Outcomes of cavotricuspid isthmus-dependent flutter ablation: randomized study comparing single vs. multiple catheter procedures-the SIMPLE study

BACKGROUND

Catheter ablation is recommended as first-line therapy for patients with symptomatic typical AFl. Although the conventional multi-catheter approach is the standard of care for cavotricuspid isthmus (CTI) ablation, a single-catheter approach was recently described as a feasible alternative. The present study sought to compare safety, efficacy, and efficiency of single vs. multi-catheter approach for atrial flutter (AFl) ablation.

METHODS

In this randomized multi-center study, consecutive patients referred for AFl ablation (n = 253) were enrolled and randomized to multiple vs. single-catheter approach for CTI ablation. In the single-catheter arm, PR interval (PRI) on the surface ECG was used to prove CTI block. Procedural and follow-up data were collected and compared between the two arms.

RESULTS

128 and 125 patients were assigned to the single-catheter and to the multi-catheter arms, respectively. In the single-catheter arm, procedure time was significantly shorter (37 ± 25 vs. 48 ± 27 minutes, p = 0.002) and required less fluoroscopy time (430 ± 461 vs. 712 ± 628 seconds, p < 0.001) and less radiofrequency time (428 ± 316 vs. 643 ± 519 seconds, p < 0.001), achieving a higher first-pass CTI block rate (55 (45%) vs. 37 (31%), p = 0.044), compared with the multi-catheter arm. After a median follow-up of 12 months, 11 (4%) patients experienced AFl recurrences (5 (4%) in the single-catheter arm and 6 (5%) in the multi-catheter arm, p = 0.99). No differences were found in arrhythmia-free survival between arms (log-rank = 0.71).

CONCLUSIONS

The single-catheter approach for typical AFl ablation is not inferior to the conventional multiple-catheter approach, reducing procedure, fluoroscopy, and radiofrequency time.

A hybrid clinical and electrocardiographic score to predict the origin of outflow tract ventricular arrhythmias

BACKGROUND

To predict the outflow tract ventricular arrhythmias (OTVA) site of origin (SOO) before the ablation procedure has important practical implications. The present study sought to prospectively evaluate the accuracy of a clinical and electrocardiographic hybrid algorithm (HA) for the prediction of OTVAs-SOO, and at the same time to develop and to prospectively validate a new score with improved discriminatory capacity.

METHODS

In this multicenter study, we prospectively enrolled consecutive patients referred for OTVA ablation (N = 202), and we divided them in a derivation sample and a validation cohort. Surface ECGs during OTVA were analyzed to compare previous published ECG-only criteria and to develop a new score.

RESULTS

In the derivation sample (N = 105), the correct prediction rate of HA and ECG-only criteria ranged from 74 to 89%. R-wave amplitude in V3 was the best ECG parameter for discriminating LVOT origin in V3 precordial transition (V3PT) patients, and was incorporated to the novel weighted hybrid score (WHS). WHS correctly classified 99 (94.2%) patients, presenting 90% sensitivity and 96% specificity (AUC 0.97) in the entire population; WHS mantained a 87% sensitivity and 91% specificity (AUC 0.95) in patients with V3PT subgroup. The high discriminatory capacity was confirmed in the validation sample (N = 97): the WHS exhibited an AUC (0.93), and a WHS ≥ 2 allowed a correct prediction of LVOT origin in 87 (90.0%) cases, yielding a sensitivity of 87% and specificity of 90%; moreover, the V3PT subgroup showed an AUC of 0.92, and a punctuation ≥ 2 predicted an LVOT origin with a sensitivity of 94% and specificity of 78%.

CONCLUSIONS

The novel hybrid score has proved to accurately anticipate the OTVA's origin, even in those with a V3 precordial transition. A Weighted hybrid score. B Typical examples of the use of the weighted hybrid score. C ROC analysis of WHS and previous ECG criteria for prediction of LVOT origin in the derivation cohort. D ROC analysis of WHS and previous ECG criteria for prediction of LVOT origin in the V3 precordial transition OTVA subgroup.

Preventive substrate ablation in chronic post-myocardial infarction patients with high-risk scar characteristics for ventricular arrhythmias: rationale and design of PREVENT-VT study

BACKGROUND

Recent studies showed that an early strategy for ventricular tachycardia (VT) ablation resulted in reduction of VT episodes or mortality. Cardiac magnetic resonance (CMR)-derived border zone channel (BZC) mass has proved to be a strong non-invasive predictor of VT in post-myocardial infarction (MI). CMR-guided VT substrate ablation proved to be safe and effective for reducing sudden cardiac death (SCD) and VA occurrence.

METHODS

PREVENT-VT is a prospective, randomized, multicenter, and controlled trial designed to evaluate the safety and efficacy of prophylactic CMR-guided VT substrate ablation in chronic post-MI patients with CMR-derived arrhythmogenic scar characteristics. Chronic post-MI patients with late gadolinium enhancement (LGE) CMR will be evaluated. CMR images will be post-processed and the BZC mass measured: patients with a BZC mass > 5.15 g will be eligible. Consecutive patients will be enrolled at 3 centers and randomized on a 1:1 basis to undergo a VT substrate ablation (ABLATE arm) or optimal medical treatment (OMT arm). Primary prevention ICD will be implanted following guideline recommendations, while non-ICD candidates will be implanted with an implantable cardiac monitor (ICM). The primary endpoint is a composite outcome of sudden cardiac death (SCD) or sustained monomorphic VT, either treated by an ICD or documented with ICM. Secondary endpoints are procedural safety and efficiency outcomes of CMR-guided ablation.

DISCUSSION

In some patients, the first VA episode causes SCD or severe neurological damage. The aim of the PREVENT-VT is to evaluate whether primary preventive substrate ablation may be a safe and effective prophylactic therapy for reducing SCD and VA occurrence in patients with previous MI and high-risk scar characteristics based on CMR.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04675073, registered on January 1, 2021.

Relationship between the posterior atrial wall and the esophagus: esophageal position and temperature measurement during atrial fibrillation ablation (AWESOME-AF). A randomized controlled trial

BACKGROUND

Pulmonary vein isolation (PVI) implies unavoidable ablation lesions to the left atrial posterior wall, which is closely related to the esophagus, leading to several potential complications. This study evaluates the usefulness of the esophageal fingerprint in avoiding temperature rises during paroxysmal atrial fibrillation (PAF) ablation.

METHODS

Isodistance maps of the atrio-esophageal relationship (esophageal fingerprint) were derived from the preprocedural computerized tomography. Patients were randomized (1:1) into two groups: (1) PRINT group, the PVI line was modified according to the esophageal fingerprint; (2) CONTROL group, standard PVI with operator blinded to the fingerprint. The primary endpoint was temperature rise detected by intraluminal esophageal temperature probe monitoring. Ablation settings were as specified on the Ablate BY-LAW study protocol.

RESULTS

Sixty consecutive patients referred for paroxysmal AF ablation were randomized (42 (70%) men, mean age 60 ± 11 years). Temperature rise (> 39.1 °C) occurred in 5 (16%) patients in the PRINT group vs. 17 (56%) in the CONTROL group (p < 0.01). Three AF recurrences were documented at a mean follow-up of 12 ± 3 months (one (3%) in the PRINT group and 2 (6.6%) in the CONTROL group, p = 0.4).

CONCLUSION

The esophageal fingerprint allows for a reliable identification of the esophageal position and its use for PVI line deployment results in less frequent esophageal temperature rises when compared to the standard approach. Further studies are needed to evaluate the impact of PVI line modification to avoid esophageal heating on long-term outcomes. The development of new imaging-derived tools could ultimately improve patient safety (NCT04394923).

Relationship between the posterior atrial wall and the esophagus: esophageal position during atrial fibrillation ablation

Background

Atrial fibrillation ablation implies a risk of esophageal thermal injury. Esophageal position can be analyzed with imaging techniques, but evidence for esophageal mobility is inconsistent.

Objectives

The purpose of this study was to analyze esophageal position stability from one procedure to another and during a single procedure.

Methods

Esophageal position was compared in 2 patient groups. First, preprocedural multidetector computerized tomography (MDCT) of first pulmonary vein isolation and redo intervention (redo group) was segmented with ADAS 3D™ to compare the stability of the atrioesophageal isodistance prints. Second, 3 imaging modalities were compared for the same procedure (multimodality group): (1) preprocedural MDCT; (2) intraprocedural fluoroscopy obtained with the transesophageal echocardiographic probe in place with CARTOUNIVU™; and (3) esophageal fast anatomic map (FAM) at the end of the procedure. Esophageal position correlation between different imaging techniques was computed in MATLAB using semiautomatic segmentation analysis.

Results

Thirty-five redo patients were analyzed and showed a mean atrioesophageal distance of 1.2 ± 0.6 mm and a correlation between first and redo procedure esophageal fingerprint of 91% ± 5%. Only 3 patients (8%) had a clearly different position. The multi-imaging group was composed of 100 patients. Esophageal position correlation between MDCT and CARTOUNIVU was 82% ± 10%; between MDCT and esophageal FAM was 80% ± 12%; and between esophageal FAM and CARTOUNIVU was 83% ± 15%.

Conclusion

There is high stability of esophageal position between procedures and from the beginning to the end of a procedure. Further research is undergoing to test the clinical utility of the esophageal fingerprinted isodistance map to the posterior atrial wall.

Personalized paroxysmal atrial fibrillation ablation by tailoring ablation index to the left atrial wall thickness: the 'Ablate by-LAW' single-centre study-a pilot study

AIMS

To determine if adapting the ablation index (AI) to the left atrial wall thickness (LAWT), which is a determinant of lesion transmurality, is feasible, effective, and safe during paroxysmal atrial fibrillation (PAF) ablation.

METHODS AND RESULTS

Consecutive patients referred for PAF first ablation. Left atrial wall thickness three-dimensional maps were obtained from multidetector computed tomography and integrated into the CARTO navigation system. Left atrial wall thickness was categorized into 1 mm layers and AI was titrated to the LAWT. The ablation line was personalized to avoid thicker regions. Primary endpoints were acute efficacy and safety, and freedom from atrial fibrillation (AF) recurrences. Follow-up (FU) was scheduled at 1, 3, 6, and every 6 months thereafter. Ninety patients [60 (67%) male, age 58 ± 13 years] were included. Mean LAWT was 1.25 ± 0.62 mm. Mean AI was 366 ± 26 on the right pulmonary veins with a first-pass isolation in 84 (93%) patients and 380 ± 42 on the left pulmonary veins with first-pass in 87 (97%). Procedure time was 59 min (49-66); radiofrequency (RF) time 14 min (12.5-16); and fluoroscopy time 0.7 min (0.5-1.4). No major complication occurred. Eighty-four out of 90 (93.3%) patients were free of recurrence after a mean FU of 16 ± 4 months.

CONCLUSION

Personalized AF ablation, adapting the AI to LAWT allowed pulmonary vein isolation with low RF delivery, fluoroscopy, and procedure time while obtaining a high rate of first-pass isolation, in this patient population. Freedom from AF recurrences was as high as in more demanding ablation protocols. A multicentre trial is ongoing to evaluate reproducibility of these results.

Left atrial wall thickness of the pulmonary vein reconnection sites during atrial fibrillation redo procedures

BACKGROUND

Left atrial wall thickness (LAWT) has been related to pulmonary vein (PV) reconnections after atrial fibrillation (AF) ablation. The aim was to integrate 3D-LAWT maps in the navigation system and analyze the relationship with local reconnection sites during AF-redo procedures.

METHODS

Consecutive patients referred for AF-redo ablation were included. Procedure was performed using a single catheter technique. LAWT maps obtained from multidetector computerized tomography (MDCT) were imported into the navigation system. LAWT of the circumferential PV line, the reconnected segment and the reconnected point, were analyzed.

RESULTS

Sixty patients [44 (73%) male, age 61 ± 10 years] were included. All reconnected veins were isolated using a single catheter technique with 55 min (IQR 47-67) procedure time and 75 s (IQR 50-120) fluoroscopy time. Mean LAWT of the circumferential PV line was 1.46 ± 0.22 mm. The reconnected segment was thicker than the rest of segments of the circumferential PV line (2.05 + 0.86 vs. 1.47 + 0.76, p < .001 for the LPVs; 1.55 + 0.57 vs. 1.27 + 0.57, p < .001 for the RPVs). Mean reconnection point wall thickness (WT) was at the 82nd percentile of the circumferential line in the LPVs and at the 82nd percentile in the RPVs.

CONCLUSION

A single catheter technique is feasible and efficient for AF-redo procedures. Integrating the 3D-LAWT map into the navigation system allows a direct periprocedural estimation of the WT at any point of the LA. Reconnection points were more frequently present in thicker segments of the PV line. The use of 3D-LAWT maps can facilitate reconnection point identification during AF-redo ablation.

Clinical recognition of pure premature ventricular complex-induced cardiomyopathy at presentation

BACKGROUND

Frequent premature ventricular complexes (PVCs) can induce or worsen left ventricular (LV) systolic dysfunction.

OBJECTIVE

The purpose of this study was to identify the clinical pattern of patients having a "pure PVC-induced" cardiomyopathy at presentation.

METHODS

This prospective multicenter study included 155 consecutive patients (age 55 ± 12 years, 96 men [62%], 23% ±12% mean PVC burden) with LV dysfunction and frequent PVCs submitted for ablation and followed up for at least 12 months. Patients with a previously diagnosed structural heart disease (50 [32%]) and those without complete PVC abolition during follow-up who did not normalize LV ejection fraction (LVEF) (24 [15%]) were excluded from the analysis.

RESULTS

Of the remaining 81 patients, 41 (51%) had a successful sustained ablation, did not have normalized LVEF, and were classified as having PVC-worsened nonischemic cardiomyopathy, and 40 (49%) who had normalized LVEF were considered as having pure PVC-induced cardiomyopathy. The latter group had higher baseline PVC burden (27% ± 12% vs 12% ± 8%; P <.001), smaller LV end-diastolic diameter (58 ± 5 mm vs 60 ± 6 mm; P = .05), and shorter intrinsic QRS (105 ± 12 vs 129 ± 24 ms; P <.001). Any of the following baseline characteristics accurately identified patients who will not normalize LVEF after PVC ablation (85% sensitivity, 98% specificity): intrinsic QRS >130 ms, baseline PVC burden <17%, and LV end-diastolic diameter >63 mm.

CONCLUSION

Almost half of patients with frequent PVCs and low LVEF of unknown origin normalize LVEF after sustained PVC abolition, and these patients can be identified before ablation.

Optimized pacing mode for hypertrophic cardiomyopathy: Impact of ECG fusion during pacing

BACKGROUND

Electrocardiographic (ECG) fusion with intrinsic QRS could reduce the benefit of atrial synchronous biventricular pacing (AS-BiVP) in patients with hypertrophic obstructive cardiomyopathy (HOCM).

OBJECTIVES

The purpose of this study was to assess the benefit of AS-BiVP and the influence of ECG fusion for reduction of left ventricular outflow tract gradient (LVOTG) in these patients.

METHODS

Twenty-one symptomatic HOCM patients with severe LVOTG were included. Twelve patients were evaluated retrospectively for the prevalence of fusion and its influence on outcomes after AS-BiVP. Eleven patients (2 of the first population were also evaluated retrospectively) were prospectively included to evaluate the benefit of performing atrioventricular node ablation (AVNA) to achieve full ventricular capture if fusion was present during AS-BiVP.

RESULTS

Seven of the first 12 patients (58%) had ECG fusion. After 54 ± 24 months of AS-BiVP, the presence of fusion was associated with lower values for reduction of resting, dynamic LVOTG and New York Heart Association (NYHA) class. In the prospectively evaluated patients, after 12 months of follow-up, resting LVOTG decreased from 98 ± 39 to 39 ± 24 mm Hg (P = .008); dynamic LVOTG decreased from 112 ± 38 to 60 ± 24 mm Hg (P = .013); NYHA class decreased from 2.8 ± 0.4 to 1.7 ± 0.6 (P = .014); endurance time during constant work rate cycling exercise (80% of peak oxygen consumption) increased from 399 ± 148 to 691 ± 249 seconds (P = .046); quality of life improved from 46 ± 22 to 22 ± 20 points (P = .02); and brain natriuretic peptide levels decreased from 318 ± 238 to 152 ± 118 pg/mL (P = .09). Eight of the 11 prospectively evaluated patients (73%) needed AVNA, which further decreased LVOTG from 108 ± 40 mm Hg at baseline to 89 ± 29 mm Hg after BiVP to 54 ± 22 mm Hg after AVNA (P = .003).

CONCLUSION

As-BiVP that ensures no ECG fusion, by means of AVNA when needed, appears to be the optimal pacing mode in HOCM patients.

Arsenic input into the catchment of the River Caudal (Northwestern Spain) from abandoned Hg mining works: effect on water quality

In Asturias (NW Spain) there are many abandoned mines, of which Hg mines are of particular significance from an environmental point of view, due to the presence of Hg and particularly As, which is found either in the form of specific (orpiment and realgar) or non-specific minerals (As-rich pyrite). The instability of these minerals leads to the presence of As-rich mine drainage and spoils heap leachates that enter surface waters or groundwaters. A study including the three most important Hg mines in the region (La Soterraña, Los Rueldos and El Terronal) has been conducted. Watercourses flowing through these mining areas are tributaries of the River Caudal, one of the most important rivers in the area. High concentrations of As were found in some of these waters, which were monitored over a period of three hydrological years and classified according to a water quality index. Those waters sampled close to the mines are generally of poor-to-bad quality, with low alkalinity and in some cases high metal content, but the quality of these waters improves with distance from the mines. The average mass load of As entering the River Caudal has been evaluated as: 200, 12 and 9,800 kg year(-1) from La Soterraña, Los Rueldos and El Terronal mine sites, respectively. Despite the constant input of about 10 tonnes of As per year, the total As concentration remains below analytical detection thresholds on account of the river's high water flow. Nevertheless, an important part of this As load is presumably retained in the river sediments, representing a potential risk of pollution of the aquatic ecosystems.

Is an emergency heart transplantation justified?

INTRODUCTION

Emergency heart transplantation remains an important controversy due to the shortage of donors and the previously demonstrated results inferior to other patients. These recipients display a worse clinical status and their donors are more often considered suboptimal. Nevertheless, it is the only therapeutic option for patients with advanced cardiomyopathy and acute decompensation with no response to other therapies. We compared results among the emergency indication with those of elective transplants.

METHODS

We analyzed the 213 patients who underwent cardiac transplantation in our center up to December 2004 to compare emergency with elective heart transplantations for preoperative and surgical variables as well as outcomes.

RESULTS

A higher percentage of emergency patients were New York Heart Association class IV, displayed renal dysfunction, and were women. Regarding donors, a higher percentage were over 40 years of age. No differences were observed in the early and first-year mortality or morbidity rates, although we noted a greater 5-year mortality rate among emergency cases.

CONCLUSIONS

In our center emergency heart transplantation was associated with only slightly worse results compared with elective transplantations. Both donors and recipients should be carefully selected to improve results.

Risk-based evaluation of the exposure of children to trace elements in playgrounds in Madrid (Spain)

Eighty samples of sandy substrate were collected in November 2002 and 2003, from 20 municipal playgrounds in Madrid (Spain) to assess the potential adverse health effects of the exposure of children to trace elements in this material during their games. In each playground, two 500 g samples were collected, dried at 45 degrees C for 48 h, sieved below 100 microm, acid digested and analyzed by ICP-MS. Doses contacted through ingestion and inhalation and the dose absorbed through the skin were calculated using USEPAs hourly exposure parameters for children and the results of an in situ survey. The toxicity values considered in this study were mostly taken from the US DoEs RAIS compilation. The results of the risk assessment indicate that the highest risk is associated with ingestion of soil particles and that the trace element of most concern is arsenic, the exposure to which results in a cancer risk value of 4.19 x 10(-6), close to the 1 x 10(-5) probability level deemed unacceptable by most regulatory agencies. Regarding non-cancer effects, exposure to playground substrate yields an aggregate Hazard Index of 0.28, below the threshold value of 1 (with As, again, as the largest single contributor, followed by Pb, Cr, Al and Mn). Although the uncertainties associated with the estimates of toxicity values and exposure factors should be reduced before any definite conclusions regarding potential health effects are drawn, risk assessment has proven to be a very useful tool to identify the contaminants and exposure pathways of most concern in urban environments.

Reduction of Ca(2+) channel activity by hypoxia in human and porcine coronary myocytes

OBJECTIVE

Oxygen (O(2)) tension is a major regulator of blood flow in the coronary circulation. Hypoxia can produce vasodilation through activation of ATP regulated K(+) (K(ATP)) channels in the myocyte membrane, which leads to hyperpolarization and closure of voltage-gated Ca(2+) channels. However, there are other O(2)-sensitive mechanisms intrinsic to the vascular smooth muscle since hypoxia can relax vessels precontracted with high extracellular K(+), a condition that prevents hyperpolarization following opening of K(+) channels. The objective of the present study was to determine whether inhibition of Ca(2+) influx through voltage-dependent channels participates in the response of coronary myocytes to hypoxia.

METHODS

Experiments were performed on porcine anterior descendent coronary arterial rings and on enzymatically dispersed human and porcine myocytes of the same artery. Cytosolic [Ca(2+)] was measured by microfluorimetry and whole-cell currents were recorded with the patch clamp technique.

RESULTS

Hypoxia (O(2) tension approximately 20 mmHg) dilated endothelium-denuded porcine coronary arterial rings precontracted with high K(+) in the presence of glibenclamide (5 microM), a blocker of K(ATP) channels. In dispersed human and porcine myocytes, low O(2) tension decreased basal cytosolic [Ca(2+)] and transmembrane Ca(2+) influx independently of K(+) channel activation. In patch clamped cells, hypoxia reversibly inhibited L-type Ca(2+) channels. RT-PCR indicated that rHT is the predominant mRNA variant of the alpha(1C) Ca(2+) channel subunit in human coronary myocytes.

CONCLUSION

Our study demonstrates, for the first time in a human preparation, that voltage-gated Ca(2+)channels in coronary myocytes are under control of O(2) tension.

Pneumocystis carinii pneumonia in heart transplant recipients

OBJECTIVES

In spite of the high prevalence of Pneumocystis carinii (PC) pneumonia in immunocompromised patients, little is known about the epidemiological characteristics of this infection, and whether the cases of PC pneumonia in immunosuppressed patients are the result of a reactivation of a latent infection or a due to a recent infection is unknown. The aim of this study was to provide information about the epidemiological characteristics of PC pneumonia in a cohort of heart transplant (HT) recipients when compared with the epidemiology of PC infection in a cohort of chronic sputum producers (CSP) representative of the general population of the same geographical area.

METHODS

We identified all the cases of PC pneumonia in the cohort of 72 subjects who underwent cardiac transplantation at our institution between January 1991 and December 1996 and compared them with the cases of PC infection identified in a non-selected cohort of 34 CSP. This second group was included to obtain an approximation of the frequency of PC carriers in the general population. Identification of PC was accomplished through customary stain techniques and immunofluorescence with monoclonal antibodies.

RESULTS

Of the 72 HT recipients four (5.5%) developed PC pneumonia, but one had two episodes. Only one had received primary chemoprophylaxis, but developed PC pneumonia 2 months after discontinuing prophylactic therapy. PC pneumonia episodes were produced 53, 102, 230, 181 and 772 days after the moment of transplant, respectively. PC was identified in two (5.8%) of the 34 CSP. No significant differences were found when the accumulative incidences of PC pneumonia in HT patients and PC infection in CSP were compared (P=0.7).

CONCLUSIONS

The frequency of PC pneumonia among HT patients is the same as the frequency of PC infection in the general population. This observation and the long interval between transplantation and the development of PC pneumonia observed in the study support the hypothesis that the occurrence of PC pneumonia in immunocompromised patients might be from a new infection rather than from the reactivation of latent organisms. Therefore, continuous prophylaxis might be indicated in areas with a high prevalence of PC for patients at highest risk.

Renal tolerance to cisplatin in patients 70 years and older

The purpose of this study was to evaluate cisplatin nephrotoxicity in patients 70 years and older and to identify factors influencing nephrotoxicity occurrence. Forty-nine (N = 49) patients older than 70 years were studied retrospectively. All patients received treatment with cisplatin. Variables under study were as follows: prechemotherapy serum creatinine levels (Crb), maximum serum creatinine level during treatment (Crmax), steady serum creatinine level 3 months after treatment completion (Crstb), as well as their corresponding creatinine clearance values (CrbC, CrmaxC, CrstbC) as calculated by the Cockroft and Gault formula. Maximum creatinine increment (Imax = Crmax - Crb), stable creatinine increment (Istb = Crstb - Crb) and the corresponding clearance decrements (Dmax and Dstb) were calculated as well. The potential relationship of the above variables to cisplatin dose intensity and accumulated dose as well as to different prognostic factors were also considered. Assessment of associated conditions was carried out by means of Charlson comorbidity index. The patients' mean age was 73 years (range: 70-79 years). There were 43 men (88%) and 6 women (12%). Mean cisplatin dose intensity was 27 mg/m2/wk. A total of 157 chemotherapy courses were administered with a mean of 3.2 per patient. Mean Crb was 1.02 mg/dl (95% CI = 1.02-1.12), mean Crmax was 1.45 (95% CI = 1.34-1.46), and mean Crstb was 1.24 (95% CI = 1.16-1.32). Imax was equal to 0 in 13 patients (26%) and more than 0.4 mg/dl in 21 patients (43%). Istb was equal to 0 or negative in 22 (45%) and more than 0.4 in only 9 patients (18.3%). No significant relationship of serum creatinine levels, creatinine clearance levels, or of their increments or decrements to cisplatin dose intensity or accumulated dose were found. These levels also did not correlate with age, sex, comorbidity or Eastern Cooperative Oncology Group score. In 85% of patients, Crmax was reached between chemotherapy initiation and the third chemotherapy course, and thereafter renal function began to recover despite continued administration of cisplatin. Cisplatin is well tolerated by patients 70 years and older and dose intensity does not seem to influence renal function deterioration. Therefore, we failed to find reasons to encourage modification or limitation of cisplatin treatment in the elderly population.

Assessment of the effectiveness of descending aortomyoplasty for nonischemic cardiac failure by means of the subendocardial viability index

INTRODUCTION

Paraaortic or external aortic counterpulsation is been investigated as a definitive ventricular assistance in cases of terminal congestive heart failure and when heart transplantation is counterindicated. Our aims is to assess the haemodynamic effects of an descending aortomyoplasty in a biological model of congestive heart failure.

MATERIALS AND METHODS

As specimens, we used 10 "Large White" pigs. Mean weight was 25,3+/-2,14 Kg. After the administration of conventional anaesthesia, dissection of the latissimus dorsi muscle was performed. Then we performed a thoracotomy at the level of the fourth intercostal space to reach the thoracic aorta. The aorta is dissected 7 centimetres from the output of the subclavia artery and it is wrapped by the dissected muscle. A cardiomyostimulator is provided in order to allow the synchronization between the diastole and the muscle contraction. The model of heart failure was provoked using Verapamil plus Propanolol i.v.

RESULTS

A significant increase of the systolic and diastolic aortic pressure (54,2+/-4,05 and 27.5+/-6.77 mmHg versus 76.5+/-6.25 and 56.4+/-5.2 mmHg, p<0,001) and a significant decrease of the left ventricle telediastolic pressures were observed (12.9+/-9 versus 2.6+/-1.57 mmHg, p<0,001). An increase of the cardiac output (0.363+/-0.11 versus 0.846+/-0.08 L/min, p<0,001) and the Subendocardial Viability Index (0.968+/-0.076 versus 1.351+/-0,107, p<0,001)were observed in a model of non-ischemic heart failure.

CONCLUSION

Descending Aortomyoplasty as a technique to support circulation in cases of acute heart failure, improves the parameters of ventricular function, aiding the functional recovery of the left ventricle and improving significantly cardiac output as well as diastolic and systolic cardiac pressure. In addition to this, improves the Subendocardial Viability Index in cases of acute heart failure, which indirectly reflects an improvement of the Transmural and Subendocardial Perfusion of the failing heart.

Phase II trial of UFT activity in pretreated breast cancer patients

Seventy metastatic breast adenocarcinoma patients, pretreated with standard hormonotherapy or chemotherapy, received continuous UFT at 10 mg/kg/day, orally, for at least two months. There were one complete response (1.5%), 12 partial responses (17%), one minor response and 37 disease stabilizations. The median duration of response was nine months. A greater efficacy was demonstrated in 29 patients with soft tissue disease, with a rate of 38% objective responses. The major toxicity was gastrointestinal, with 45% of patients developing nausea and vomiting and 30%, diarrhea. Bone marrow toxicity was slight. UFT has shown antitumor activity in our group of pretreated patients, especially these with the cutaneous tumoral and/or inflammatory form of the disease.

Phase I study of UFT plus leucovorin in advanced colorectal cancer: a double modulation proposal

Twenty-six patients with advanced colorectal cancer were treated with UFT and leucovorin (LV). On day 1, patients received LV 500 mg/m2 in IV infusion, followed by 15 mg/12 h for 13 days. On days 1 to 14, patients took oral UFT twice daily. Three cycles were given every 28 days, unless grade III-IV toxicity appeared. The initial dose of UFT (200 mg/day) was increased until 800 mg/day. Dose limiting toxicities were stomatitis, diarrhea and epigastralgia. The maximum tolerated dose of UFT was 390 +/- 10 mg/m2. Three out of 24 evaluable patients achieved a partial response and 1 a complete response with UFT doses of 260 to 390 mg/m2. These results warrant confirmation in phase II studies.

Non-small-cell lung cancer (NSCLC): chemotherapy in advanced disease. Our experience in ten years

This is a review of the therapeutic schedules used in our service during the past 10 years for the therapy of advanced non-small-cell lung cancer. During the first years, nonrandomized trials were conducted and several combinations were tested: MACC (methotrexate, doxorubicin, cyclophosphamide, and CCNU), cisplatin-etoposide, and cisplatin-vindesine. The results of these trials were invariably discouraging: objective responses hardly reached 30%, while the survival was around 15 months in the best case. On December 1985 a new randomized trial, based on the combination MIP (mytomicin, ifosfamide, cisplatin) was designed; 60.7% of objective responses were achieved, with 9 complete remissions (17.6%) and 22 partial remissions (43.1%). Median survival was 15 months. In order to reduce the toxicity of this combination, carboplatin was substituted for cisplatin. Unfortunately, results were very poor. No complete remission, and only 5 partial responses (20%) were achieved. At the present time, a new randomized trial is being conducted. In it, MIP combination is compared with VIP (vindesine, ifosfamide, cisplatin). Preliminary results have shown no differences between both arms in response, toxicity, or survival. New therapeutic approaches, as neoadjuvant therapy, are being explored.

Acute leukemia and pregnancy

Acute leukemia was diagnosed in five pregnant patients who received chemotherapy during the course of pregnancy. Three were undergoing chemotherapy at conception. One patient died in the fifth month of pregnancy and the anatomic study of the fetus was normal. Four babies had low birth weights at birth. Of the four one was born prematurely, but without malformations. Later development was normal. The results are reviewed and compared with data from the literature, leading to the conclusion that pregnancy is not an absolute contraindication for cytostatic treatment, except in the first trimester, in which cytostatic treatment should be avoided.

Somatostatin analog SMS 201-995 and insulin needs in insulin-dependent diabetic patients studied by means of an artificial pancreas

SMS 201-995 is a new somatostatin analog which is 10-60 times more potent and specific than somatostatin as an inhibitor of GH and insulin release. The aim of this study was to assess its value as an adjunct to insulin therapy in insulin-dependent diabetic- (IDD) patients. Six IDD patients were studied. Their average insulin doses ranged from 22-46 U/day, and hemoglobin A1c levels varied between 6.5-11.5%. Two patients had background retinopathy and mild sensorimotor neuropathy. After 12 h of glucemic stabilization, the patients were kept normoglycemic by connecting them to the Biostator-GCIIS. The study entailed two parts in random order, in which standardised mixed meals were administered at 0800, 1400, and 2000 h with or without sc bolus injections of 50 micrograms SMS 201-995 immediately before meal ingestion. Plasma free insulin, C-peptide, GH, and glucagon were measured by RIA. Postprandial hyperglycemia was significantly diminished by SMS 201-995 after breakfast, lunch, and dinner. Insulin requirements, both total and 2-h postprandially, decreased significantly with a parallel reduction in free insulin levels. Postprandial glucagon levels also significantly decreased, but GH profiles were similar. In conclusion, the somatostatin analog SMS 201-995 has a potential value as an adjunct to insulin in the management of IDD patients.