Recanalisation of coronary chronic total occlusions with new techniques including the retrograde approach via collaterals

Objective

Percutaneous treatment of coronary chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The strategies of recanalisation in CTO have changed drastically due the development of new techniques such as the retrograde approach via collaterals. In this single-centre experience we sought to analyse the success rates with the use of different CTO techniques, the complication rates, and we evaluated predictors of failed CTO recanalisation attempts.

Methods and Results

In this single-centre observational study we analysed the prospectively entered data of 331 consecutive patients, undergoing percutaneous coronary intervention (PCI) for CTO in 338 lesions at the Heart Center Wuppertal between June 2007 and July 2010. Nineteen lesions were attempted twice and one lesion three times (=358 procedures). The lesion-related success rates were 81.1%. Single-wire usage was the predominant strategy used in 198 antegrade cases (65.6%) followed by parallel wire technique and see-saw technique in 94 cases (31.1%). In the retrograde procedures, the reverse CART technique was predominantly used (35.7%), followed by retrograde wire passage (17.9%), marker wire (17.9%) and CART (14.3%). The in-hospital complications were low and comparable with conventional PCI data. The presence of blunt stump, severe calcification, severe tortuosity and occlusion length >30 mm were independent predictors of procedural failure.

Conclusions

A high degree of success with low in-hospital complications comparable with conventional PCI data can be expected in the hands of experienced CTO operators. A second try with a retrograde approach after antegrade failure should be considered.     

Percutaneous coronary intervention versus medical therapy for chronic total coronary occlusions: a systematic review and meta-analysis of randomised trials

Background

The results of chronic total occlusion percutaneous coronary intervention (CTO-PCI) trials are inconclusive. Therefore, we studied whether CTO-PCI leads to improvement of clinical endpoints and patient symptoms when combining all available randomised data.

Methods and results

This meta-analysis was registered in PROSPERO prior to starting. We performed a literature search and identified all randomised trials comparing CTO-PCI to optimal medical therapy alone (OMT). A total of five trials were included, comprising 1790 CTO patients, of whom 964 were randomised to PCI and 826 to OMT. The all-cause mortality was comparable between groups at 1‑year [risk ratio (RR) 1.70, 95% confidence interval (CI) 0.50–5.80, p = 0.40] and at 4‑year follow-up (RR 1.14, 95% CI 0.38–3.40, p = 0.81). There was no difference in the incidence of major adverse cardiac events (MACE) between groups at 1 year (RR 0.69, 95% CI 0.36–1.33, p = 0.27) and at 4 years (RR 0.85, 95% CI 0.60–1.22, p = 0.38). Left ventricular function and volumes at follow-up were comparable between groups. However, the PCI group had fewer target lesion revascularisations (RR 0.28, 95% CI 0.15–0.52, p < 0.001) and was more frequently free of angina at 1‑year follow-up (RR 0.65, 95% CI 0.50–0.84, p = 0.001), although the scores on the subscales of the Seattle Angina Questionnaire were comparable.

Conclusion

In conclusion, in this meta-analysis of 1790 CTO patients, CTO-PCI did not lead to an improvement in survival or in MACE as reported at long-term follow-up of up to 4 years, or to improvement of left ventricular function. However, CTO-PCI resulted in less angina and fewer target lesion revascularisations compared to OMT.

     

Advances in percutaneous coronary intervention for chronic total occlusions: current antegrade dissection and reentry techniques and updated algorithm

Percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) is considered relatively complex with low success rates and high complication rates. Treating a CTO with PCI using the hybrid algorithm increases success rates with acceptable complication rates. An essential part of the hybrid algorithm is antegrade dissection and reentry (ADR). In PCI of a non-CTO coronary lesion, the guidewire over which the stent is advanced and placed stays within the true lumen of the coronary artery. ADR techniques make it possible to cross the lesion through the wall of the coronary artery, the subintimal space, thus creating a small bypass within the architecture of the coronary artery and restoring antegrade blood flow. ADR increases success rates, especially in more difficult CTO procedures. In the last decade, new materials and techniques have been introduced in quick succession, which are summarised in this review. Consequently an updated ADR algorithm is presented, which can support the CTO operator during an ADR procedure.

     

A computed tomography algorithm for crossing coronary chronic total occlusions: riding on the wave of the proximal cap and distal vessel segment

With wider adoption of coronary computed tomography angiography (coronary CTA), chronic total occlusions (CTOs) are being increasingly identified and characterised by non-invasive angiography. In particular, the ability of coronary CTA to clearly delineate atherosclerotic plaque, as well as to display three-dimensional vessel trajectories, has garnered particular attention in the context of preprocedural planning and periprocedural guidance of CTO percutaneous coronary intervention (PCI). Single CTO features and combined scoring systems derived from CTA (mostly exceeding the diagnostic performance of the angiographic J‑CTO score) have been used to predict time-efficient guidewire crossing, and thus grade the CTO difficulty level prior to PCI. In addition, the introduction of three-dimensional CTA/fluoroscopy co-registration for periprocedural navigation during CTO PCI offers the unprecedented opportunity to resolve proximal cap ambiguity and clearly visualise the distal CTO segment, thereby potentially influencing CTO PCI strategies and techniques. In this review, the potential advantages of non-invasive evaluation of CTO by coronary CTA are described, and a CTA-based hybrid algorithm is introduced for further enhancing the efficiency of CTO PCI. Further studies are clearly needed to verify the proposed approach. However, several luminary operators have already implemented coronary CTA for planning and periprocedural guidance of CTO interventions using the hybrid algorithm.

     

Tooth impact rate in the song of a shorthorned grasshopper: A parameter carrying specific behavioral information

Summary Receptive females of the gomphocerine grasshopperOmocestus viridulus L. were offered different artificial grasshopper songs in a one- or two-channel test situation. In the computer generated songs the tooth-impact-rate and the amplitude functions of the chirp were varied.The results of the one-channel experiments showed that the grasshoppers preferred signals with normal tooth-impact-rate to signals with half the rate. The amplitude function seems to play a minor role in the recognition process, unless this parameter is changed very radically.The results of the two-channel tests were ambiguous. A third test series was developed to interpret these results. It was found that female grasshoppers once excited by an acceptable signal afterwards responded to former unacceptable signals. Accordingly, if just one of the two signals is able to excite the female, the female may subsequently choose randomly between the signals. If the signals are of different sound levels, the louder is preferred.The shorthorned grasshopper may interpret the tooth-impact-rate as a frequency. It is proposed that the grasshopper may use the four sense cell groups of the ear as a simple sort of a spectral analyzer. These cells are tuned to different frequencies and/or differently tuned.The running Root Mean Square value of a grasshopper signal, its dependence on the applied integration time and its possible relation to perceived energy are reported in an appendix.     

Rationale and design of EXPLORE: a randomized, prospective, multicenter trial investigating the impact of recanalization of a chronic total occlusion on left ventricular function in patients after primary percutaneous coronary intervention for acute ST-elevation myocardial infarction

Background

Hypothyroidism is a prevalent endocrine condition. Individuals with this disease are commonly managed through supplementation with synthetic thyroid hormone, with the aim of alleviating symptoms and restoring normal thyroid stimulating hormone levels. Generally this management strategy is effective and well tolerated. However, there is research to suggest that a significant proportion of hypothyroid sufferers are being inadequately managed. Furthermore, hypothyroid patients are more likely to have a decreased sense of well-being and more commonly experience constitutional and neuropsychiatric complaints, even with pharmacological intervention. The current management of hypothyroidism follows a biomedical model. Little consideration has been given to a biopsychosocial approach to this condition. Within the chiropractic profession there is growing support for the use of a biopsychosocial-based intervention called Neuro-Emotional Technique (NET) for this population.

Methods/Design

A placebo-controlled, single-blinded, randomised clinical pilot-trial has been designed to assess the influence of Neuro-Emotional Technique on a population with primary overt hypothyroidism. A sample of 102 adults (≥18 years) who meet the inclusion criteria will be randomised to either a treatment group or a placebo group. Each group will receive ten treatments (NET or placebo) over a six week period, and will be monitored for six months. The primary outcome will involve the measurement of depression using the Depression, Anxiety and Stress Scale (DASS). The secondary outcome measures to be used are; serum thyroid stimulating hormone, serum free-thyroxine, serum free-triiodothyronine, serum thyroid peroxidase auto-antibodies, serum thyroglobulin auto-antibodies as well as the measurement of functional health and well-being using the Short-Form-36 Version 2. The emotional states of anxiety and stress will be measured using the DASS. Self-measurement of basal heart rate and basal temperature will also be included among the secondary outcome measures. The primary and secondary measures will be obtained at commencement, six weeks and six months. Measures of basal heart rate and basal temperature will be obtained daily for the six month trial period, with recording to commence one week prior to the intervention.

Discussion

The study will provide information on the influence of NET when added to existing management regimens in individuals with primary overt hypothyroidism.

Trial Registration

ANZCTR Number: 12607000040460     

Modeling the temperature effect on the specific growth rate of phytoplankton: a review

Phytoplankton are key components of ecosystems. Their growth is deeply influenced by temperature. In a context of global change, it is important to precisely estimate the impact of temperature on these organisms at different spatial and temporal scales. Here, we review the existing deterministic models used to represent the effect of temperature on microbial growth that can be applied to phytoplankton. We first describe and provide a brief mathematical analysis of the models used in constant conditions to reproduce the thermal growth curve. We present the mechanistic assumptions concerning the effect of temperature on the cell growth and mortality, and discuss their limits. The coupling effect of temperature and other environmental factors such as light are then shown. Finally, we introduce the models taking into account the acclimation needed to thrive with temperature variations. The need for new thermal models, coupled with experimental validation, is argued.     

Plasmid DNA production for pharmaceutical use: role of specific growth rate and impact on process design

Application of plasmid DNA as pharmaceutical to be used in gene therapy and vaccination has been investigated intensively in recent years. To be able to provide sufficient material that is in accordance with quality of pharmaceutical grade it is mandatory to gain comprehensive process knowledge which is even requested by regulatory agencies. Regarding plasmid DNA production the specific growth rate has been identified as one of the key parameters. The reduction of specific growth rate results in an increase of plasmid DNA formation. However, quantitative explanations that allow for efficient process development and design are still missing. The presented study proposes a model that clearly demonstrates the relationship between specific growth rate and plasmid formation due to identification of the specific plasmid production rate as relevant key parameter. In addition the model is proved to serve as a useful tool in process development and design.     

The visual system as a constraint on the survival and success of specific artworks

Why should vision science turn its gaze towards artworks? One possibility is that understanding visual processing might yield some fundamental insight into the nature of art. However, there are many examples of phenomena that can be seen - such as automobiles, clouds or leaves - but which are not explained in any deep sense by the properties of human visual perception. We examine one art historical question that might benefit from knowledge about the visual system: why do some artworks 'survive' historically while others fade into the dustbin of time? One possible reason, suggested by studies of rapid visual categorization, is that some objects are recognized more quickly and easily than others and thus are less culturally specific in terms of pictorial representation. A second, related, explanation is that many artistic techniques use the eyes as a channel to evoke other senses, cognition, emotions and the motor system. 'Art' is a social and historical construct - after all, the concept of 'fine art' was invented in the 18th century - and thus many aspects of artistic appreciation are specific to particular cultural and historical contexts. Some great works, however, may be adopted by successive generations because of an ability to appeal to a shared perceptual system.     

Deleterious impact of feto-maternal MHC compatibility on the success of pregnancy in a macaque model

The impact of feto-maternal histocompatibility on reproduction has inspired long-lasting debates. However, after the review of numerous articles, the impact of HLA allele sharing within couples on fecundity remains questionable. We decided to explore the impact of major histocompatibility complex (MHC) feto-maternal compatibility on reproduction in a cynomolgus macaque facility composed of animals of Mauritian descent. The Mauritian-derived macaque population presents a very restricted MHC polymorphism (only seven founding haplotypes) due to a strong founding bottleneck effect. The MHC polymorphism was investigated in 237 trios (male, female and offspring) using 17 microsatellite markers distributed across the MHC. Haplotypes were confirmed by segregation analysis. We evaluated the relative frequencies of MHC-compatible and MHC-semi-compatible offspring with the mothers. Among the 237 trios, we selected 42 trios for which the identity of the father is certain and for which the theoretical probabilities of fully compatible and semi-compatible offspring were equal. We found 11 offspring fully compatible and 31 offspring semi-compatible with their respective mother. The observed proportions were clearly outside the interval of confidence of 99 % and therefore most probably resulted from a selection of the semi-compatible offspring during pregnancy. We concluded that MHC fully compatible cynomolgus macaque offspring have a selective survival disadvantage in comparison with offspring inheriting a paternal MHC haplotype differing from maternal haplotypes.     

The confirmation rate of primary hits: a predictive model

HTS data from primary screening are usually analyzed by setting a cutoff for activity, in order to minimize both false-negative and false-positive rates. An alternative approach, based on a calculated probability of being active, is presented here. Given the predicted confirmation rate derived from this probability, the number of primary positives selected for follow-up can be optimized to maximize the number of true positives without picking too many false positives. Typical cutoff-determining methods are more serendipitous in their nature and not easily optimized in an effort to optimize screening efforts. An additional advantage of calculating a probability of being active for each compound screened is that orthogonal mixtures can be deconvoluted without presetting a deconvolution threshold. An important consequence of using the probability of being active with orthogonal mixtures is that individual compound screening results can be recorded irrespective of whether the assays were performed on single compounds or on cocktails.     

The impact of intermittent umbilical cord occlusions on the inflammatory response in pre-term fetal sheep

Fetal hypoxic episodes may occur antepartum with the potential to induce systemic and cerebral inflammatory responses thereby contributing to brain injury. We hypothesized that intermittent umbilical cord occlusions (UCOs) of sufficient severity but without cumulative acidosis will lead to a fetal inflammatory response. Thirty-one chronically instrumented fetal sheep at ～0.85 of gestation underwent four consecutive days of hourly UCOs from one to three minutes duration for six hours each day. Maternal and fetal blood samples were taken for blood gases/pH and plasma interleukin (IL)-1β and IL-6 levels. Animals were euthanized at the end of experimental study with brain tissue processed for subsequent counting of microglia and mast cells. Intermittent UCOs resulted in transitory fetal hypoxemia with associated acidemia which progressively worsened the longer umbilical blood flow was occluded, but with no cumulative blood gas or pH changes over the four days of study. Fetal arterial IL-1β and IL-6 values showed no significant change regardless of the severity of the UCOs, nor was there any evident impact on the microglia and mast cell counts for any of the brain regions studied. Accordingly, intermittent UCOs of up to three minutes duration with severe, but limited fetal hypoxemia and no cumulative acidemia, do not result in either a systemic or brain inflammatory response in the pre-term ovine fetus. However, fetal IL-1B and IL-6 values were found to be well correlated with corresponding maternal values supporting the placenta as a primary source for these cytokines with related secretion into both circulations. Female fetuses were also found to have higher IL-1β levels than males, indicating that gender may impact on the fetal inflammatory response to various stimuli.     

Of fleas and geese: the impact of an increasing nest ectoparasite on reproductive success

Past studies on the relationship between nest ectoparasites and avian fitness have been primarily limited to altricial hosts. Life history strategies of precocial and altricial birds vary considerably, limiting our ability to infer the effect of nest parasites on fitness of precocial species. Ross's Chen rossii and lesser snow goose Chen caerulescens caerulescens populations have been growing at unprecedented high rates. New limiting factors on vital rates of these precocial birds may arise after populations have been released from previously regulating factors. The flea Ceratophyllus vagabundus vagabundus is an apparently newly emerging nest parasite in the arctic goose colony at Karrak Lake, Nunavut, Canada. We examined the relationship between flea abundance (measured by the proportion of goose eggs covered by blood in each nest) and goose reproductive success from 2001–2004. In three of four years of study, nest success was inversely related to flea abundance in nests. Despite the potential for high costs to individuals, the overall effects of fleas on goose nesting success have thus far been small. We demonstrated that nest parasites negatively influence reproductive success of precocial bird hosts despite host life history strategy of leaving the nest quickly after hatch, which results in minimal exposure to nest parasites compared to altricial birds that raise their young in the nest.     

Prey kills predator: Counter-attack success of a spider mite against its specific phytoseiid predator

Success of counter-attack by the spider mite,Schizotetranychus celarius (Banks), against its specific phytoseiid predator,Typhlodromus bambusae Ehara, was examined under experimental conditions. The success of counter-attack by prey females (mothers) against a predaceous larva depended upon the former's density per nest. About 30% of the predaceous larvae were killed when they intruded into a nest containing eight females and their offspring. On the other hand, the prey males (fathers) effectively killed the predators, i.e. one male in the nest killed ca. 40% of the predators while two or three males destroyed up to 80%.The presence of prey parents in a nest considerably enhanced the success of the counter-attack. One male and two young females could kill 70% of the predator's larvae, while two males and two females killed 90% of such larvae. This suggests a kind of cooperative brood defence amongstS. celarius parents.Although more robust, protonymphs of the predator also suffered damage by the prey's counter-attack. However, prey male and female could not destroy the predator's eggs and adult females, whilst the latter often killed spider mite adults.From these as well as previous experiments, it is concluded thatS. celarius has evolved some kind of biparental care for its offspring. It is further proposed that the predator—prey interactions observed in this study provide a unique contribution towards understanding predator—prey coevolution.     

Choice of PCR microtube can impact on the success of long-range PCRs

We compared four brands of microtubes with respect to their suitability for long-range polymerase chain reactions (PCRs). One of the four brands was found to have an inhibitory effect, decreasing PCR yields. The effect was universal across different PCR or enzyme systems. Increased ultraviolet absorbance suggests leaching of unknown chemical species into PCR mixtures. However, this could not be confirmed by high-performance liquid chromatography–mass spectrometry analysis. Nevertheless, our article demonstrates a clear impact of the choice of microtubes on long-range PCR success. Due consideration should be given to the PCR microtubes when determining optimal reaction conditions for long-range PCR.     

Perinatal adaptation in mammals: the impact of metabolic rate

Mammalian birth is accompanied by profound changes in metabolic rate that can be described in terms of body size relationship (Kleiber's rule). Whereas the fetus, probably as an adaptation to the low intrauterine pO₂, exhibits an “inappropriately” low, adult-like specific metabolic rate, the term neonate undergoes a rapid metabolic increase up to the level to be expected from body size. A similar, albeit slowed, “switching-on” of metabolic size allometry is found in human preterm neonates whereas animals that are normally born in a very immature state are able to retard or even suppress the postnatal metabolic increase in favor of weight gain and O₂ supply. Moreover, small immature mammalian neonates exhibit a temporary oxyconforming behavior which enhances their hypoxia tolerance, yet is lost to the extent by which the size-adjusted metabolic rate is “locked” by increasing mitochondrial density. Beyond the perinatal period, there are no other deviations from metabolic size allometry among mammals except in hibernation where the temporary “switching-off” of Kleiber's rule is accompanied by a deep reduction in tissue pO₂. This gives support to the hypothesis that the postnatal metabolic increase represents an “escape from oxygen” similar to the evolutionary roots of mitochondrial respiration, and that the overall increase in specific metabolic rate with decreasing size might contribute to prevent tissues from O₂ toxicity.     

Improving bioreactor production of a recombinant glycoprotein in Escherichia coli: Effect of specific growth rate on protein glycosylation and specific productivity

In the last decades bacterial glycoengineering emerged as a new field as the result of the ability to transfer the Campylobacter jejuni N- glycosylation machinery into Escherichia coli for the production of recombinant glycoproteins that can be used as antigens for diagnosis, vaccines, and therapeutics. However, the identification of critical parameters implicated in the production process and its optimization to jump to a productive scale is still required. In this study, we developed a dual expression glycosylation vector for the production of the recombinant glycoprotein AcrA-O157, a novel antigen that allows the serodiagnosis of the infection with enterohemorrhagic E. coli O157 in humans. Volumetric productivity was studied in different culture media and found that 2xYP had 6.9-fold higher productivity than the extensively used LB. Subsequently, bioreactor batch and exponential-fed-batch cultures were designed to determine the influence of the specific growth rate (μ) on AcrA-O157 glycosylation efficiency, production kinetics, and specific productivity. At μ_max, AcrA glycosylation with O157-polysaccharide and the specific synthesis rate were maximal, constituting the optimal physiological condition for AcrA-O157 production. Our findings should be considered for the design, optimization, and scaling up of AcrA-O157 production and other recombinant glycoproteins attractive for industrial applications.