Long-term prognosis of patients treated by coronary sinus-based percutaneous annuloplasty: single centre experience

AIMS

This study aims to report long-term mortality, echocardiographic, and clinical outcomes of patients receiving treatment for functional mitral regurgitation (FMR) with the Carillon device.

METHODS AND RESULTS

This was a single centre analysis of prospectively collected data from patients treated with the Carillon Mitral Contour System for symptomatic congestive heart failure despite guideline-directed medical therapy, who were included from a single centre from the TITAN II study. All patients presented with New York Heart Association (NYHA) class 2 or greater symptoms, grade 2+ to 4+ FMR, left ventricular enlargement, and reduced ejection fraction. Surviving patients were evaluated for long-term follow-up post-procedure, averaging 6.9 years. Fifteen (15) patients (mean age 72 years, 60% male, 100% NYHA class III or IV, 50% MR grade 3+ or 4+) were treated with the Carillon device. The Kaplan-Meier mortality rate was 40% at 6 years of follow-up. Long-term survival through 6 years was associated with echocardiographic improvement in mitral regurgitation (change in effective regurgitant orifice area in survivors versus non-survivors from baseline to 1 year follow-up, -9.0 ± 5.6 vs. -1.7 ± 1.5, P = 0.02) and clinical status at 12 months (difference in NYHA at 1 year follow-up between survivors versus non-survivors, P = 0. 05) which was sustained throughout follow-up. All patients at 6 year follow-up had ≤2+ MR, with 6 of 7 having 0-1+ MR. Left ventricular end-diastolic volume was reduced from 154.0 ± 65.7 mL at baseline to 104.5 ± 59.2 mL at 6 year follow-up, P = 0.03 in survivors with both measurements.

CONCLUSIONS

Among patients with congestive heart failure treated with the Carillon device, long-term survival is associated with favourable 1 year and sustained improvements in mitral regurgitation, left ventricular volume, ejection fraction, and clinical status.

The REDUCE FMR Trial: A Randomized Sham-Controlled Study of Percutaneous Mitral Annuloplasty in Functional Mitral Regurgitation

OBJECTIVES

This study sought to evaluate the effects of the Carillon device on mitral regurgitation severity and left ventricular remodeling.

BACKGROUND

Functional mitral regurgitation (FMR) complicates heart failure with reduced ejection fraction and is associated with a poor prognosis.

METHODS

In this blinded, randomized, proof-of-concept, sham-controlled trial, 120 patients receiving optimal heart failure medical therapy were assigned to a coronary sinus-based mitral annular reduction approach for FMR or sham. The pre-specified primary endpoint was change in mitral regurgitant volume at 12 months, measured by quantitative echocardiography according to an intention-to-treat analysis.

RESULTS

Patients (69.8 ± 9.5 years of age) were randomized to either the treatment (n = 87) or the sham-controlled (n = 33) arm. There were no significant differences in baseline characteristics between the groups. In the treatment group, 73 of 87 (84%) had the device implanted. The primary endpoint was met, with a statistically significant reduction in mitral regurgitant volume in the treatment group compared to the control group (decrease of 7.1 ml/beat [95% confidence interval [CI]: -11.7 to -2.5] vs. an increase of 3.3 ml/beat [95% CI: -6.0 to 12.6], respectively; p = 0.049). Additionally, there was a significant reduction in left ventricular volumes in patients receiving the device versus those in the control group (left ventricular end-diastolic volume decrease of 10.4 ml [95% CI: -18.5 to -2.4] vs. an increase of 6.5 ml [95% CI: -5.1 to 18.2]; p = 0.03 and left ventricular end-systolic volume decrease of 6.2 ml [95% CI: -12.8 to 0.4] vs. an increase of 6.1 ml [95% CI: -1.42 to 13.6]; p = 0.04).

CONCLUSIONS

The Carillon device significantly reduced mitral regurgitant volume and left ventricular volumes in symptomatic patients with functional mitral regurgitation receiving optimal medical therapy. (Carillon Mitral Contour System for Reducing Functional Mitral Regurgitation [REDUCE FMR]; NCT02325830).

T-lineage cells require the thymus but not VDJ recombination to produce IL-17A and regulate granulopoiesis in vivo

IL-17A and IL-17F regulate granulopoiesis and are produced by memory T cells. Rag1(-/-) recombinase-activating gene-deficient mice cannot produce mature T cells but maintain normal neutrophil counts. Athymic nude mice are neutropenic or have near-normal neutrophil counts, depending on the prevailing intestinal flora, and do not produce IL-17A. By contrast, thymi from Rag1(-/-) mice contain as much IL-17A as those from wild-type (WT) mice. IL-17A-producing cells are found in the double negative DN1 compartment of the Rag1(-/-) thymus and express intracellular CD3. These cells colonize the spleen and mesenteric lymph node and secrete IL-17A in vitro following stimulation with IL-23 at a level similar to that of WT splenocytes. Adoptively transferred Rag1(-/-) or WT thymocytes correct neutrophil counts in neutropenic nude mice. We conclude that the development of IL-17A-producing T-lineage cells requires an intact thymic epithelium, but not V(D)J recombination.

IL-17A inhibits the expansion of IL-17A-producing T cells in mice through "short-loop" inhibition via IL-17 receptor

IL-23 and IL-17A regulate granulopoiesis through G-CSF, the main granulopoietic cytokine. IL-23 is secreted by activated macrophages and dendritic cells and promotes the expansion of three subsets of IL-17A-expressing neutrophil-regulatory T (Tn) cells; CD4(-)CD8(-)alphabeta(low), CD4(+)CD8(-)alphabeta(+) (Th17), and gammadelta(+) T cells. In this study, we investigate the effects of IL-17A on circulating neutrophil levels using IL-17R-deficient (Il17ra(-/-)) mice and Il17ra(-/-)Itgb2(-/-) mice that lack both IL-17R and all four beta(2) integrins. IL-17R deficiency conferred a reduction in neutrophil numbers and G-CSF levels, as did Ab blockade against IL-17A in wild-type mice. Bone marrow transplantation revealed that IL-17R expression on nonhemopoietic cells had the greatest effects on regulating blood neutrophil counts. Although circulating neutrophil numbers were reduced, IL-17A expression, secretion, and the number of IL-17A-producing Tn cells were elevated in Il17ra(-/-) and Il17ra(-/-)Itgb2(-/-) mice, suggesting a negative feedback effect through IL-17R. The negative regulation of IL-17A-producing T cells and IL-17A and IL-17F gene expression through the interactions of IL-17A or IL-17F with IL-17R was confirmed in splenocyte cultures in vitro. We conclude that IL-17A regulates blood neutrophil counts by inducing G-CSF production mainly in nonhemopoietic cells. IL-17A controls the expansion of IL-17A-producing Tn cell populations through IL-17R.

IL-23 is required for neutrophil homeostasis in normal and neutrophilic mice

IL-23 is secreted by macrophages and dendritic cells in response to microbial products and inflammatory cytokines. IL-23 is a heterodimer composed of the unique IL-23p19 subunit linked to the common p40 subunit that it shares with IL-12. IL-23 is implicated in autoimmune diseases, where it supports the expansion of IL-17A-producing CD4+ Th17 cells. IL-23 also regulates granulopoiesis in a neutrostat regulatory feedback loop through IL-17A-producing neutrophil regulatory (Tn) cells, most of which express gammadelta TCR. This homeostatic system is disrupted in mice lacking adhesion molecules like beta2-integrins (Itgb2-/-) which have defective neutrophil trafficking and neutrophilia. To test the role of IL-23 in the homeostatic regulation of circulating neutrophil numbers, we measured blood neutrophil numbers in p40-deficient (IL12b-/-) mice and found them reduced compared with wild-type mice. IL12b-/-Itgb2-/- mice, lacking beta2-integrins, IL-12, and IL-23 showed significantly blunted neutrophilia compared with Itgb2-/- mice. Treatment of both IL12b-/- and IL12b-/-Itgb2-/- mice with IL-23, but not IL-12, restored circulating neutrophil counts. Serum levels of IL-17A were readily detectable in Itgb2-/- mice, but not in IL12b-/-Itgb2-/- mice, suggesting that IL-17A production is reduced when IL-23 is absent. Similarly, tissue mRNA expression of IL-17A was reduced in IL12b-/-Itgb2-/-mice compared with Itgb2-/- controls. The total number of CD3+ IL-17A-producing Tn cells were significantly reduced in the spleen and lamina propria of IL12b-/-Itgb2-/- mice, with the largest reduction found in gammadelta+ T cells. Our results suggest a prominent role of IL-23 in the regulation of granulopoiesis and the prevalence of IL-17A-producing Tn cells.

IL-17A-Producing Tn cells escape thymic selection and regulate granulopoiesis in Rag-1−/− mice. (83.16)

Interleukin- (IL-) 23 and IL-17A play pivotal roles in the regulation of granulopoiesis in mice via a regulatory neutrostat feedback loop. Dendritic cells (DC) and macrophages release IL-23 in response to microbial products. IL-23 enhances the release of IL-17A from three Tn cell subsets, CD4−CD8−αβlow, CD4+CD8−αβ+ and γδ+. IL-17A levels correlate with neutrophil (PMN) and G-CSF levels in the blood. The feedback loop is closed by the trafficking of PMN’s into the tissues, their apoptosis and engulfment by resident DC, which curbs secretion of IL-23. As most granulopoiesis is controlled by T cells, athymic (nude) mice are neutropenic. However, Rag-1−/− mice have normal PMN numbers and if crossed onto a neutrophillic mouse background, remain neutrophilic, suggesting that immature T cells also regulate granulopoiesis. Here, we show that WT and Rag-1−/− mouse splenocytes secrete IL-17A without TCR cross-linking, and Tn cells are found in the thymus, spleen and MLN of both mouse models. Characterization of these cells places them into the DN1e category of prothymocytes which do not express classical lineage markers and are CD25−, CD117−, CD24− and CD44+. Adoptive transfer of Rag-1−/− thymocytes into nude mice rescued their neutropenia, with 99.8% of PMN’s being recipient derived. Thus, IL-17A-producing thymocytes are able to escape thymic selection and regulate granulopoiesis in the periphery of mice.

Supported by NIH HL 73361

IL-17A-producing neutrophil-regulatory Tn lymphocytes

The proinflammatory cytokine IL-17A, mainly produced by specialized T cells, plays an important homeostatic role in regulating neutrophil production and blood neutrophil counts. This review will assemble and discuss the evidence for this function of IL-17A-producing cells, which are collectively called neutrophil-regulatory T cells or Tn cells. IL-17A-producing lymphocytes are most abundant in the mesenteric lymph node, where they account for 0.15% of all lymphocytes. About 60% of the Tn cells are gammadelta T cells, about 25% NKTlike cells, and less than 15% are CD4 T cells. These latter cells are also known as T-17 or ThIL-17 cells, a subset of Tn cells that also plays an important role in autoimmune diseases. IL-17A produced by Tn cells regulates the production of G-CSF, which in turn promotes the proliferation of promyelocytes and maturation of neutrophils. This homeostatic mechanism plays an important role in normal physiology and in host defense against bacterial infections. This review is aimed at highlighting the important role of IL-17A-producing T cells at the interface between the adaptive and innate immune system.

Phagocytosis of apoptotic neutrophils regulates granulopoiesis via IL-23 and IL-17

Homeostatic regulation of neutrophil production is thought to match neutrophil elimination to maintain approximately constant numbers in the blood. Here, we show that IL-17, a cytokine that regulates granulopoiesis through G-CSF, is made by gammadelta T cells and unconventional alphabeta T cells. These neutrophil-regulatory T cells (Tn) are expanded in mice that lack leukocyte adhesion molecules, which have neutrophilia and defective neutrophil trafficking. Normal neutrophils migrate to tissues, where they become apoptotic and are phagocytosed by macrophages and dendritic cells. This curbs phagocyte secretion of IL-23, a cytokine controlling IL-17 production by Tn cells. Adoptive transfer of wild-type, but not adhesion molecule-deficient, neutrophils into mice deficient in beta2 integrins transiently decreases neutrophilia and reduces levels of serum IL-17. Antibody blockade of the p40 subunit of IL-23 reduces neutrophil numbers in wild-type mice. These findings identify a major homeostatic mechanism for the regulation of neutrophil production in vivo.

Critical role of macrophage 12/15-lipoxygenase for atherosclerosis in apolipoprotein E-deficient mice

BACKGROUND

Mice lacking leukocyte type 12/15-lipoxygenase (12/15-LO) show reduced atherosclerosis in several models. 12/15-LO is expressed in a variety of cells, including vascular cells, adipocytes, macrophages, and cardiomyocytes. The purpose of this study was to determine which cellular source of 12/15-LO is important for atherosclerosis.

METHODS AND RESULTS

Bone marrow from 12/15-LO-/-/apoE-/- mice was transplanted into apoE-/- mice and vice versa. Deficiency of 12/15-LO in bone marrow cells protected apoE-/- mice fed a Western diet from atherosclerosis to the same extent as complete absence of 12/15-LO, although plasma 8,12-iso-iPF2alpha-IV, a measure of lipid peroxidation, remained elevated. 12/15-LO-/-/apoE-/- mice regained the severity of atherosclerotic lesion typical of apoE-/- mice after replacement of their bone marrow cells with bone marrow from apoE-/- mice. Peritoneal macrophages obtained from wild-type but not 12/15-LO-/- mice caused endothelial activation in the presence of native LDL. Absence of 12/15-LO decreased the ability of macrophages to form foam cells when exposed to LDL.

CONCLUSIONS

We conclude that macrophage 12/15-LO plays a dominant role in the development of atherosclerosis by promoting endothelial inflammation and foam cell formation.

Nature as a complementary therapy for women

Evaluating the safety and effectiveness of complementary therapies is a challenge for nurses. Many people enjoy spending time in nature. The purpose of this article is to examine the theoretical and empirical evidence for using nature as a complementary therapy to rest and restore one's ability to concentrate. As women become active participants in their health care, a complementary therapy to restore and maintain concentration may help promote self-care.

Relationship of psychosocial tasks of pregnancy and attentional functioning in the third trimester

Because childbearing women function in multiple roles, the capacity to focus or concentrate is an important resource while preparing for birth and parenting. In addition to daily tasks that require mental effort, gravidas have psychosocial demands related to pregnancy. The purpose of this study was to examine the relationship between the psychosocial tasks of pregnancy and the capacity to focus or direct attention. A convenience sample of 57 pregnant women in their third trimester was recruited from prenatal education classes to participate in this descriptive correlational study. After other variables thought to influence attentional functioning were considered, women experiencing the greatest conflict in psychosocial tasks had the most difficulty using directed attention and more negatively evaluated their attentional functioning. In order to empower gravidas to participate in their health care, it is important for researchers and practitioners to understand and support directed attentional functioning, an important area for nursing care and research.

Is it difficult to concentrate during the 3rd trimester and postpartum?

OBJECTIVE

The purpose of this study was to examine changes in women's directed attention, the ability to focus or concentrate, during the last trimester of pregnancy and during 1st week postpartum.

DESIGN

Pregnant women were tested at enrollment (during the 3rd trimester), at 37 weeks gestation, and during the 1st postpartum week for this descriptive, repeated measures study.

SETTING

Women were recruited from childbirth education classes in southwestern Michigan.

PARTICIPANTS

Fifty-seven women in their 3rd trimester of pregnancy.

MAIN OUTCOME MEASURES

Directed attention was measured objectively by the Digits Span Forward and Backward, Trailmaking A and B, and Category Matching tests. Subjective measures were the Attentional Function Index and Mental Effort in Tasks tests.

RESULTS

Participant means on the objective measures were within the normal range at all three time points. Some individuals, however, showed limitations in the capacity to direct their attention. Ability to use directed attention was lowest at enrollment and improved during the study, with statistically significant changes from Times 1 to 2 on several measures. Subjectively, the participants felt that they had moderately low competence on tasks that required directed attention throughout the study.

CONCLUSIONS

Women had the greatest difficulty focusing during the 3rd trimester. Some individuals had problems with tasks requiring directed attention at all three time points. Many participants perceived that their ability to pay attention was lower than normal. Some women may benefit from nursing interventions to reduce attentional demands during the 3rd trimester and early postpartum period.

Psychosocial adjustment during pregnancy: the experience of mature gravidas

OBJECTIVE

To determine if gravidas ages 35 years and older have greater conflict in adapting to pregnancy than do younger gravidas.

DESIGN

Static group comparison.

SETTING

Prenatal care facilities and prenatal education classes.

PARTICIPANTS

Sixty-four older gravidas (35 years and older) and 46 younger gravidas (32 years and younger) who were in their 3rd trimester of pregnancy.

MAIN OUTCOME MEASURE

Lederman Prenatal Self-Evaluation Questionnaire II, which contains seven scales measuring conflict in psychosocial tasks during pregnancy.

RESULTS

Older gravidas had significantly less fear of helplessness and loss of control in labor than did younger gravidas. Age and education but not parity may account for this finding.

CONCLUSIONS

Age and education may balance the additional concerns older gravidas may have about pregnancy and allow older gravidas to adjust to pregnancy as well as younger women do.