Changes in demographics, treatment and outcomes in a consecutive cohort who underwent transcatheter aortic valve implantation between 2005 and 2020.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) has matured to the treatment of choice for most patients with aortic stenosis (AS). We sought to identify trends in patient and procedural characteristics, and clinical outcomes in all patients who underwent TAVI between 2005 and 2020. METHODS: A single-centre analysis was performed on 1500 consecutive patients who underwent TAVI, divided into three tertiles (T) of 500 patients treated between November 2005 and December 2014 (T1), January 2015 and May 2018 (T2) and June 2018 and April 2020 (T3). RESULTS: Over time, mean age and gender did not change (T1 to T3: 80, 80 and 79 years and 53%, 55% and 52% men, respectively), while the Society of Thoracic Surgeons risk score declined (T1: 4.5% to T3: 2.7%, p < 0.001). Use of general anaesthesia also declined over time (100%, 24% and 1% from T1 to T3) and transfemoral TAVI remained the default approach (87%, 94% and 92%). Median procedure time and contrast volume decreased significantly (186, 114 and 56 min and 120, 100 and 80 ml, respectively). Thirty-day mortality (7%, 4% and 2%), stroke (7%, 3% and 3%), need for a pacemaker (19%, 22% and 8%) and delirium (17%, 12% and 8%) improved significantly, while major bleeding/vascular complications did not change (both approximately 9%, 6% and 6%). One-year survival was 80%, 88% and 92%, respectively. CONCLUSION: Over our 15 years' experience, patient age remained unchanged but the patient risk profile became more favourable. Simplification of the TAVI procedure occurred in parallel with major improvement in outcomes and survival. Bleeding/vascular complications and the need for pacemaker implantation remain the Achilles' heel of TAVI.

Clinical consequences of consecutive self-expanding transcatheter heart valve iterations.

OBJECTIVE: To compare early clinical outcomes after transcatheter aortic valve implantation (TAVI) with three consecutive generations of self-expanding valves (SEVs). METHODS: Clinical endpoints of consecutive patients who underwent TAVI with CoreValve, Evolut R or Evolut PRO were included in a prospective database. RESULTS: TAVI was performed with CoreValve (n = 116), Evolut R (n = 160) or Evolut PRO (n = 92). Evolut R and Evolut PRO showed a tendency towards lower permanent pacemaker implantation (PPI) rates compared to CoreValve (CoreValve 27% vs Evolut R 16% vs Evolut PRO 18%, p = 0.091). By multivariable regression analysis CoreValve had a significantly higher risk for PPI (odds ratio (OR) 2.79, 95% confidence interval (CI) 1.31-5.94, p = 0.008) compared to Evolut R, while Evolut R and PRO were similar. Severe paravalvular leakage (PVL) occurred only with CoreValve, but no significant difference was observed in moderate PVL (10% vs 8% vs 6%, p = 0.49). CoreValve had a tendency towards a higher risk for more-than-mild PVL as compared with the Evolut platform (R + PRO) (OR 2.46, 95% CI 0.98-6.16, p = 0.055). No significant differences in all-cause mortality (7% vs 4% vs 1%, p = 0.10), stroke (6% vs 3% vs 2%, p = 0.21) or major vascular complications (10% vs 12% vs 4%, p = 0.14) were observed. CONCLUSIONS: TAVI with self-expanding valves was safe, and device iterations may result in a lower need for PPI. More-than-mild PVL seemed to occur less often with repositionable technology.

British Dietetic Association evidence-based guidelines for the dietary management of Crohn's disease in adults.

BACKGROUND: Crohn's disease is a debilitating chronic inflammatory bowel disease. Appropriate use of diet and nutritional therapy is integral to the overall management strategy of Crohn's disease. The aim was to develop evidence-based guidelines on the dietary management of Crohn's disease in adults. METHODS: Questions relating to the dietary management of Crohn's disease were developed. These included the roles of enteral nutrition to induce remission, food re-introduction diets to structure food re-introduction and maintain remission, and dietary management of stricturing disease, as well as whether probiotics or prebiotics induce or maintain remission. A comprehensive literature search was conducted and relevant studies from January 1985 to November 2009 were identified using the electronic database search engines CINAHL, Cochrane Library, EMBASE, MEDLINE, Scopus and Web of Science. Evidence statements, recommendations, practical considerations and research recommendations were developed. RESULTS: Fifteen research papers were critically appraised and the evidence formed the basis of these guidelines. Although corticosteroids appear to be more effective, enteral nutrition (elemental or non-elemental) can be offered as an alternative option to induce disease remission. After a course of enteral nutrition, food re-introduction diets may be useful to structure food re-introduction and help maintain disease remission. Dietary fibre is contraindicated in the presence of strictures as a result of the risk of mechanical obstruction. The use of probiotics and prebiotics is not currently supported. CONCLUSIONS: As an alternative to corticosteroids, evidence supports enteral nutrition to induce disease remission. Food re-introduction diets provide structure to food re-introduction and help maintain disease remission. These guidelines aim to reduce variation in clinical practice.

Serum OPG/TRAIL ratio predicts the presence of cardiovascular disease in people with type 2 diabetes mellitus.

AIMS: Cardiovascular disease (CVD) is the leading cause of mortality in type 2 diabetes mellitus (T2DM). Epidemiological studies suggest serum Osteoprotegrin (OPG)/Tumour-necrosis-factor-related-apoptosis-inducing- ligand (TRAIL) ratio may be a useful marker of cardiovascular risk. This study aimed to compare serum levels of TRAIL, OPG and OPG/TRAIL ratio in people with T2DM, with and without a history of CVD, and controls; and to determine which of these indices, if any, predict cardiovascular risk. METHODS: In this single centre observational study of 133 participants, people with T2DM, with and without a history of a cardiovascular event in the last 5 years, were recruited along with a control cohort without T2DM or CVD. Demographic information and anthropometric measurements were recorded. Blood samples were taken and OPG and TRAIL were measured using ELISA. RESULTS: People with T2DM and CVD had higher OPG/TRAIL ratios compared to controls or those with a new diagnosis of T2DM. After adjustment for potential confounding factors, OPG/TRAIL ratio was significantly associated with the presence of CVD in people with T2DM and an OPG/TRAIL ratio cut-off > 38.6 predicted the presence of CVD in this cohort with a sensitivity of 80% and specificity of 82%. CONCLUSION: This study suggests that OPG/TRAIL ratio may have a role as a biomarker of CVD in people with T2DM.

Seismic imaging and petrology explain highly explosive eruptions of Merapi Volcano, Indonesia.

Our seismic tomographic images characterize, for the first time, spatial and volumetric details of the subvertical magma plumbing system of Merapi Volcano. We present P- and S-wave arrival time data, which were collected in a dense seismic network, known as DOMERAPI, installed around the volcano for 18 months. The P- and S-wave arrival time data with similar path coverage reveal a high Vp/Vs structure extending from a depth of ≥20 km below mean sea level (MSL) up to the summit of the volcano. Combined with results of petrological studies, our seismic tomography data allow us to propose: (1) the existence of a shallow zone of intense fluid percolation, directly below the summit of the volcano; (2) a main, pre-eruptive magma reservoir at ≥ 10 to 20 km below MSL that is orders of magnitude larger than erupted magma volumes; (3) a deep magma reservoir at MOHO depth which supplies the main reservoir; and (4) an extensive, subvertical fluid-magma-transfer zone from the mantle to the surface. Such high-resolution spatial constraints on the volcano plumbing system as shown are an important advance in our ability to forecast and to mitigate the hazard potential of Merapi's future eruptions.

Inhibition of major integrin αV ß3 reduces Staphylococcus aureus attachment to sheared human endothelial cells.

Essentials Staphylococcus aureus (S. aureus) binds and impairs function of vascular endothelial cells (EC). We investigated the molecular signals triggered by S. aureus adhesion to EC. Inhibition of the EC integrin αVß3 reduces S. aureus binding and rescues EC function. αVß3 blockade represents an attractive target to treat S. aureus bloodborne infections. SUMMARY: Background Vascular endothelial dysfunction with associated edema and organ failure is one of the hallmarks of sepsis. Although a large number of microorganisms can cause sepsis, Staphylococcus aureus (S. aureus) is one of the primary etiologic agents. Currently, there are no approved specific treatments for sepsis, and the initial management bundle is therefore focused on cardiorespiratory resuscitation and mitigation of the immediate threat of uncontrolled infection. The continuous emergence of antibiotic-resistant strains of bacteria necessitates the development of new therapeutic approaches for this disease. Objective To identify the molecular mechanisms leading to endothelial dysfunction as a result of S. aureus binding. METHODS: Binding of wild type and Clumping factor A (ClfA) deficient S. aureus Newman to the endothelium was measured in vitro and in the mesenteric circulation of C57Bl/6 mice. The effects of the αV ß3 blocker-cilengitide-on bacterial binding, endothelial VE-cadherin expression, apoptosis, proliferation and permeability were assessed. Results The major S. aureus cell wall protein ClfA bound to endothelial cell αV ß3 in the presence of fibrinogen. This interaction resulted in disturbances in barrier function mediated by VE-cadherin in endothelial cell monolayers, and ultimately cell death by apoptosis. With a low concentration of cilengitide, ClfA binding to αV ß3 was significantly inhibited both in vitro and in vivo. Moreover, preventing S. aureus from attaching to αV ß3 resulted in a significant reduction in endothelial dysfunction following infection. Conclusion Inhibition of S. aureus ClfA binding to endothelial cell αV ß3 by cilengitide prevents endothelial dysfunction.

Pyroglutamyl peptidase: an overview of the three known enzymatic forms.

Pyroglutamyl peptidase can be classified as an omega peptidase which hydrolytically removes the amino terminal pyroglutamate (pGlu) residue from specific pyroglutamyl substrates. To date, three distinct forms of this enzyme have been identified in mammalian tissues. Type I is typically a cytosolic, cysteine peptidase displaying a broad pyroglutamyl substrate specificity and low molecular mass. Type II has been shown to be a membrane anchored metalloenzyme of high molecular mass with a narrow substrate specificity restricted to the hypothalamic releasing factor, thyrotropin-releasing hormone (TRH, pGlu-His-Pro-NH2). A third pyroglutamyl peptidase activity has also been observed in mammalian serum which displays biochemical characteristics remarkably similar to those of tissue Type II, namely a high molecular mass, sensitivity to metal chelating agents, and a narrow substrate specificity also restricted to TRH. This serum activity has subsequently been designated 'thyroliberinase'. This review surveys the biochemical, enzymatic, and structural properties of this interesting and unique class of peptidases. It also addresses the putative physiological roles which have been ascribed to these enzymes. Pyroglutamyl peptidase activities isolated and characterized from bacterial sources are also reviewed and compared with their mammalian counterparts.

Myosin adenosinetriphosphatase activity and light chain subunit composition of human right and left ventricle.

Myosin was isolated from the free right and left ventricular wall of normal adult human myocardium and purified until actin contamination was considered negligible as judged by sodium dodecyl sulphate polyacrylamide gel electrophoresis and adenosine triphosphatase assay in the presence of magnesium chloride. Ca2+ and K+ ethylenediaminetetra-acetic acid activated adenosine triphosphatase activities were determined in the presence of 3 mmol.litre-1 adenosine triphosphate. Myosin light chain subunits, VLC-1 and VLC-2, were analysed by polyacrylamide gel electrophoresis using: (i) sodium dodecyl sulphate at pH 7.0; (ii) 6 mol.litre-1 urea at pH 8.5; and (iii) isoelectric focusing in 9.2 mol.litre-1 urea over the pH range 4 to 6. No inherent differences in enzymic or physiochemical properties of the myosins from the human right and left ventricle were observed. Similar results were obtained in the baboon and dog.

Cardiac myosin light and heavy chain isotypes in tetralogy of Fallot.

Myosin isotype composition was examined in ventricular infundibular muscle from 40 patients with tetralogy of Fallot, aged from 7 months to 38 years. Results were compared with normal samples of ventricular infundibulum from subjects in the same age range, from 18-20 week old fetuses to 6 month old neonates, and from 43-81 year old adults. Myosin light chain isotypes were examined by one dimensional and two dimensional gel electrophoresis and quantified densitometrically. Heavy chain isotypes were examined by electrophoresis of whole heavy chains and peptide mapping after limited proteolytic digestion with chymotrypsin. At mid-gestation in normal tissues, only ventricular light chain 2 was present but light chain 1 consisted almost equally of atrial and ventricular isotypes. Amounts of atrial light chain 1 declined towards birth and disappeared during the first year after birth, gradually being replaced by ventricular light chain 1. Relative amounts of total light chains 1 and 2 remained equal. In tetralogy of Fallot atrial light chain 1 expression did not cease neonatally with mean values of 11.8% of total light chain 1 present between 7 months and 2 years, decreasing to 1.7% at 6.5-12 years and then increasing again to 3.4% in adults. A value of 34% atrial light chain 1 was present in one subject. As in normal subjects, equimolar amounts of total light chains 1 and 2 were retained. No evidence of new light chain isotypes was found in tetralogy of Fallot. Heavy chain expression was constant in normal infundibulum with only beta-heavy chain (V3 isozyme) present in the fetus, neonate, and adult.(ABSTRACT TRUNCATED AT 250 WORDS)

Uptake of radioiodinated cardiac specific troponin-I antibodies in myocardial infarction.

STUDY OBJECTIVE: To examine the potential diagnostic value of the cardiac myofibrillar protein troponin-I as a target for radiolabelled antibodies in detecting heart damage, the uptake of 131I labelled polyclonal cardiac troponin-I Fab was investigated in necrotic myocardial cells in canine myocardial infarction. DESIGN: Cardiac specific troponin-I Fab was prepared by immunoaffinity chromatography and injected 5 h after coronary artery ligation. Whole body gamma camera scintigraphic images were taken after the injection, and heart slices were examined for the presence of labelled antibody. SUBJECTS: Adult dogs of either sex (n = 6) were used. MEASUREMENTS AND MAIN RESULTS: Scintigraphic whole body images at 24 and 40 h after troponin-I Fab injection showed increased 131I-localisation over the apical region of the heart which corresponded to the infarcted areas. Localisation in infarcted tissue was confirmed in isolated heart and histochemically stained heart slice images. Uptake of 131I Fab was up to 24 times greater in necrotic than in normal myocardium and was inversely related to regional blood flow as determined by 141cerium microsphere distribution. Confirmation that 131I Fab uptake was due to direct binding to troponin-I in necrotic cells was obtained by coinjection of non-immune 125I labelled Fab. CONCLUSIONS: Results indicate that troponin-I could act as a suitable target for detecting myocardial necrosis.

Bovine brain pyroglutamyl aminopeptidase (type-1): purification and characterisation of a neuropeptide-inactivating peptidase.

Pyroglutamyl aminopeptidase type-1 (PAP-I) is reported to be a soluble, broad specificity aminopeptidase, capable of removing the pyroglutamic acid (pGlu) residue from the amino terminus of pGlu-peptides (e.g. TRH, LHRH, neurotensin and bombesin). The central aim of this study was to undertake, for the first time, the complete purification and characterisation of a PAP activity observed within the cytosolic fraction of bovine whole brain and to compare the properties of the enzyme with previous findings. A series of chromatographic steps (DEAE-Sepharose, Sephacryl S-200 and Activated Thiol Sepharose 4B) generated a soluble PAP activity purified to near homogeneity with a total active yield of 6.6% The enzyme displayed a native molecular mass of approximately 23,700 Da, which compares well with that value obtained under denaturing conditions via SDS-PAGE (24,000 Da), suggesting that the enzyme exists as a monomer. The expression of PAP activity displayed an absolute requirement for the presence of a disulphide bond-reducing agent such as DTT, whilst optimum activity was observed at pH 8.5. strong inhibition of PAP activity was observed with a number of different agents, including transition metal ions, sulphydryl-blocking agents and 2-pyrrolidone (a pGlu analog). A broad pyroglutamyl substrate specificity, which excludes substrates commencing with the pGlu-Pro bond, was also demonstrated for the bovine brain enzyme. Based on a comparison of these findings with those reported for PAP-I in other mammalian tissues, the soluble PAP activity observed in bovine whole brain can tentatively be classified as a pyroglutamyl aminopeptidase type-1 (EC 3.4.19.3).

Metabolic changes in the autotransplanted baboon heart.

Chronic denervation of the heart leads to depletion of tissue catecholamines, giving rise to metabolic abnormalities, including a reduction in cardiac glucose oxidation. Impaired glucose oxidation could cause an increased oxidation of fat, which in turn could lead to development of coronary artery disease. Cardiac glucose oxidation (using 14C-(U),D-glucose) was studied in female baboons, before, and three to five weeks after, autotransplantation. Systemic arterial and coronary sinus samples were analyzed for total CO2 content, O2 content, 14CO2, glucose, lactate, pH, PCO2, and PO2. Tissue for metabolite assays (adenosine-5'-triphosphate [ADP] and creatine phosphate [CP]; glucose-6-phosphate [G6P] and fructose 6-phosphate [F6P] was obtained from the right ventricle before and after autotransplantation in some animals. There were no significant changes. Tissue was also obtained postmortem for analysis of noradrenaline, soluble tyrosine hydroxylase activity, and contractile and regulatory proteins. There was a large decrease in tissue noradrenaline, suggesting almost total sympathetic denervation. The level of tyrosine hydroxylase activity shows that the denervated heart can synthesize dopamine. There were no detectable changes in the contractile or regulatory proteins. In six of the nine baboons successfully studied, there was a distinct decrease in the oxidation of glucose after autotransplantation (P less than 0.05). This indicates that the removal of the sympathetic and parasympathetic nerve supply to the heart affects the ratio of glucose oxidized to other substrates.

The association of metalloendopeptidase EC 3.4.24.15 at the extracellular surface of the AtT-20 cell plasma membrane.

Endopeptidase EC 3.4.24.15 (EP24.15) is a soluble, neuropeptide-degrading metalloenzyme, widely expressed in the brain, pituitary and gonads. For the physiological metabolism of neuropeptides, the enzyme should be located extracellularly, either associated with the plasma membrane or in the extracellular milieu. Western immunoblot analyses of crude cytosolic and post-nuclear membrane fractions prepared by differential centrifugation revealed a slightly smaller molecular mass ( approximately 2 kDa) for EP24.15 in the post-nuclear membrane fraction. This smaller EP24.15 species was also present in an enriched fraction of plasma membrane prepared by Percoll gradient centrifugation. To ascertain whether EP24.15 is associated with the extracellular surface of plasma membrane, two sets of experiments were carried out. First, Western immunoblot analysis of AtT-20 cells treated with the membrane-impermeable, thiol-cleavable cross-linker, 3, 3'-dithio-bis(sulpho-succinimidyl-propionate) (DTSSP), indicated an extracellular membrane association. After cross-linking and thiol-reduction, a distinct band corresponding to EP24.15 was significantly diminished under non-reducing conditions. Second, immunocytochemical studies performed at 4 degrees C on non-permeabilized AtT-20 cells (i.e., non-fixed to prevent antibody internalization), indicated that EP24.15 was expressed on the surface of the AtT-20 cells. We furthermore determined that EP24.15 enzymatic activity is present on the extracellular surface of the cell discernable from the secreted enzyme. These results suggest that the EP24.15 is associated with the extracellular surface of the AtT-20 cell plasma membrane and is enzymatically active. Taken together, the results are consistent with a putative role in the degradation of neuropeptides acting at the external cell surface.

QM/MM and SCRF studies of the ionization state of 8-methylpterin substrate bound to dihydrofolate reductase: existence of a low-barrier hydrogen bond.

Using combined semiempirical quantum mechanics and molecular mechanics (QM/MM) and ab initio self-consistent reaction field (SCRF) calculations, we determined that a low-barrier hydrogen bond (LBHB) is formed when the mechanism-based substrate 8-methylpterin binds to dihydrofolate reductase (DHFR). The substrate initially was assumed bound either in the ion-pair form corresponding to N3-protonated substrate hydrogen (H) bonded to the unprotonated (carboxylate) of the conserved Glu30 residue in the active site, or in the neutral-pair form corresponding to unprotonated substrate H bonded to the neutral (carboxylic acid) from of Glu30. The free energy of interaction of these H-bonded systems with the protein/solvent surroundings was computed using a coordinate-coupled free energy perturbation (FEP) method implemented within the molecular dynamics (MD) simulation scheme and using a semiempirical (PM3) QM/MM force field. The free energy obtained from the QM/MM force-field simulations corresponds most closely with the corresponding free energy component obtained from HF/6-31G* SCRF calculations using a value of 2 for the dielectric constant (epsilon) for the solvated protein. Calculations were performed at levels ranging from HF/6-31G to MP2/6-31G* to B3LYP/6-31 + G**, with varying dielectric constants. The energy-minimized path for motion of the proton in the H bond along a one-dimensional reaction coordinate was calculated at HF/6-31G, HF/6-31G* (epsilon = 1) and B3LYP/6-31G* (epsilon = 2) levels. These calculations identified a second neutral-pair complex, involving the 2-amino group of substrate, which also interacts with Glu30, which is lower in energy than the ion-pair form. A harmonic vibrational analysis shows that the first vibrational state appears to lie near or above the TS connecting potential energy minima corresponding to the two neutral-pair configurations, thus indicating an LBHB. Consequently, the H-bonded system will have a significant probability of being found in the ion-pair form, in agreement with experimental spectral studies indicating an enzyme-bound cation and suggesting that the LBHB would activate substrate towards hydride-ion transfer from NADPH.

114Inm oxine-labelled lymphocytes--therapeutic applications.

It has shown that, after intravenous administration of autologous lymphocytes labelled with the beta-emitting radionuclide 114Inm, the cells initially migrate normally before succumbing to the toxic effects of the radiation. The radioactive material is then released from the cell and taken up by neighbouring radioresistant macrophages, thereby localizing a field of radiation to the site of lymphocyte death. Using this technique, lymphocytopoenia has been produced in rats. We have measured the whole-body distribution and excretion of radioactivity in patients who received escalating activities of 114Inm-labelled lymphocytes. All patients had active non-Hodgkin's lymphoma involving the spleen and liver which proved resistant to combination chemotherapy and conventional radiotherapy. Following intravenous administration, the labelled cells cleared rapidly from the vasculature with only 15% remaining in the peripheral blood at 30 min. The radioactivity continued to fall over the next 5 days to approximately 3% and was maintained at approximately 2% for up to 90 days. There was an almost immediate uptake of radioactivity by the spleen and liver which reached approximately 85% of the injected dose by 48 h. The localization of radioactivity stabilized by 48 h and thereafter the whole-body content fell by approximately 0.8% per day. Up to 5% of the administered radioactivity accumulated in the bone marrow. The activities administered were too low to produce a therapeutic response and no toxicity was experienced by the patients. A therapeutic study at higher activities is now underway.

Computer-aided design of mechanism-based pterin analogues and MD/FEP simulations of their binding to dihydrofolate reductase.

Using a combined theoretical and experimental approach we have been able to predict several chemical properties and the contributions of the many factors which determine the macroscopic binding behaviour of these new mechanism-based compounds with DHFR, and also analyse experimental data to develop structure-activity relationships.

First Dutch experience with percutaneous left atrial appendage transcatheter occlusion.

BACKGROUND: Patients with atrial fibrillation (AF) have an increased risk of thromboembolic stroke, dependent on clinical variables. Oral anticoagulation significantly decreases the risk of stroke or embolism, but sometimes this is difficult to manage and may be contraindicated. Approximately 90% of atrial thrombi in nonrheumatic AF are found in the left atrial appendage (LAA). A new device has been developed which allows percutaneous LAA occlusion (PLAATO) and might be an alternative to oral anticoagulation. Feasibility in dogs and humans was described previously. METHODS AND RESULTS: As part of an international multicentre trial, three patients received a percutaneous transcatheter LAA occlusion device. Implantations were performed without general anaesthesia, guided by intracardiac and transoesophageal echocardiography and without major complications. The implantations were well tolerated by the patients, who entered a long-term follow-up to be compared with a historical control group. CONCLUSION: Transseptal percutaneous LAA occlusion is feasible. Its role as an alternative to oral anticoagulation, however, needs to be further defined.