Intracoronary administration of recombinant human vascular endothelial growth factor to patients with coronary artery disease.

BACKGROUND: Patients with severe myocardial ischemia who are not candidates for percutaneous or surgical revascularization have few therapeutic options. Therapeutic angiogenesis in animal models with use of recombinant human vascular endothelial growth factor (rhVEGF) has resulted in successful revascularization of ischemic myocardium. This was a dose escalation trial designed to determine the safety and tolerability of intracoronary rhVEGF infusions. METHODS AND RESULTS: Patients were eligible if they had stable exertional angina, a significant reversible perfusion defect by stress myocardial perfusion study, and coronary anatomy that was suboptimal for percutaneous coronary intervention or coronary artery bypass grafting. rhVEGF was administered to a total of 15 patients by 2 sequential (eg, right and left) intracoronary infusions, each for 10 minutes, at rates of 0.005 (n = 4), 0.017 (n = 4), 0.050 (n = 4), and 0.167 mg/kg/min (n = 3). Pharmacokinetic sampling and hemodynamic monitoring were performed for 24 hours. Radionuclide myocardial perfusion imaging was performed before treatment and at 30 and 60 days after treatment. Follow-up angiograms were performed on selected patients at 60 days. The maximally tolerated intracardiac dose of rhVEGF was 0.050 mg/kg/min. Minimal hemodynamic changes were seen at 0.0050 mg/kg/min (2% +/- 7% [SD] mean decrease in systolic blood pressure from baseline to nadir systolic blood pressure), whereas at 0.167 mg/kg/min there was a 28% +/- 7% mean decrease from baseline to nadir (136 to 95 mm Hg systolic). Myocardial perfusion imaging was improved in 7 of 14 patients at 60 days. All 7 patients with follow-up angiograms had improvements in the collateral density score. CONCLUSION: rhVEGF appears well tolerated by coronary infusion at rates up to 0.050 mg/kg/min. This study provides the basis for future clinical trials to assess the clinical benefit of therapeutic angiogenesis with rhVEGF.

Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial--the Cardiovascular Thrombolytic to Open Occluded Lines (COOL) efficacy trial.

PURPOSE: Central venous access devices (CVADs) are a mainstay of current medical therapy but often become occluded by thrombus. Tissue plasminogen activator (alteplase), at a dose of 2 mg per 2 mL, has been shown to be effective in restoring flow to catheters proven by radiographic contrast injection to be occluded by thrombus. The purpose of this double-blind placebo-controlled multicenter trial was to determine the efficacy of alteplase in occluded catheters without earlier contrast injections or radiographic examinations. MATERIALS AND METHODS: Patients were eligible for inclusion if blood could not be withdrawn from their catheter after a period of normal function of at least 48 hours. Single or multiple catheters, peripherally inserted central catheters, catheters with valves, and implanted ports were eligible; catheters used for hemodialysis were not included. Patients were randomly assigned to one of two groups. In one group, patients received a first dose of 2 mg alteplase followed, if needed, by a second dose of 2 mg alteplase and a third dose of placebo. The other group received placebo first followed by one 2-mg dose of alteplase and then a second, if needed. Each dose was allowed to dwell for 2 hours and ability to withdraw blood from the catheter was reassessed. The endpoint was restoration of the ability to withdraw and infuse through the catheter. One hundred forty-nine patients were randomized: 74 received placebo first, 75 received alteplase first. RESULTS: After the first 2-hour treatment, function was restored to 74% in the alteplase arm and 17% in the placebo arm (P <.0001 compared to placebo). After one or two treatments, function was restored in 90% of patients. There were no serious study-drug-related adverse events, no intracranial hemorrhage, no major hemorrhage, and no embolic events. CONCLUSION: Infusion of alteplase appeared to be safe and effective in restoring flow to occluded catheters without need for pretreatment radiographic evaluation.

Multicenter clinical experience with rescue atherectomy for failed angioplasty.

Directional coronary atherectomy (DCA) has been proposed as a "rescue" technique for failed or suboptimal percutaneous transluminal coronary angioplasty (PTCA) in an attempt to avoid myocardial infarction or emergency coronary artery bypass grafting. In this report we review the utilization and outcome of rescue atherectomy from the clinical experience of The Cleveland Clinic Foundation and Medical College of Virginia from November 1988 through January 1993, and from the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT) database. This analysis includes 100 patients with 103 treated lesions from 44 patients at the Cleveland Clinic, 36 patients from the Medical College of Virginia, and 20 patients from the CAVEAT database. The etiology of failed PTCA was primarily from dissection in 52 lesions (50.5%), "recoil" in 43 lesions (41.8%), and recurrent thrombosis in 8 lesions (7.8%). Complete vessel closure was present in 23 lesions (22.3%). The vessels treated included 51.5% left anterior descending, 24.3% right coronary, and 16.5% circumflex coronary arteries. The average reference vessel diameter in the group was 3.10 +/- 0.06 mm (SEM), with an average stenosis of 78.9 +/- 1.2% before PTCA, 55.8 +/- 2.4% after PTCA, and 24.1 +/- 2.2% after rescue DCA. DCA was successful (Thrombosis in Myocardial Infarction [TIMI] grade 3 flow with > 20% stenosis reduction without death, Q-wave myocardial infarction, or coronary artery bypass grafting) in 94 of 103 lesions (91.3%). Complications included 1 patient with perforation (1%), 2 deaths within 24 hours (2.0%), and 6 patients requiring coronary artery bypass grafting (6%).(ABSTRACT TRUNCATED AT 250 WORDS)

Thromboxane A2 does not contribute to arrhythmogenesis during evolving canine myocardial infarction.

During the healing phase of evolving myocardial infarction, inflammatory cells invade the affected region and produce metabolites that may influence electrophysiological parameters and the genesis of malignant arrhythmias. We have recently shown an increased synthetic capacity within an evolving infarct for thromboxane A2 (TXA2), a metabolite that has been implicated in arrhythmias associated with early ischemia. The present study used both in vivo and in vitro procedures to define the electrophysiological and arrhythmogenic effects, if any, of thromboxane during evolving myocardial infarction. Thirty-three dogs divided into three groups were studied 3-7 days after transient left anterior descending coronary artery ligation. One group (n = 24) was examined by programmed electrical stimulation in the conscious state and, of the five dogs in this group with sustained ventricular tachycardia (VT), none demonstrated consistent limitation of inducibility by selective inhibition of thromboxane synthetase using three different agents. In the second group, (n = 5) regional conduction velocity was assessed using detailed three-dimensional activation analysis from 232 simultaneous intramyocardial sites, and no change was induced by the thromboxane synthetase inhibitor OKY-1581 in either normal or infarcted myocardial zones during sinus rhythm or with pacing. In the third group (n = 4), isolated ventricular muscle was studied in vitro using both intracellular transmembrane action potential recordings and surface extracellular maps from 48 simultaneous points. Neither intracellular action potential parameters nor extracellularly recorded activation patterns were altered by superfusion with the stable thromboxane analog STA2, the activity of which was verified by bioassay. Thus, despite increased synthetic capacity for thromboxane generation, the presence of TXA2 does not directly influence either electrophysiological indices or arrhythmogenesis.

Temporal changes in 12-HETE formation in two models of canine myocardial infarction.

Arachidonic acid (AA) metabolism by infarcted canine myocardium was studied and correlated with matched histologic analyses following permanently occluded or reperfused infarction. Histologic analysis of tissues from reperfused infarcts showed a marked acceleration of inflammatory cell invasion and of granulation tissue formation when compared to the occlusive infarct. In the reperfused infarct, polymorphonuclear leukocytes (PMNs) were very prominent at one day after infarction while in the occlusive infarcts the neutrophilic invasion was less intense but more sustained. At one day following reperfused infarction the major arachidonate product, which co-migrated by thin layer chromatography with the mono-hydroxyeicosatetraenoic acids (HETEs), was significantly elevated (254 +/- 49 pmoles/gm wet weight, n = 3) when compared to normal tissue (48 +/- 6 pmoles/gm n = 19). This occurred at a time when the number of PMNs was maximal in the infarcted tissue. Addition of the calcium ionophore A23187 caused a further marked stimulation in HETE production in the one day reperfused infarct but not at the other time points studied. The production of HETE was not significantly different in the infarcted tissue than in the normal tissue at three and seven days following reperfused infarction or at one, three, or seven days after occlusive infarction. The identity of this HETE product was investigated using reverse phase high performance liquid chromatography (RP-HPLC) and gas chromatography-mass spectrometry (GC-MS) and found to be predominantly 12-hydroxy-5,8,10,14-eicosatetraenoic acid (12-HETE) with a small amount of 15-HETE. Thus the production of 12-HETE parallels the number of neutrophils invading the infarcted area of the heart.

Arachidonic acid metabolic pathways in the rabbit pericardium.

Minced rabbit pericardium actively converts [1-14C]arachidonic acid into the known prostaglandins (6-[1-14C]ketoprostaglandin F1 alpha, [1-14C]prostaglandin E2 and [1-14C]prostaglandin F2 alpha) and into several unidentified metabolites. The major metabolite was separated by C18 reverse-phase high-pressure liquid chromatography (HPLC) and identified by gas chromatography-mass spectrometry (GC-MS) to be 6,15-[1-14C]diketo-13,14-dihydroprostaglandin F1 alpha. The other nonpolar metabolites were 15-[1-14C]hydroxy-5,8,11,13-eicosa-tetraenoic acid (15-HETE), 11-[1-14C]hydroxy-5,8,12,14-eicosatetraenoic acid (11-HETE) and 12-[1-14C]hydroxy-5,8,10,14-eicosatetraenoic acid (12-HETE). Arachidonic acid metabolites actively produced by the pericardium could influence the tone of surface blood vessels on the myocardium.

In vivo inhibition of thromboxane synthetase in infarcted canine myocardium.

The in vivo effectiveness of the thromboxane synthetase inhibitor OKY-1581 was tested in normal and infarcted canine myocardium. A rapid in vitro assay was developed which permits an accurate assessment of the status of the tissue thromboxane synthetase at the time of sacrifice. Reperfused infarcts were created by two hours of coronary artery occlusion followed by release of occlusion and three days of recovery. OKY-1581 was infused at 100 micrograms/kg/min for 15 minutes, a dose previously found to cause an 85% inhibition of canine platelet thromboxane synthetase in vivo. The heart was rapidly excised and transmural tissue plugs of infarcted and normal areas were obtained. These were incubated for 5 minutes with prostaglandin endoperoxide (PGH2) in phosphate buffer. Thromboxane production was inhibited from 16 +/- 1 ng TxB2 per tissue plug to 5 +/- 1 in normal myocardium and from 27 +/- 5 to 6 +/- 1 in infarcted areas of myocardium. Control incubations showed no further inhibition with the in vitro addition of 20 micrograms/ml OKY-1581, confirming the completeness of in vivo inhibition. Thus significant inhibition of thromboxane synthetase by intravenous OKY-1581 occurs even in a reperfused zone of infarction.

Pharmacological manipulation of canine cyclooxygenase and thromboxane synthetase in vivo: differential renal and platelet recovery rates.

Aspirin (acetylsalicylic acid) was chronically infused i.v. into dogs at a low dose (0.1 mg/kg/hr) using a surgically implanted Alzet osmotic pump. The time course for inhibition of cyclooxygenase and for its recovery after removal of the pump were followed in washed platelet preparations and in kidney medulla microsomes using [14C]arachidonic acid metabolism. Chronic acetylsalicylic acid infusion inhibited platelet cyclooxygenase 60% after 1 day of treatment and 95% after 3 days. Recovery of platelet arachidonate metabolism after removal of the osmotic pump was very rapid (T 1/2 = 0.9 days). Renal cyclooxygenase was also completely inhibited after 3 days but showed a slower recovery rate (T 1/2 = 2.8 days). Therefore, canine platelets, unlike human platelets, recover more rapidly from acetylsalicylic acid inhibition than do the kidneys. We have also established a whole blood method to study the effective time course of thromboxane synthetase inhibitors. The relative potencies for inhibiting platelet thromboxane synthetase after i.v. bolus administration of the agents studied was OKY-1581 greater than OKY-046 = dazoxiben much greater than Ro 22-7878. The effective half-life of OKY-1581, OKY-046 and dazoxiben was 2 hr while the half-life of Ro 22-7878 was 0.5 hr.

The arachidonic acid metabolic capacity of canine myocardium is increased during healing of acute myocardial infarction.

The relative capacity for metabolizing [14C]arachidonic acid into biologically active products was studied in microsomes prepared from both normal and infarcted regions of myocardium at three different times after circumflex coronary artery occlusion in the dog. At 3 days after infarction, when polymorphonuclear leukocytes were the predominant invading cell, the ability of infarcted left ventricle microsomes to produce arachidonic acid metabolites was greater than that of microsomes from normal areas of the same hearts. At 3 weeks after infarction, when macrophages were the predominant infiltrating cell and there was a proliferation of blood vessels and fibroblasts, there continued to be significant increases in the production of both prostacyclin (measured as 6-keto PGF1 alpha) and thromboxane (measured as TxB2). This enhanced production was still seen at 3 months after infarction at a time when histological examination of the tissue showed that it was still healing with both blood vessels and fibroblasts present. The production of 6-keto PGF1 alpha was 31.7 +/- 4 picomoles per milligram protein per hour (pmol/mg per hr) in noninfarcted regions of left ventricle, whereas the production was significantly increased to 71.7 +/- 15 at 3 days, 64.1 +/- 10 at 3 weeks, and 67.2 +/- 15 even at 3 months after infarction. The thromboxane synthetase activity rose significantly from 30.1 +/- 5 pmol mg per hr in noninfarcted regions to 73.7 +/- 18 at 3 days, 71.2 +/- 5 at 3 weeks, and 92.4 +/- 40 at 3 months. The enhanced ability to metabolize arachidonic acid may result from the inflammatory cell invasion or fibroblast activation which accompany healing of acute infarcts.