patients after this period. The follow-up was 13.3 +/- 4.5 years. The survival rate was 77.7 +/- 4.6% (SE) for isolated MS, and 71.1 +/- 6.3% for MS associated with an aortic valve lesion (NS). The prognosis of MS is very good: the survival rate at 20 years follow-up is 75%. The association of aortic stenosis or tricuspid stenosis does not appear to alter this survival, but numbers are small. Important aortic regurgitation is a significant predictor of higher mortality in patients with MS.

[Long-term results and prognostic factors after mitral valve replacement using the Starr-Edwards 6120 prosthesis]

Between 1970 and 1984, 386 mitral valve replacements with the SE 6120 prosthesis were performed with a mean post-operative follow-up of 75 +/- 44 months or a total follow-up of 2520 patient years (PY). Rapid post-operative mortality was 6.7 percent and the delayed mortality 26.5 percent, the 5-year actuarial survival rate was 80 +/- 2% and that at 10 years 67 +/- 2% (including early mortality). There was no significant difference for survival between single-valve replacements (n = 183) and multiple-valve replacements (n = 203). Multifactorial prognosis analysis (Cox) gave two post-operative prognosis: X (n = 386) = 0.0391 (age) + 0.2421 (NYHA stage); Y (n = 147) = 0.8561 (X) + 0.6299 (VG type). The incidence of complications related to the prosthesis is 4.16 per 100 PY, including sudden deaths. The current actuarial analysis shows that at 5 years 91 +/- 1% at 10 years 78 +/- 2% of the operated subjects are devoid of any such complication and of thrombosis of the valve. Statistically, it was found that permanent atrial fibrillation (p = 0.03), the size of the right atrium (p = 0.02) played a promoting role. With a post-operative follow-up in excess of 8 years. 79% of the survivors are symptom-free or present few symptoms and the myocardial response is poor in 52 patients (NYHA stage III or IV).

[Late results of isolated aortic valve replacement by Björk-Shiley prosthesis. Apropos of 596 cases]

Between 1970 and 1985, 596 patients underwent isolated aortic valve replacement with a Björk-Shiley prosthesis: 448 men and 148 women, average age 52 +/- 13 years (range 10-78 years). The valve lesion was aortic stenosis in 158 cases, aortic regurgitation in 218 cases and mixed valve disease in 220 cases. Fifty-four per cent of patients had invalidating cardiac failure (Stage III of the NYHA Classification). Thirteen per cent of patients had an associated non valvular surgical procedure. The hospital mortality was 5.7% and 77% of the early deaths were of cardiac origin. Results were analysed after an average follow-up period of 90 +/- 15 months, a total of 3817 patient-years. The late mortality was 94 (16.7%). Actuarial survival was 87 +/- 1% at 5 years and 79 +/- 2% at 10 years. A prognostic score was established from a multifactorial analysis: Cox = 0.44 (NYHA Stage 1, 2, 3, 4) + 5.29 C/T (absolute value) + 1.15 associated procedure (0.1) + 0.65 (RBBB) (0.1). In the long-term, 84.8% of survivors were asymptomatic (NYHA Stages I and II). The incidence of thrombo-embolism was 0.5/100 patient-years. At 10 years, 95% of patients had no thromboembolic complication. The incidence of ineffective endocarditis was 0.3/100 patient-years and that of complications of anticoagulant therapy was 0.4/100 patient-years. The incidence of valve dehiscence was 0.1/100 patient-years and the reoperation rate was 0.4/100 patient-years but there were no cases of valve dysfunction. The global complication rate in this series was 1.35/100 patient-years. These results confirm the good results of aortic valve replacement with a mechanical prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition of coronary artery thrombosis by SIN-1, a donor of nitric oxide

Molsidomine and its metabolite, SIN-1, a donor of nitric oxide, are potent coronary vasodilator and anti-ischemic agents. Recently, SIN-1 and nitric oxide have also been shown to inhibit platelet adhesion and aggregation in vitro. The present study in dogs was designed to evaluate the in vivo antithrombotic properties of SIN-1. Coronary intimal damage and stenosis are known to induce coronary cyclic flow variations that reflect platelet thrombus formation followed by disaggregation and embolization (Folts preparation). This model of coronary artery thrombosis appears to simulate the combination of some of the factors contributing to unstable angina and myocardial infarction in human. SIN-1 infusion (10 micrograms/kg/min) significantly reduced the frequency of cyclic flow variations: 4.9 +/- 6.2/h vs. 14 +/- 4.6/h (before treatment, p less than 0.03, n = 6). Results were similar to those obtained with aspirin (5 mg/kg, bolus i.v.: 1.5 +/- 0.6/h vs. 11.7 +/- 3/h, p less than 0.03, n = 5) whereas saline had no effect (17.8 +/- 2.2/h vs. 19.3 +/- 2.4/h, n = 5). As expected, blood pressure was decreased only in the SIN-1 group: 56.2 +/- 7.8 vs. 87.3 +/- 9.3 mm Hg (p less than 0.02) (mean arterial blood pressure). The present results suggest that the well-documented anti-ischemic properties of SIN-1 could be partly due to its antithrombotic activity, clearly demonstrated with the model of coronary thrombosis used here in the dog.