Resultados alejados de la reparación versus reemplazo en insuficiencia mitral degenerativa / Long-term results of repair versus replacement for degenerative mitral valve regurgitation

Background: Mitral valve repair is considered better than mitral valve replacement for degenerative mitral regurgitation. Aim: To evaluate late clinical results of mitral valve repair as compared to mitral valve replacement in patients with degenerative mitral regurgitation. Patients and methods: All patients subjected to open heart surgery for degenerative mitral regurgitation between 1990 and 2002 were assessed for surgical mortality, late cardiac and overall mortality, reoperation, readmission to hospital, functional capacity and anticoagulant therapy. Eighty eight patients (48 males) had mitral valve repair and 28 (19 males) had mitral valve replacement (23 with a mechanical prosthesis). Mean age was 59.9 ± 14.8 (SD) and 61.3 ± 14.6 years, respectively. Sixty three percent of patients with repair and 50% of those with valve replacement were in functional class III or IV before surgery. Results: Operative mortality was 2.3% for mitral valve repair and 3.6% for mitral valve replacement (NS). Also, there was no statistical difference in the need of reoperation during the follow-up period between both procedures (2.3% and 0%, respectively). Ninety four percent of the replacement patients but only 26% of the repair patients were in anticoagulant therapy at the end of the follow-up period (p <0.001). Ten years survival rates were 82 ± 6% for mitral valve repair and 54 ± 11% for replacement. The corresponding cardiac related survival rates were 89 ± 6% and 79 ± 10%. At the end of follow-up, all surviving patients were in functional class I or II. Ten years freedom from cardiac event rates (death, cardiac related rehospitalization and reoperation) were 90 ± 3% for mitral valve repair and 84 ± 6% for replacement. Conclusion: Repair of the mitral valve offers a better overall survival and a better chance of freedom from cardiac events as well as need for anticoagulation 10 years after surgery.

Ciruguía reparadora de la válvula aórtica bicúspide insuficiente / Valve repair surgery for incompetent bicuspid aortic valves

Background: Surgical valve repair is a good alternative for correction of incompetent bicuspid aortic valve. Aim: To report the early and late surgical, clinical and ecochardiographic results of surgical repair of incompetent bicuspid aortic valves. Patients and methods: Retrospective review of medical records of 18 patients aged 19 to 61 years, with incompetent bicuspid aortic valve in whom a valve repair was performed. Four patients had infectious endocarditis and 17 were in functional class I or II. Follow up ranged from 3 to 113 months after surgery. Results: A triangular resection of the prolapsing larger cusp, which included the middle raphe, was performed in 17 cases; in 13 of these, a complementary subcommisural annuloplasty was performed. In the remaining case, with a perforation of the non-coronary cusp, a pericardial patch was implanted; this procedure was also performed in 2 other cases. In 3 cases large vegetations were removed. Postoperative transesophageal echocardiography showed no regurgitation in 11 patients (62percent) and mild regurgitation in 7 (38percent). There was no operative morbidity or mortality. There were no deaths during the follow-up period. In 3 patients (17percent) the aortic valve was replaced with a mechanical prosthesis, 8 to 108 months after the first operation. Reoperation was not needed in 93percent±6,4percent at 1 year and 85percent±9,5percentat 5 years, these patients were all in functional class I at the end of the follow-up period. 60percen had no aortic regurgitation, 20percent had mild and 20percent moderate aortic regurgitation on echocardiographic examination. A significant reduction of the diastolic diameter of the left ventricle was observed, but there were no significant changes in systolic diameter or shortening fraction. Conclusions: Surgical repair of incompetent bicuspid aortic valves has low operative morbidity and mortality and has a low risk of reoperation.

Analysis of rat liver foci growth with a quantitative two-cell model after treatment with 2,4,5,3',4'-pentachlorobiphenyl.

A biologically based, quantitative foci-growth model was used to analyze the effect of 20 and 52 weeks treatment with 2,4,5,3', 4'-pentachlorobiphenyl (PCB118) on the development of enzyme-altered foci in rat liver initiated with partial hepatectomy and diethylnitrosamine. Hepatocyte proliferation was examined and the data were used in the selection of division rates for the computer simulations of foci growth. The bromodeoxyuridine-labeling index in foci was generally larger than in nonfocal tissue. A strong correlation was found between foci occurrence and proliferation in focal as well as nonfocal tissue, suggesting that cytotoxicity and regenerative proliferation are involved in the foci growth caused by PCB118. The foci growth model adequately simulated the foci data when certain assumptions were introduced. Given the general view that PCB118 is a nonmutagenic compound, the foci data could not be modeled assuming one homogeneous cell population, but was adequately fitted assuming two separate initiated cell populations that respond differently to the promotion stimulus. Other assumptions were a selective growth advantage for initiated cells during and shortly after the initiation treatment, and a transient increase of proliferation in focal hepatocytes at the first PCB administration in the higher dose groups. The model predicted an increased rate of focal cell death, at high doses, to adequately fit the foci data. These assumptions are supported by experimental data for other carcinogens, indicating the importance of studying cell kinetics in heterogeneous subpopulations of initiated cells in PCB-induced hepatocarcinogenesis.

Contribution of planar (0-1 ortho) and nonplanar (2-4 ortho) fractions of Aroclor 1260 to the induction of altered hepatic foci in female Sprague-Dawley rats.

The hepatic tumor promoting activity of the planar 0-1 ortho ( approximately 9.7% w/w) and the nonplanar 2-4 ortho ( approximately 90.3% w/w) fraction of the commercial PCB mixture Aroclor 1260 was studied using a medium-term two-stage initiation/promotion bioassay in female Sprague-Dawley rats. Fractionation was carried out on an activated charcoal column. The composition of the effluent from the column was tested by GC-ECD. The absence of planar compounds in the 2-4 ortho fraction was confirmed by GC-MS analysis. The dioxin-like toxic potency of the fractions was determined with the DR-CALUX assay. The animal experiment was started with the initiation procedure (diethylnitrosamine injection, 30 mg/kg body wt ip, 24 h after (2)/(3) hepatectomy), followed 6 weeks later by the promotion treatment, which consisted of a weekly subcutaneous injection during 20 weeks. Exposure groups (n = 10) received the following treatments (dose/kg body wt/week): Aroclor 1260 (10 mg), 0-1 ortho fraction (0.97 mg), 2-4 ortho fraction (1, 3, or 9 mg), a reconstituted 0-4 ortho fraction (9.97 mg), 2,2',4,4',5,5'-hexachlorobiphenyl (PCB 153; 1 or 9 mg), 2,3,7,8-TCDD (1 microg; positive control) or corn oil (1 ml; vehicle control). One group did not receive a promotion treatment. All exposure groups exhibited a significantly increased volume fraction of the liver occupied by hepatic foci positive for the placental form of glutathione-S-transferase-p compared to the corn oil control, except for the groups treated with 0-1 ortho fraction and 1 mg PCB 153/kg body wt/week. Approximately 80% of the total tumor promoting capacity of the reconstituted 0-4 ortho fraction could be explained by the 2-4 ortho PCB fraction while the 0-1 ortho fraction had only a negligible contribution. These results suggest that the majority of the tumor promotion potential of PCB mixtures resides in the non-dioxin-like fraction, which is not taken into account in the toxic equivalency factor (TEF) approach for risk assessment of PCBs. This may result in an underestimation of the tumor promotion potential of environmental PCB mixtures.

Liver tumor-promoting activity of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in TCDD-sensitive and TCDD-resistant rat strains.

Risk assessment of dioxins is currently based on induction of liver tumors in rats. The toxicity of dioxins is characterized by large sensitivity differences among animal species and even strains of the same species, which complicates the risk assessment. The significance of these differences in dioxin-induced carcinogenicity is not known. We therefore studied the liver tumor-promoting activity of 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in the sensitive Long-Evans (L-E) and the resistant Han/Wistar (H/W) rats differing >1000-fold in their sensitivity to the acute lethaity of TCDD. Female rats were partially hepatectomized, initiated with nitrosodiethylamine, and treated with TCDD for 20 weeks. Altered hepatic foci (AHF) were stereologically quantitated using glutathione S-transferase P as a marker. AHF were significantly (P < 0.001) and dose dependently increased in L-E rats at 10 and 100 ng/kg/day, but in H/W rats only at 1000 ng/kg/day and above, indicating a remarkable (approximately 100-fold) sensitivity difference between L-E and H/W rats. The same sensitivity difference but 10-fold less foci were observed between nonhepatectomized/noninitiated L-E and H/W rats. Induction of AHF was related to hepatotoxicity but not to cytochrome P4501A1 activity in the liver. Liver TCDD concentrations were similar in both strains. H/W rats are exceptionally resistant to induction of AHF by TCDD, and the resistance is associated with an altered transactivation domain of the aryl hydrocarbon receptor. Genetic differences may account for significant interindividual/intraspecies sensitivity differences in dioxin-induced carcinogenesis. Understanding the role of transactivation domain of the aryl hydrocarbon receptor in carcinogenesis is therefore likely to improve dioxin risk assessment.

Induction of altered hepatic foci by a mixture of dioxin-like compounds with and without 2,2',4,4',5,5'-hexachlorobiphenyl in female Sprague-Dawley rats.

The hepatic tumor-promoting activity of a mixture of polyhalogenated aromatic hydrocarbons (PHAHs) was studied in a medium term two-stage initiation/promotion bioassay in female Sprague-Dawley rats. The PHAH mixture contained 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), 1, 2,3,7,8-pentachlorodibenzo-p-dioxin (PeCDD), 2,3,4,7, 8-pentachlorodibenzofuran (PeCDF), 3,3',4,4',5-pentachlorobiphenyl (PCB 126), 2,3',4,4',5-pentachlorobiphenyl (PCB 118), 2,3,3',4,4', 5-hexachlorobiphenyl (PCB 156), 2,2',4,4',5,5'-hexachlorobiphenyl (PCB 153) and covered >90% of the total toxic equivalents (TEQ) present in Baltic herring. To determine possible interactive effects of di-ortho-substituted PCBs, the PHAH mixture was tested with (PHAH+) and without (PHAH-) PCB 153. Rats were initiated by a diethylnitrosamine injection (30 mg/kg body wt i.p.) 24 h after a partial 23 hepatectomy. Six weeks after initiation, the PHAH mixtures were administered once a week by subcutaneous injections for 20 weeks. Treatment with the PHAH mixtures caused liver enlargement and an increased activity of the hepatic cytochrome P4501A1/2 and P4502B1/2. All PHAH exposure groups exhibited an increased occurrence of hepatic foci positive for the placental form of glutathione-S-transferase. In the PHAH-group dosed 1 microgram TEQ/kg body wt/week, the volume fraction of the liver occupied by foci was significantly lower compared to the TEQ equivalent dosed TCDD group (3.8 vs 8.7%). The volume fraction was significantly increased in the groups treated with 0.5, 1, or 2 micrograms TEQ/kg body wt/week of the PHAH+ mixture (4.5, 5.2, and 6.6%, respectively) compared to the corn oil group (2.0%), but to a lower extent than expected on basis of the TEQ doses. Overall, the TEQ-based administered dose overestimated the observed tumor-promoting effects of this PHAH mixture. The applicability of the toxic equivalency factor concept, the role of differences in toxicokinetic properties and interactive effects of PCB 153 on hepatic deposition of the dioxin-like congeners are discussed.

Toxicokinetics of an environmentally relevant mixture of dioxin-like PHAHs with or without a non-dioxin-like PCB in a semi-chronic exposure study in female Sprague Dawley rats.

Female Sprague Dawley rats were treated subcutaneously for 20 weeks with an environmentally relevant mixture of dioxin-like PHAHs with (PHAH+) or without (PHAH-) 2,2',4,4',5,5'-hexachlorobiphenyl. The hepatic retention (% of given dose) of the various PHAH congeners differed considerably and in the following order: 2,3,4,7,8-pentachlorodibenzofuran (30.5-43.1%), 3,3',4,4',5-pentachlorobiphenyl (12.8-17.6%), 1,2,3,7,8-pentachlorodibenzo-p-dioxin (6.9-10.8%), 2,3,7,8-tetrachlorodibenzo-p-dioxin (3.2-4.5%), 2,3,3',4,4',5-hexachlorobiphenyl (1.0-1.7%), 2,2',4,4',5,5'-hexachlorobiphenyl (0.5-0.8%) and 2,3',4,4',5-pentachlorobiphenyl (0.2-0.4%). A decrease of the hepatic retention of 2,3,7,8-TCDD, 1,2,3,7,8-PeCDD and 2,3,4,7,8-PeCDF was found at increasing doses of the PHAH+ mixture. 2,2',4,4',5,5'-Hexachlorobiphenyl increased the hepatic retention (1.3-2 times) of all congeners in the PHAH+ group, compared to the TEQ equivalent dosed PHAH- group. No interactions were observed on the ethoxyresorufin-O-deethylase activity.

Interactive effects of three structurally different polychlorinated biphenyls in a rat liver tumor promotion bioassay.

Interactive effects between the non-ortho-substituted 3,3', 4,4', 5-pentachlorobiphenyl (PCB126), the mono-ortho-substituted 2,3,3',4, 4'-pentachlorobiphenyl (PCB105), and the di-ortho-substituted 2,2',4, 4',5,5'-hexachlorobiphenyl (PCB153) were studied in an initiation/promotion bioassay. Female Sprague-Dawley rats were injected with 30 mg/kg ip of N-nitrosodiethylamine 24 h after partial hepatectomy. Five weeks later, weekly sc administrations of the three PCBs in 15 systematically selected dose combinations started. After 20 weeks of administration, the animals were killed and the livers were analyzed for areas expressing placental glutathione-S-transferase as a marker of preneoplastic foci. In addition, concentration of liver and kidney retinoids and plasma retinol was analyzed, as well as body and organ weights, plasma transaminases, and induction of hepatic cytochrome P450 1A1/2 (CYP1A1/2) and CYP2B1/2 activities. Data were analyzed with a multivariate method. At the doses applied in this study, weak antagonism was observed between PCB126 and PCB153 for effects on volume fraction of foci, number of foci/cm3, concentration of plasma retinol and liver retinoids, relative liver weight, and induction of CYP2B1/2 activity. Weak antagonism was also observed between PCB126 and PCB105 for effects on volume fraction of foci, number of foci/cm3, and plasma retinol concentration. No interactions other than pure additivity were observed between PCB105 and PCB153. Synergism was not observed within the dose ranges investigated in this study. Knowledge of interactive effects is important for risk assessment of environmental mixtures of dioxin-like compounds. Antagonism between congeners generally results in risk assessments that overestimate human risk. The significance to human risk assessment of the relatively weak antagonism observed in this study is however unclear, considering many other uncertainties involved in the toxic equivalency factor (TEF) concept. A change of the TEF concept for risk assessments of dioxin-like substances is not motivated based on the results of this study.

Promotion of enzyme altered foci in female rat 2,3,3',4,4',5-hexachlorobiphenyl.

The tumor promoting activity of 2,3,3',4,4',5-hexachlorobiphenyl (PCB 156) was studied in an initiation/promotion bioassay in female Sprague-Dawley rats initiated with N-nitrosodiethylamine after partial hepatectomy. PCB 156 (50, 300, 1500, or 7500 microg/kg body weight/week) was administered by once-weekly subcutaneous injections for 20 weeks. Some high dose animals were left without treatment for an additional 20 weeks to study posttreatment effects. The volume fraction of the liver occupied by glutathione S-transferase P-positive foci was significantly increased to 2.9, 3.3, and 12% at 300, 1500, and 7500 microg/kg body weight/week, respectively, compared to 1.2% in the controls. The volume fraction was 43% in the high dose group 20 weeks after treatment was stopped, probably reflecting the slow body clearance of PCB 156 as indicated by the sustained liver and adipose tissue concentrations. Treatment with PCB 156 following initiation caused decreased body weight gain, thymic atrophy, liver enlargement, induction of hepatic cytochrome P450 1A1/2 (CYP1A1/2) and CYP2B1/2 activities, histopathological effects, and increased activities of aspartate aminotransferase and gamma-glutamyltransferase in plasma. These results show that PCB 156 can enhance the growth of altered foci in rat liver and probably act as a tumor promoter of hepatocarcinogenesis. Based on promotional activity a relative potency of PCB 156 to 2,3,7, 8-tetrachlorodibenzo-p-dioxin of 0.0001-0.001 is proposed.

Promotion of altered hepatic foci by 2,3',4,4',5-pentachlorobiphenyl in Sprague-Dawley female rats.

The tumor promotion potential of 2,3',4,4',5-pentachlorobiphenyl (PCB-118) was studied in a two-stage initiation/promotion bioassay in female Sprague-Dawley rats. The animals were initiated by intraperitoneal administration of N-nitrosodiethylamine after partial hepatectomy. After 5 weeks of recovery, the promotion period commenced by once-weekly subcutaneous administrations of PCB-118 at six dose levels (10, 40, 160, 640, 2500, and 10,000 microg/kg body weight/week) for 20 weeks. In addition, three of these dose levels (40, 640, and 10,000 microg/kg body weight/week) were administered for 52 weeks. Evaluation of hepatic foci positive for glutathione S-transferase P demonstrated that the mono-ortho chlorine substituted congener PCB-118 significantly increased the number of foci/cm3 of liver in the two highest dose groups after 20 weeks, but did not significantly increase the percentage of the liver occupied by foci. After 52 weeks of treatment, both the percentage and the number of foci/cm3 were significantly increased in the highest dose group. A toxic equivalency factor based on foci development during 20 weeks of treatment would be less than 0.00002. Altered relative liver and thymus weights were observed after treatment with both substances as well as an induction of methyl cholanthrene- and phenobarbital-inducible isoenzymes of cytochrome P450 monooxygenase. These results show that PCB-118 has a potency to enhance foci growth in rat liver, although the potency is low compared to that of structurally related compounds.

Benzo[a]pyrene metabolism and induction of enzyme-altered foci in regenerating rat liver.

The metabolism of benzo[a]pyrene (BP) in regenerating rat liver and the induction of enzyme-altered foci (EAF) in the liver of partially hepatectomized rats, treated with BP and promoted with 2-acetylaminofluorene (2-AAF)/CCl4 was investigated. The aim was to examine factors that might be of importance for the tumorigenicity of BP in the regenerating rat liver, such as cytochrome P-450 activity and glutathione levels. In regenerating rat liver, obtained 18 h after partial hepatectomy (PH), the amount of microsomal cytochrome P-450 was reduced by 20% whereas the level of glutathione was elevated by 15% and the cytosolic glutathione transferase activity towards chlorodinitrobenzene and (+/-)-7 beta,8 alpha-dihydroxy-9 alpha, 10 alpha-epoxy-7,8,9,10-tetrahydro-BP (BPDE) was unaffected. Microsomes from these animals had a reduced capacity to activate (-)-trans-7,8-dihydroxy-7,8-dihydro-BP (BPD) to DNA-binding products but the pattern of BP metabolites was similar to that observed with control rat liver microsomes. Treatment of rats with 3-methylcholanthrene (MC, 50 mg/kg body wt.) increased cytochrome P-450 levels and glutathione transferase activity towards both substrates. Regenerating livers from these animals retained their cytochrome P-450 level and enzymatic activity towards BP and BPD. Regenerating rat liver microsomes from MC-treated animals were about 35 times more efficient in activating BPD than microsomes from uninduced, partially hepatectomized animals. Intraperitoneal administration of BP (50 mg/kg body wt.) 18 h after PH induced EAF in rats subsequently promoted with 2-AAF/CCl4. Pretreatment of rats with MC 66 h before PH and 84 h before BP administration, increased the number of EAF. In accordance with results by Tsuda et al. (Cancer Res., 40 (1980) 1157-1164), these studies demonstrate that BP is tumorigenic in regenerating rat liver, despite a reduced ability of the liver to activate this compound. Furthermore, MC, an inducer of certain cytochrome P-450 species ("aryl hydrocarbon hydroxylase"), potentiates the effect of BP.