Change in enrollment patterns, patient selection, and clinical outcomes with the availability of drug-eluting stents in the Bypass Angioplasty Revascularization Investigation 2 Diabetes trial.

BACKGROUND: In the BARI 2D trial, patients with type 2 diabetes and stable coronary artery disease were randomized to prompt revascularization versus intensive medical therapy (IMT). This analysis sought to evaluate how the availability of drug-eluting stents (DESs) has changed practice and outcomes. METHODS: In BARI 2D, 1,605 patients were in the percutaneous coronary intervention (PCI)-intended stratum. As DES became available midway through recruitment, we report clinical outcomes among patients who underwent IMT versus prompt PCI with bare-metal stents (BMSs) or DES up to 4 years. RESULTS: In North America, after DES became available, selection for the PCI-intended stratum increased from 73% to 79% (P = .003). Fewer BMS than DES patients had total occlusions treated or underwent rotational atherectomy (5.6% vs 9.7%, P = .02, and 1.2% vs 3.7%, P < .01, respectively). Subsequent revascularization (IMT 39%, BMS 29%, DES 21%, P < .01) and target vessel revascularization (BMS 16.1% vs DES 9.6%, P = .03) were lower with DES. Angina at 2 years tended to be less common with DES (IMT 39%, BMS 37%, DES 29%, P = .04, for 3 groups, P = .07 for DES vs BMS). The composite of death, myocardial infarction, or stroke was IMT 16.0%, BMS 20.5%, DES 17.5%; P = .80. CONCLUSIONS: When DES became available in North America, patients were more likely to be selected into the PCI-intended stratum. Compared with patients receiving BMS, those receiving DES tended to have less target vessel revascularization and angina.

Catheter ablation of hemodynamically unstable ventricular tachycardia with mechanical circulatory support.

BACKGROUND: Catheter ablation of hemodynamically unstable ventricular tachycardia (VT) is possible with mechanical circulatory support (MCS), little is known regarding the relative safety and efficacy of different supporting devices for such procedures. METHODS AND RESULTS: Sixteen consecutive patients (aged 63 ± 11 years with left ventricular ejection fraction of 20 ± 9%) who underwent ablation of hemodynamically unstable VT were included in this study. Hemodynamic support included percutaneous (Impella® 2.5, n = 5) and implantable left ventricular assist devices (LVADs, n = 6) and peripheral cardiopulmonary bypass (CPB, n = 5). Except for 2 Impella cases, hemodynamic support was adequate (with consistent mean arterial pressure of > 60 mmHg) to permit sufficient activation mapping for ablation. In the Impella and CPB groups, mean time under hemodynamic support was 185 ± 86 min, and time in VT was 78 ± 36 min. Clinical VT could be terminated at least once by ablation in all patients except 1 case with Impella due to hemodynamic instability. Peri-procedural complications included hemolysis in 1 patient with Impella and surgical intervention for percutaneous Impella placement problems in another 2. The median number of appropriately delivered defibrillator therapies was significantly decreased from 6 in the month before VT ablation to 0 in the month following ablation (p = 0.001). CONCLUSIONS: Our data suggest that peripheral CPB and implantable LVAD provide adequate hemodynamic support for successful ablation of unstable VT. Impella® 2.5, on the other hand, was associated with increased risk of complications, and may not provide sufficient hemodynamic support in some cases.

The development of porous alginate/elastin/PEG composite matrix for cardiovascular engineering.

The development of suitable three-dimensional matrices for the maintenance of cellular viability and differentiation is critical for applications in tissue engineering and cell biology. To this end, gel matrices of different proportions of alginate/elastin/polyethylene glycol (Alg/Ela/PEG) were prepared and examined. The composite matrix membranes were evaluated for their porous scaffold using SEM, enzymatic degradation and water content. An equal blend of Alg/Ela with a ratio of Alg/Ela: PEG (7:3) was selected for fabricating Alg/Ela/PEG scaffolds for this study. The Alg/Ela/PEG membranes fabricated at 20 degrees C and - 20 degrees C had a mean surface pore size of 35-45 microm. However, their ultrastructures had shown bigger pore structures (60-75 microm) compared to their surface. It is interesting to note that the membranes of Alg/Ela/PEG prepared at 20 degrees C had larger ultrastructural pores than that of membranes prepared at -20 degrees C. Further, the SEM studies revealed that in the absence of PEG the composite membranes of Alg/Ela formed with less porous structures. The water content of membranes prepared at 20 degrees C was higher with Alg/Ela/PEG (61.6 +/- 4.8%), compared to Alg/Ela (49.9 +/- 0.3%). The enzymatic degradation and water content studies also revealed that the membranes fabricated at - 20 degrees C had high water uptake and low enzymatic degradation, as that of the membranes prepared at 20 degreees C. In other words the larger pore structured membranes had less water content and high degradation profile. This study proposes that this novel composite matrix produces a hierarchical structure that is useful for generating tissue scaffolds for repairing the failing cardiac muscles. However, more detailed investigations with cytocompatibility studies are needed to find applications.

Changes in cisplatin delivery due to surface-coated poly (lactic acid)-poly(epsilon-caprolactone) microspheres.

Smooth muscle cell proliferation plays a major role in the genesis of restenosis after angioplasty or vascular injury. Local delivery of agents capable of modulating vascular responses, have the potential to prevent restenosis. However, the development of injectable microspheres for sustained drug delivery to the arterial wall is a major challenge. We demonstrated the possibility of entrapping an antiproliferative agent, cisplatin, in a series of surface coated biodegradable microspheres composed of poly(lactic acid)poly(caprolactone) blends, with a mean diameter of 2-10 pm. The microspheres were surface coated with poly ethylene glycol (PEG), chitosan (Chit), or alginate (Alg). A solution of cisplatin and a 50:50 blend of polylactic acid (PLA)-polycaprolactone (PCL) dissolved in acetone-dichloromethane mixture was poured into an aqueous solution of PEG (or polyvinyl alcohol or Chit or Alg) with stirring using a high speed homogenizer, for the formation of microspheres. Cisplatin recovery in microspheres ranged from 25-45% depending on the emulsification system used for the preparations. Scanning electron microscopy revealed that the PLA-PCL microspheres were spherical in shape and had a smooth surface texture. The amount of drug release was much higher initially (20-30%), this was followed by a constant slow-release profile for a 30-day period of study. It has been found that drug release depends on the amount of entrapped drug, on the presence of extra cisplatin in the dispensing phase, and on the polymer coatings. This PEG or Alg-coated PLA/PCL microsphere formulation may have potential for the targeted delivery of antiproliferative agents to treat restenosis.

Delivery of LMW heparin via surface coated chitosan/peg-alginate microspheres prevents thrombosis.

Heparin remains the gold-standard inhibitor of the process involved in the vascular response to injury. Continued anticoagulation is achieved by subcutaneous administration of low-molecular-weight heparin (LMW Hep) or with an orally active anticoagulant such as warfarin. An oral heparin would avoid the inconvenience of subcutaneous injections and adverse events associated with warfarin. A mild chitosan/PEG/calcium alginate microencapsulation process, as applied to encapsulation of biological macromolecules such as heparin and LMW Hep was investigated. Heparin and LMW Hep entrapped alginate beads were further surface/enteric coated with chitosan and cellulose acetate phthalate (CAP) via carbodiimide (EDC) functionalities. It was observed that approximately 70% of the content is being released into Tris-HCl buffer, pH 7.4 within the initial 6 hours and no significant release of LMW Hep was observed from enteric coated microspheres (12%) during treatment with 0.1 M HCl, pH 1.0 for 4 hours. But acid treated capsules had released almost all the entrapped LMW Hep into Tris-HCl, pH 7.4 media within 6 hours. From scanning electron microscopic and swelling studies, it appeared that the surface coatings (via chitosan and CAP) had modified the alginate microspheres and subsequently the drug release. The released heparin and LMW Hep had shown their anticoagulant functions. These results established the feasibility of modifying the formulation in order to obtain the desired controlled release of bioactive agent (LMW Hep), for a convenient pH dependent delivery system.