G-CSF-mobilized peripheral blood progenitor cells for allogeneic transplantation: safety, kinetics of mobilization, and composition of the graft

Allogeneic transplantation of peripheral blood progenitor cells (PBPC) makes the general anaesthesia of the donor unnecessary and may result in more rapid engraftment and faster recovery of the immune system. We have studied G-CSF-mediated PBPC mobilization in healthy donors and analysed the cellular composition of the resulting PBPC grafts. PBPC grafts were obtained from nine healthy donors (18-67 years old) for allogeneic or syngeneic transplantation. Six donors received 10 micrograms/kg G-CSF per day, the others 5-6 micrograms/kg. Mobilization and harvesting were well tolerated except for moderate bone pain which occurred in all donors primed with 10 micrograms/kg. With 10 micrograms/kg, a 31-fold (9-62) enrichment of circulating CD34+ cells was observed with peak values constantly occurring on day 5 after the start of G-CSF administration. Starting harvest on day 5, one to three collections on consecutive days yielded 5.5 x 10(6)/kg (0.9-10.7) CD34+ cells, 219 x 10(6)/kg (106-314) T cells, and 34 x 10(6)/kg (23-67) NK cells per 10 litres leukapheresis volume. Altogether, PBPC grafts contained 3 times more CD34+ cells, 7 times more T cells, and 20 times more NK cells than five allogeneic marrow grafts that were analysed for comparison. The yield of CD34+ cells per 10 litres apheresis volume as well as the height of the CD34+ peak in peripheral blood were inversely correlated to the age of the donor. In the donors primed with 5-6 micrograms/kg G-CSF the increase of circulating CD34+ cells (4-7-fold enrichment) and the CD34+ cell yield per 10 litres leukapheresis volume (1 x 10(6)/kg [0.8-2.2]) was much smaller compared with the 10 micrograms/kg group. In conclusion, sufficient amounts of PBPC capable of restoring haemopoiesis in allogeneic recipients can be mobilized safely by administration of G-CSF (10 micrograms/kg s.c. for 5 d) in healthy donors, and harvested with one or two leukapheresis procedures. Whether the large numbers of T-cells and NK cells that are contained in the collection products may influence graft-versus-host and graft-versus-leukaemia reactivities of PBPC grafts remains to be determined.

Everolimus-eluting bioresorbable stent vs. durable polymer everolimus-eluting metallic stent in patients with ST-segment elevation myocardial infarction: results of the randomized ABSORB ST-segment elevation myocardial infarction-TROFI II trial

AIMS

Patients with ST-segment elevation myocardial infarction (STEMI) feature thrombus-rich lesions with large necrotic core, which are usually associated with delayed arterial healing and impaired stent-related outcomes. The use of bioresorbable vascular scaffolds (Absorb) has the potential to overcome these limitations owing to restoration of native vessel lumen and physiology at long term. The purpose of this randomized trial was to compare the arterial healing response at short term, as a surrogate for safety and efficacy, between the Absorb and the metallic everolimus-eluting stent (EES) in patients with STEMI.

METHODS AND RESULTS

ABSORB-STEMI TROFI II was a multicentre, single-blind, non-inferiority, randomized controlled trial. Patients with STEMI who underwent primary percutaneous coronary intervention were randomly allocated 1:1 to treatment with the Absorb or EES. The primary endpoint was the 6-month optical frequency domain imaging healing score (HS) based on the presence of uncovered and/or malapposed stent struts and intraluminal filling defects. Main secondary endpoint included the device-oriented composite endpoint (DOCE) according to the Academic Research Consortium definition. Between 06 January 2014 and 21 September 2014, 191 patients (Absorb [n = 95] or EES [n = 96]; mean age 58.6 years old; 17.8% females) were enrolled at eight centres. At 6 months, HS was lower in the Absorb arm when compared with EES arm [1.74 (2.39) vs. 2.80 (4.44); difference (90% CI) -1.06 (-1.96, -0.16); Pnon-inferiority < 0.001]. Device-oriented composite endpoint was also comparably low between groups (1.1% Absorb vs. 0% EES). One case of definite subacute stent thrombosis occurred in the Absorb arm (1.1% vs. 0% EES; P = ns).

CONCLUSION

Stenting of culprit lesions with Absorb in the setting of STEMI resulted in a nearly complete arterial healing which was comparable with that of metallic EES at 6 months. These findings provide the basis for further exploration in clinically oriented outcome trials.

The value of class IC antiarrhythmic drugs for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm

In a single-blind randomized study, the efficacy and safety of intravenous propafenone (2 mg/kg body weight per 10 min) versus flecainide (2 mg/kg per 10 min) were assessed in 50 patients with atrial fibrillation or flutter. Treatment was considered successful if sinus rhythm occurred within 1 h. Conversion to sinus was achieved in 11 (55%) of 20 patients with atrial fibrillation treated with propafenone and in 18 (90%) of 20 with atrial fibrillation treated with flecainide (p less than 0.02). If atrial fibrillation was present less than or equal to 24 h, conversion to sinus rhythm was achieved in 8 (57%) of 14 patients in the propafenone group and 13 (93%) of 14 in the flecainide group (p less than 0.05). Atrial flutter was converted in two (40%) of five patients treated with propafenone and in one (20%) of five with flecainide (p = NS). Mean time to conversion was 16 +/- 10 min in the propafenone group versus 18 +/- 13 min in the flecainide group (p = NS). QRS lengthening (83 +/- 15 to 99 +/- 20 ms) was observed only in the patients treated with flecainide (p less than 0.001). Patients successfully treated with propafenone showed significantly higher plasma levels than those whose arrhythmia did not convert to sinus rhythm. Transient adverse effects were more frequent in the flecainide group (40%) than in the propafenone group (8%) (p less than 0.01). In conclusion, at a dose of 2 mg/kg in 10 min, flecainide is more effective than propafenone for conversion of paroxysmal atrial fibrillation to sinus rhythm. However, considering the propafenone plasma levels and very few adverse effects, the dose or infusion rate, or both, used in the propafenone group may not have been sufficient to achieve an optimal effect. Neither drug seems very effective in patients with atrial flutter.

Spinal manipulative therapy for low back pain

BACKGROUND

Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain.

OBJECTIVES

To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened.

SELECTION CRITERIA

Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure.

DATA COLLECTION AND ANALYSIS

Two authors, who served as the reviewers for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage).

MAIN RESULTS

Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.

REVIEWER'S CONCLUSIONS

There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Comparative effects of hydrofluoroalkane and chlorofluorocarbon beclomethasone dipropionate inhalation on small airways: assessment with functional helical thin-section computed tomography

A double-blind, randomized, parallel-group pilot study compared the relative efficacy of hydrofluoroalkane-134a beclomethasone dipropionate (HFA-BDP [QVAR]; mass median aerodynamic diameter, 0. 8-1.2 m) versus cholorofluorocarbon-11/12 BDP (CFC-BDP [Beclovent]; mass median aerodynamic diameter, 3.5-4.0 m) in 31 steroid naive patients with mild to moderate asthma (PC(20,) 4 mg/mL). Functional high-resolution computed tomography was used to assess the relative efficacy of HFA-BDP and CFC-BDP on regional air trapping, as an indirect measure of small airways function and on regional hyperreactivity. Pretreatment functional computed tomography was performed at residual volume before and after methacholine challenge. After 4 weeks of treatment, functional imaging was repeated before and after the same concentration of methacholine that was administered before the treatment (n = 19 patients). Quantitative assessment of changes in distribution of lung attenuation was performed. After 4 weeks of treatment, the HFA-BDP group showed significantly more improvement in air trapping overall (a shift in the lung attenuation curve at residual volume toward more attenuation) on the posttreatment computed tomography scan (P <.05; Fisher's Exact Test). After an equal constrictor stimulus (methacholine concentration), subjects treated with HFA-BDP (n = 10 patients) showed less increase in air trapping overall than subjects treated with CFC-BDP (n = 9 patients) on the posttreatment scans compared with the pretreatment scans (P <.001; Fisher's Exact Test). No significant difference was demonstrated between the 2 treatment groups with respect to improvement in symptoms, spirometry, or methacholine responsiveness assessed by FEV(1), except for a greater reduction in breathlessness in the HFA-BDP group (P <.05). We conclude that HFA-BDP may have greater efficacy in the peripheral airways and that this effect is better assessed with functional imaging computed tomography techniques than with conventional physiologic tests.

Recurrence of paroxysmal atrial fibrillation or flutter after successful cardioversion in patients with normal left ventricular function

One hundred twenty-four consecutive patients (85%) with paroxysmal atrial fibrillation (AF) and 21 (15%) with atrial flutter (AFI) were studied immediately after pharmacologic or electrical cardioversion to sinus rhythm. Mean age was 59 +/- 13 years (range 23 to 79). Patients with reduced left ventricular function were excluded from the study. After restoration to sinus rhythm, the clinical course of all patients was followed for the first recurrence of paroxysmal AF or AFI irrespective of the therapeutic approach. Mean follow-up was 23 +/- 16 months. After 12 months of follow-up, 50% of all patients remained in sinus rhythm. Univariate analysis indicated that coronary artery disease (relative risk 1.9; 95% confidence interval 0.9-3.9), history of paroxysmal AF or AFI (2.3; 1.1-5.0), female sex (2.3; 1.1-4.6), pulmonary disease (3.9; 1.9-7.6) and valvular heart disease (4.4; 2.2-8.8) were associated with an increased risk for recurrent or frequent episodes of paroxysmal AF or AFI. No predictors were found to be associated with a decrease in length of the recurrence-free period after successful conversion to sinus rhythm. Multivariate analysis identified history of AF or AFI (odds ratio 2.5; 95% confidence interval 0.9-6.4), coronary artery disease (3.1; 1.1-8.2) and female sex (3.4; 1.3-8.9) as independent predictors for recurrent or frequent episodes of paroxysmal AF or AFI. The presence of these risk factors should be taken into account when prophylactic therapy with antiarrhythmic drugs is being considered in the treatment of paroxysmal AF or AFI.

Intravenous flecainide versus verapamil for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm

In a single-blind randomized study, the efficacy of intravenous flecainide (2 mg/kg/10 minutes) versus verapamil (10 mg/1 minute) was assessed in 40 patients with paroxysmal atrial fibrillation (AF) or atrial flutter (AFI). The treatment was considered successful if sinus rhythm occurred within 1 hour. Of 20 patients receiving flecainide, 14 of 17 (82%) with AF converted to sinus rhythm, but in 3 patients with AFI flecainide failed. All patients treated with verapamil (17 AF, 3 AFI) showed lower ventricular rates after 1 hour; however, only 1 (6%) with AF converted to sinus rhythm and 1 (6%) converted to AFI. Patients who did not convert to sinus rhythm after treatment with verapamil were treated with flecainide and observed for another hour. After the change to flecainide, 9 of 15 patients (60%) with AF still converted. Thus, 23 of 32 patients (72%) with AF and none of 7 with AFI converted to sinus rhythm after treatment with flecainide. Conversion to sinus rhythm was achieved in 19 of 22 patients (86%) when AF lasted less than 24 hours and in 4 of 10 (40%) when the arrhythmia lasted greater than 24 hours. Transient adverse effects were noted in 10 patients (26%) after flecainide. In summary, flecainide is an effective and safe drug for conversion of paroxysmal AF to sinus rhythm, but ineffective for AFI. Verapamil appears to be of no use for conversion of AF or AFI to sinus rhythm.

Effectiveness of sotalol in preventing supraventricular tachyarrhythmias shortly after coronary artery bypass grafting

To investigate the effectiveness and safety of low-dose sotalol (a class III antiarrhythmic beta-blocking agent) in the prevention of supraventricular tachyarrhythmias (SVTs) and to identify predictors for the occurrence of these arrhythmias shortly after coronary artery bypass grafting, 300 consecutive patients were randomized in a double-blind, placebo-controlled fashion. Patients with severely depressed left ventricular function or other contraindications for beta blockers were excluded. Beginning at 4 hours and up to the sixth day after surgery, 150 patients received 40 mg of sotalol every 6 hours. SVT was observed in 24 (16%) of 150 low-dose sotalol-and in 49 (33%) of 150 placebo-treated patients [p less than 0.005]. In patients receiving sotalol, atrial fibrillation was the only noted tachyarrhythmia, whereas in the placebo group, 42 (28%) patients had atrial fibrillation, 3 (2%) atrial flutter, 1 (0.7%) atrial tachycardia and 3 (2%) sinus tachycardia. Drug-related adverse effects necessitating discontinuation of the drug were noted in only 2 (1%) sotalol-treated patients and 4 (3%) placebo-treated patients (p = not significant). For both groups, univariate analysis indicated that older age, 1- or 2-vessel coronary artery disease, long bypass (greater than or equal to 150 minutes) and aorta cross-clamp time (greater than or equal to 120 minutes) were predictive variables for the occurrence of SVTs. Multivariate analysis showed that male sex (odds ratio 2.3), 1- or 2-vessel coronary artery disease (odds ratio 2.0) and older age (odds ratio 1.1) were independent risk factors for increased occurrence of postoperative SVT.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid Angioplasty and Stent Placement: Comparison of Transcranial Doppler US Data and Clinical Outcome with and without Filtering Cerebral Protection Devices in 509 Patients

PURPOSE

To prospectively evaluate emboli detected at transcranial Doppler ultrasonography (US) and outcome of carotid angioplasty and stent placement and compare these findings in patients treated with the use of filtering cerebral protection devices (CPDs) with the findings in patients treated without the use of filtering CPDs.

MATERIALS AND METHODS

This study was approved by the institutional human research committee. Written informed consent was obtained for all patients. Patients were divided into three groups: 161 patients treated before filtering CPDs had become available (group 1), 151 patients treated with filtering CPDs (group 2), and 197 patients treated without CPDs after CPDs had become available (group 3). Clinical end points were cerebral ischemic events and death. Transcranial Doppler US end points included isolated microemboli, microembolic showers, macroemboli, and distal thrombus. The procedure was divided into five phases: wiring, predilation, stent deployment, postdilation, and CPD handling. Data not distributed normally were analyzed with the Mann-Whitney U statistic. For binomial data, the chi(2) test was used. P < .05 indicated statistical significance.

RESULTS

For each phase, median and interquartile range (IQR) for isolated microemboli in group 2 versus group 3 were as follows: wiring, 51 (IQR, 31-69) versus 27 (IQR, 15-48); predilation, 19 (IQR, 13-33) versus 13 (IQR, 8-19); stent deployment, 64 (IQR, 46-82) versus 48.5 (IQR, 33.25-66); and postdilation, 24 (IQR, 14-39) versus 16 (IQR, 11-27.5) (P < .001 for each phase). Median and IQR for microembolic showers were as follows: wiring, 0 (IQR, 0-3) versus 0 (IQR, 0-0); predilation, 1.5 (IQR, 0-4) versus 0 (IQR, 0-2); stent deployment, 22 (IQR, 11-36) versus 11 (IQR, 6-17); postdilation, three (IQR, 0-9) versus one (IQR, 0-4); (postdilation phase, P = .001; all other phases, P < .001). Median for isolated microemboli in group 1 versus groups 2 and 3 combined were as follows: predilation, 10 (IQR, 5-22.75) versus 16 (IQR, 9-25) (P = .001); stent deployment, 32 (IQR, 15-58) versus 54 (IQR, 40.5-74) (P < .001); and postdilation, 11 (IQR, 6-19) versus 18 (IQR, 12-33) (P < .001). Median for microembolic showers during stent deployment were six (IQR, 1-14) versus 13 (IQR, 7-26) (P < .001). Five patients died, and five major strokes and 14 minor strokes occurred. Eight macroemboli occurred in unprotected procedures; six distal thrombi occurred in protected procedures.

CONCLUSION

Carotid angioplasty and stent placement yielded more microemboli in patients treated with filtering CPDs than in unprotected procedures. The infrequent occurrence of cerebral sequelae did not allow comprehensive statistical comparison between groups.

Specificity of purified monoacylglycerol lipase, palmitoyl-CoA hydrolase, palmitoyl-carnitine hydrolase, and nonspecific carboxylesterase from rat liver microsomes

The comparative substrate specificities of five purified serine hydrolases from rat liver microsomes have been investigated, especially their action upon natural lipoids. All enzymes had high carboxylesterase activities with simple aliphatic and aromatic esters and thioesters. The broad pH optima were in the range of pH 6-10. Synthetic amides were less potent substrates. The hydrolytic activities towards palmitoyl-CoA and monoacyl glycerols were generally high, whereas phospholipids and palmitoyl carnitine were cleaved at moderate rates. Acetyl-CoA, acetyl carnitine, and ceramides were not cleaved at all. The closely related hydrolases with the highest isoelectric points (pI 6.2 and 6.4) were most active with palmitoyl-CoA and palmitoyl glycerol. One of these enzymes might also be responsible for the low cholesterol oleate-hydrolyzing capacity of rat liver microsomes. Among the other hydrolases, that with pI 6.0 showed significant activities with simple butyric acid esters, 1-octanoyl glycerol, and octanoylamide. The esterase with pI 5.6 had the relatively highest activities with palmitoyl carnitine and lysophospholipids. The purified enzyme with pI 5.2 showed some features of the esterase pI 5.6, but generally had lower specific activities, except with 4-nitrophenyl acetate. The lipoid substrates competitively inhibited the arylesterase activity of the enzymes. The varying activities of the individual hydrolases were influenced in parallel by a variety of inhibitors, indicating that the purified hydrolases possessed a relatively broad specificity and were not mixtures of more specific enzymes. The nomenclature of the purified hydrolases is discussed.

Allogeneic bone marrow transplantation for chronic myelomonocytic leukemia in childhood: a report from the European Working Group on Myelodysplastic Syndrome in Childhood

PURPOSE

To evaluate the role of allogeneic bone marrow transplantation (BMT) in children with chronic myelomonocytic leukemia (CMML).

PATIENTS AND METHODS

Forty-three children with CMML given BMT and reported to the European Working Group on Myelodysplastic Syndrome in Childhood (EWOG-MDS) data base were evaluated. In 25 cases, the donor was a human leukocyte antigen (HLA)-identical or a one-antigen-disparate relative, in four cases a mismatched family donor, and in 14 a matched unrelated donor (MUD). Conditioning regimens consisted of total-body irradiation (TBI) and chemotherapy in 22 patients, whereas busulfan (Bu) with other cytotoxic drugs was used in the remaining patients.

RESULTS

Six of 43 patients (14%), five of whom received transplants from alternative donors, failed to engraft. There was a significant difference in the incidences of chronic graft-versus-host disease (GVHD) between children transplanted from compatible/one-antigen-mismatched relatives and from alternative donors (23% and 87%, respectively; P < .005). Probabilities of transplant-related mortality for children given BMT from HLA-identical/one-antigen-disparate relatives or from MUD/ mismatched relatives were 9% and 46%, respectively. The probability of relapse for the entire group was 58%, whereas the 5-year event-free survival (EFS) rate was 31%. The EFS rate for children given BMT from an HLA-identical sibling or one-antigen-disparate relative was 38%. In this latter group, patients who received Bu had a better EFS compared with those given TBI (62% v 11%, P < .01).

CONCLUSION

Children with CMML and an HLA-compatible relative should be transplanted as early as possible. Improvement of donor selection, GVHD prophylaxis, and supportive care are needed to ameliorate results of BMT from alternative donors.

Imatinib mesylate is effective in children with chronic myelogenous leukemia in late chronic and advanced phase and in relapse after stem cell transplantation

A multicentric phase 2 study was conducted to determine the efficiency and the tolerance of imatinib mesylate in children with chronic myelogenous leukemia (CML) in advanced phase of the disease, in relapse after stem cell transplantation, or in case of failure to an interferon alpha-based regimen. In all, 30 children from eight European countries were enrolled. In 18 children assessable for hematologic response, imatinib mesylate induced complete hematologic response in eight (80%) of the 10 patients included in chronic phase and in six (75%) of eight enrolled in advanced phase of the disease with acceptable toxicity. In 27 patients assessable for cytogenetic response, imatinib mesylate induced disappearance of Philadelphia chromosome-positive bone marrow cells in 12 (60%) of 20 children included in chronic phase and in two (29%) of seven included in advanced phase. A reduction of the bcr-abl/abl ratio to less than 10(-4) was achieved in 11 (50%) of the children included in chronic phase. Estimated 12-month overall survival rate was 95% (95% CI, 87-100%) for the patients included in chronic phase and 75% (95%CI, 45-100%) for those enrolled in advanced phase. Imatinib mesylate is well tolerated and molecular remission can be achieved in children with CML.

Extension of a spontaneous coronary artery dissection due to thrombolytic therapy

We describe a case of spontaneous coronary artery dissection in a 38-year-old woman presenting with anterior myocardial infarction who was initially treated with thrombolysis. During the administration of thrombolytics the clinical symptoms and the electrocardiogram (ECG) deteriorated. Coronary angiography revealed a major dissection in the proximal left descending coronary artery. A spontaneous dissection was hypothesized to have extended by thrombolytic-induced bleeding into the dissected vessel wall. Therefore, we advocate that, especially in young female patients presenting with an acute myocardial infarction and without cardiac risk factors, direct coronary angiography be considered, rather than thrombolytic therapy, in order to decide for the optimal therapeutic strategy.

Hypertrophic obstructive cardiomyopathy. Initial results and long-term follow-up after Morrow septal myectomy

BACKGROUND

This study was performed to assess the initial results and long-term follow-up of Morrow septal myectomy for patients with hypertrophic obstructive cardiomyopathy (HOCM).

METHODS AND RESULTS

We studied 38 consecutive patients with HOCM (age, 13 to 74 years) who underwent a Morrow septal myectomy between 1977 and 1992. There were no perioperative deaths, and the postoperative course was uneventful for all except 2 of the patients. One patient required implantation of a pacemaker due to a complete heart block, and in 1 patient a small ventricular septal defect was caused. Follow-up (mean, 6.8 years) was 100% complete. No patient was reoperated for recurrent HOCM. All except 1 patient experienced a major functional improvement with a decrease of the mean New York Heart Association functional class from 3.0 before operation to 1.5 at follow-up (P < .001). Symptoms persisting during follow-up were angina pectoris in 3 of 22 patients (14%), dyspnea in 6 of 30 patients (20%), dizzy spells in 2 of 12 patients (17%), and syncope in 2 of 10 patients (20%). During follow-up no HOCM related death occurred. All patients were restudied by Doppler echocardiography. The peak gradient in the left ventricular outflow tract decreased from 72 +/- 30 mm Hg (range, 31 to 144 mm Hg) to 6 +/- 4 mm Hg (range, 0 to 20; P < .001). A systolic anterior movement was seen in 8 patients (21%) compared with 32 patients (97%) before the operation (P < .001). The left ventricular outflow tract diameter increased from 17 +/- 3 mm (range, 10 to 23 mm) to 22 +/- 3 mm (range, 15 to 33 mm; P < .001), and the mean subaortic septal thickness decreased from 23 +/- 5 mm (range, 15 to 35 mm) to 15 +/- 6 mm (range, 8 to 30 mm; P < .001).

CONCLUSIONS

Morrow septal myectomy for patients with HOCM is a safe procedure with an excellent clinical and Doppler echocardiographic long-term follow-up.

Effective mobilisation of peripheral blood progenitor cells with 'Dexa-BEAM' and G-CSF: timing of harvesting and composition of the leukapheresis product

The mini-BEAM regimen (BCNU, etoposide, cytarabine, melphalan) and its modification 'Dexa-BEAM' are effective salvage protocols for relapsed Hodgkin's disease and non-Hodgkin's lymphoma. Since many patients with relapsed lymphoma are eligible for high-dose chemotherapy with autologous stem cell rescue, we were interested in the suitability of these second line regimens for mobilising peripheral blood progenitor cells (PBPC). The kinetics of PBPC were studied in 15 patients treated with Dexa-BEAM and granulocyte colony-stimulating factor (G-CSF). Leukocytes started to rise from < 0.5 nL-1 on day 18 (16-22) after Dexa-BEAM, and exceeded 10 nL-1 on day 20 (18-28). Peripheral blood CFU-GM peaked on day 21 (19-28) and declined slowly thereafter; the median leukocyte count was 18.7 nL-1 (12.2-60) on the day of CFU-GM-peak. The maximum number of CFU-GM circulating in peripheral blood was inversely correlated to the duration of leukopenia after Dexa-BEAM. Measurement of CD34+ cells with the monoclonal antibody 8G12-PE (HPCA-2) predicted the number of CFU-GM precisely in both peripheral blood and leukapheresis products (r = 0.90-0.95). Two to six leukapheresis procedures yielded 6.39 x 10(8) mononuclear cells kg-1 (1.82-13.49) containing 44.4 x 10(4) CFU-GM kg-1 (2.2-213.8). Immunophenotypical analysis revealed that the percentage of CD19+ B cells was very low in all collection products (less than 1%). Nine patients were autografted with PBPC (15.4-213.8 x 10(4) CFU-GM kg-1) after myeloablative chemotherapy and experienced rapid and sustained engraftment (Platelets > 50 nL-1 on day +13 [9-22]). We conclude that PBPC can be mobilised effectively by Dexa-BEAM plus G-CSF. An adequate timing of PBPC collection (when the leukocyte count has exceeded 10 nL-1) and evaluation of the progenitor content of the leukapheresis products with 8G12-PE will allow to minimise the number of leukaphereses.

Acute pharmacologic conversion of atrial fibrillation and flutter: the role of flecainide, propafenone, and verapamil

Efficacy and safety of intravenous flecainide (2 mg/kg body weight in 10 minutes), verapamil (10 mg in 1 minute), and propafenone (2 mg/kg body weight in 10 minutes) were investigated in 90 consecutive patients with atrial fibrillation (AF) or flutter (AFL). In the first 40 patients, flecainide and verapamil were evaluated; in the second 50 patients, flecainide and propafenone were compared, both in a single-blind randomized study design. The primary end point was sinus rhythm occurring within 1 hour after start of infusion. Sinus rhythm was attained in 32 of 37 patients (86%) with AF treated with flecainide and in 11 of 20 patients (55%) with AF treated with propafenone. In recent onset AF (less than or equal to 24 hours) conversion rates were 24 of 25 patients (96%) in the flecainide group and 8 of 14 patients (57%) in the propafenone group (p less than 0.05). Conversion of AFL occurred in only 1 of 8 patients (13%) in the flecainide-treated patients and in 2 of 5 patients (40%) treated with propafenone (difference not significant). Verapamil was almost ineffective, since only 1 of 20 patients (5%) responded within 1 hour. Time to conversion was 21 +/- 17 minutes in the flecainide group and 16 +/- 10 minutes in the propafenone group. QRS widening occurred in flecainide-treated patients (83 +/- 15 to 99 +/- 20 msec; p less than 0.001), but not after propafenone (83 +/- 11 to 86 +/- 12 msec). Significantly higher plasma levels were found in patients with conversion within 1 hour using propafenone.(ABSTRACT TRUNCATED AT 250 WORDS)

Restenosis after carotid angioplasty and stenting: a follow-up study with duplex ultrasonography

OBJECTIVES

To prospectively document the incidence, location, risk factors for and clinical consequences of restenosis after carotid artery angioplasty and stenting (CAS).

METHODS

Serial duplex and neurological examinations were performed in 217 patients one day (n = 216), 3 (n = 189), 12 (n = 129) and 24 (n = 48) months, after CAS. The relationship between patient, lesion and procedure variables and restenosis was determined at 12 months.

RESULTS

The prevalence of restenosis > or = 50% was 14, 16, 18, and 21%, respectively, and was only significantly related with loss of proximal stent apposition (odds ratio 3.4, 95% confidence interval: 1.0-11.7, p < 0.05). Four restenoses were symptomatic.

CONCLUSIONS

Restenosis after CAS is common, unpredictable but infrequently symptomatic.

Long-term impact of chronic total occlusion recanalisation in patients with ST-elevation myocardial infarction

Background

During primary percutaneous coronary intervention (PCI), a concurrent chronic total occlusion (CTO) is found in 10% of patients with ST-elevation myocardial infarction (STEMI). Long-term benefits of CTO-PCI have been suggested; however, randomised data are lacking. Our aim was to determine mid-term and long-term clinical outcome of CTO-PCI versus CTO-No PCI in patients with STEMI with a concurrent CTO.

Methods

The Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) was a multicentre randomised trial that included 302 patients with STEMI after successful primary PCI with a concurrent CTO. Patients were randomised to either CTO-PCI or CTO-No PCI. The primary end point of the current study was occurrence of major adverse cardiac events (MACE): cardiac death, coronary artery bypass grafting and MI. Other end points were 1-year left ventricular function (LVF); LV-ejection fraction and LV end-diastolic volume and angina status.

Results

The median long-term follow-up was 3.9 (2.1–5.0) years. MACE was not significantly different between both arms (13.5% vs 12.3%, HR 1.03, 95% CI 0.54 to 1.98; P=0.93). Cardiac death was more frequent in the CTO-PCI arm (6.0% vs 1.0%, P=0.02) with no difference in all-cause mortality (12.9% vs 6.2%, HR 2.07, 95% CI 0.84 to 5.14; P=0.11). One-year LVF did not differ between both arms. However, there were more patients with freedom of angina in the CTO-PCI arm at 1 year (94% vs 87%, P=0.03).

Conclusions

In this randomised trial involving patients with STEMI with a concurrent CTO, CTO-PCI was not associated with a reduction in long-term MACE compared to CTO-No PCI. One-year LVF was comparable between both treatment arms. The finding that there were more patients with freedom of angina after CTO-PCI at 1-year follow-up needs further investigation.

Clinical trial registration

EXPLORE trial number NTR1108 www.trialregister.nl.

Multicenter evaluation of the phosphorylcholine-coated biodivYsio stent in short de novo coronary lesions: The SOPHOS study

AIMS: The BiodivYsio trade mark stent (Biocompatibles Ltd, Farnham, UK) is coated with a phosphorylcholine (PC)-containing copolymer to confer biocompatibility. The SOPHOS (Study Of PHosphorylcholine coating On Stents) study was designed to assess the safety and efficacy of this novel coronary stent and by indirect comparison to indicate equivalence with other formal stent studies. METHODS AND RESULTS: Patients with angina and a single short (#x2A7F;12 mm) de novo lesion in a native coronary artery of >/=2.75 mm diameter were included. A total of 425 patients were allocated in 24 centers. Clinical data were collected at one-, six- and nine-month follow-up. Angiography was performed before and after the stent implantation. In addition, in the first 200 patients (SOPHOS A) angiography was routinely performed at six months. The following 225 patients (SOPHOS B) were merely followed up clinically. The primary end-point of the study, the six-month MACE-rate (MACE = Major Adverse Cardiac Events) was 13.4% (two cardiac death; five Q-wave/nine non-Q-wave myocardial infarctions (MI); nine CABG and 32 target lesion revascularization (TLR), which is similar to the calculated 15% MACE-rate in comparable reference studies. Secondary end-points included among others restenosis at six months in the SOPHOS A population. The target vessel diameter was 2.98 +/- 0.48 mm. Minimal lumen diameter pre/post procedure and at follow-up was 1.00 +/- 0.32, 2.69 +/- 0.37, 1.91 +/- 0.71 mm, respectively. The binary restenosis rate (>/=50% diameter stenosis at follow-up) was 17.7%. CONCLUSION: The coronary BiodivYsio stent is safe and effective as a primary device for the treatment of native coronary artery lesions in patients with stable or unstable angina pectoris. Clinical and angiographic results are in the statistical range of equivalence with comparable studies with other current stents.

Efficacy and safety of percutaneous treatment of iatrogenic femoral artery pseudoaneurysm by biodegradable collagen injection

OBJECTIVES; The goal of this study was to assess the safety and efficacy of femoral artery pseudoaneurysm (FAP) closure by collagen injection. BACKGROUND; The FAP is an infrequent but troublesome complication after percutaneous transfemoral catheter procedures. If ultrasound-guided compression repair (UGCR) fails, vascular surgery is indicated. We have developed a less invasive method to close FAPs percutaneously by injecting collagen and, thus, inducing clotting within the aneurysm.

METHODS

Via a 9F needle or 11F sheath, a biodegradable adhesive bovine collagen is injected percutaneously into the FAP, guided by angiography from the contralateral site.

RESULTS

From 1993 to 2000, compression and UGCR had failed to obliterate 110 FAPs. These patients have been treated by collagen injection. Mean age of the patients was 65.6 +/- 10.2 years (range: 32 to 85 years), and 50% were women. Immediate closure of the FAP was achieved in 107/110 patients (97.3%) without any complication or adverse effect. In one patient the collagen could not be applied due to unfavorable anatomy. One patient needed a second session of collagen injection. In one patient too much collagen was inserted, which resulted in external compression of the artery, and surgical intervention was required. The overall success rate was 108/110 (98%, 95% confidence interval: 93.5% to 99.8%). Among the patients with successful procedures, there were no recurrences during six months follow-up.

CONCLUSIONS

The percutaneous treatment of iatrogenic FAP, by injection with collagen, is an effective and safe strategy. This method provides an excellent therapeutic alternative to the traditional surgical management.

Effect of coumarins started before coronary angioplasty on acute complications and long-term follow-up: a randomized trial

BACKGROUND

Coronary angioplasty frequently creates a thrombogenic surface, with subsequent mural thrombosis that may lead to acute complications and possibly stimulates the development of restenosis. Whether coumarins can prevent these complications is unclear. The objective of this open, randomized trial was to assess the clinical effect of coumarins started before coronary angioplasty and continued for 6 months.

METHODS AND RESULTS

Before coronary angioplasty, 530 patients were randomly assigned to aspirin plus coumarins and 528 patients to aspirin alone. At the start of the angioplasty, the mean international normalized ratio was 2.7+/-1.1; during follow-up, it was 3.0+/-1.1. At 30 days, the composite end point of death, myocardial infarction, target-lesion revascularization, and stroke was observed in 18 patients (3.4%) treated with aspirin plus coumarin compared with 34 patients (6.4%) treated with aspirin alone (relative risk, 0.53; 95% CI, 0.30 to 0.92). At 1 year, these figures were 14.3% and 20.3%, respectively (relative risk, 0.71; 95% CI, 0.54 to 0.93). The incidence of major bleeding and false aneurysm during hospitalization was 3.2% and 1.0%, respectively (relative risk, 3.39; 95% CI, 1.26 to 9.11). The benefit of coumarins was observed in both stented and nonstented patients.

CONCLUSIONS

Coumarins in addition to aspirin started before PTCA and continued for 6 months was more effective than aspirin alone in the prevention of acute and late complications after coronary angioplasty. This benefit was accompanied by a small but significant increase in bleeding complications.

Percutaneous transluminal angioplasty of the left subclavian artery to prevent or treat the coronary-subclavian steal syndrome

A hemodynamic significant left subclavian artery stenosis or occlusion proximal to the origin of the left internal mammary artery (LIMA) can result in an impaired or reversed flow through the LIMA and the coronary artery to which it has been anastomosed. In this study, we report on our immediate and long-term follow-up results in 31 consecutive patients who underwent percutaneous transluminal coronary angioplasty of the left subclavian artery shortly before or after coronary artery bypass grafting with use of the LIMA.

Autografting of highly purified peripheral blood progenitor cells following myeloablative therapy in patients with lymphoma: a prospective study of the long-term effects on tumor eradication, reconstitution of hematopoiesis and immune recovery

In a prospective study, we have investigated CD34+ selection of peripheral blood progenitor cells (PBPC) for autotransplantation in patients with lymphoma. Twenty-six consecutive patients (10 follicular lymphomas, seven mantle cell lymphomas, seven B-CLL, two immunocytomas) were mobilized using chemotherapy plus G-CSF. Sufficient numbers of PBPC could be collected from 24 patients and were immunoselected with the semiautomated Isolex 300 (n = 17) or the fully integrated Isolex 300i (n = 7) devices. The selection products were assayed by PCR amplification of clonal CDRIII or t(14;18) rearrangements for residual tumor cell content. Residual disease and long-term hematopoietic and immune recovery were studied by assessing the following parameters at 3, 6, and 12 months post-transplant: CDRIII or t(14;18) PCR, platelet count, lymphocyte subsets, serum IgG, serum IgA, and measles titer. With the Isolex 300 device 26% (10-65) of input CD34+ cells were recovered with a median purity of 89.2% (49.4-98.9) after CD34+ selection. The Isolex 300i device allowed significantly better recoveries (46% (22-86)) and purities of CD34+ cells (98.8% (92.2-99.2)). The overall purging efficacy was 3.2 (0.6-5.1) log. Twenty patients have been reinfused with CD34+ selected grafts after myeloablative preparation. Rapid engraftment occurred in all patients. With a median follow-up of 28 (19-42) months, 14 patients are alive without clinical or molecular evidence of disease recurrence, whereas five have relapsed and one additional patient shows persistent presence of the disease-specific molecular marker without clinical progression. Cellular and serological parameters of hematopoietic and immune functions were largely normal at 12 months post-transplant including the measles titer which was present in all patients. Kinetics of immunohematopoietic recovery were similar to those of 12 control patients who had received unmanipulated PBPC during the same time period except for the recovery of CD4+ CD45RA+ T cells which was significantly delayed in the CD34+ group. During the first year post-transplant, transient monoclonal or oligoclonal gammopathies were observed in seven of 16 study patients. We conclude that CD34+ selection with the Isolex system allows preparation of highly purified CD34+ fractions and effective tumor cell depletion. The CD34+ products can be reinfused safely after myeloablative treatment and result in sustained hematopoietic and immune recovery. The fact that all patients retained their specific measles immunity suggests that myeloablative treatment with reinfusion of highly purified CD34+ PBPC is not immunoablative.