Should the controlled provision of heroin be a treatment option? Australian feasibility considerations

A proposal for a trial to provide heroin to dependent users in a controlled manner is currently being considered in the Australian Capital Territory. The political background to this proposal is outlined, as is the current ‘drug scene’. A Stage 1 examination found that a trial of controlled provision of heroin is feasible in principle and recommended a further stage (Stage 2) of feasibility investigations to explore the practicalities. The results of the Stage 1 investigations and the proposals for Stage 2 are incorporated into discussion about three important issues: the feasibility research process, the therapeutic relationship, and social control. These considerations have wider applicability, both for treatment services for illegal drug users generally and for informing drug policy debates. Much can be learnt from the feasibility considerations, whether or not a trial of the controlled provision of heroin eventuates in Australia.     

Serum Apolipoproteins,Lipoproteins and Fatty Acids in Relation to Ischaemic Heart Disease in Northern and Southern European Males

ABSTRACT Serum apolipoprotein and lipoprotein concentrations, fatty acid spectra of various lipids, dietary habits and common risk factors for ischaemic heart disease were studied in 73 and 77 randomly selected, 50-year-old healthy men in Naples and Stockholm, respectively. Mean serum cholesterol concentration was higher in Stockholm than in Naples men (6.23 vs. 5.47 mmol/l, p < 0.001) as were low (LDL) (4.08 vs. 3.57 mmol/l, p < 0.001) and high (HDL) (1.40 vs. 1.25 mmol/l, p < 0.001) density lipoprotein fractions. Mean serum triglyceride concentrations did not differ. Mean apolipoprotein B and C-I concentrations were higher in Stockholm men (1116 vs. 1020 mg/l, p < 0.05 and 96 vs. 79 mg/l, p < 0.01, respectively). Stockholm men derived significantly more of their calories from fat (38 vs. 28%, p < 0.001) and the dietary fat had significantly lower polyunsaturated-to-saturated fatty acid ratio (P/S-ratio 0.29 vs. 0.51, p < 0.001), and less from carbohydrate (44 vs. 49%, p < 0.001) than Naples men, respectively. Mean caloric intake and mean weight/height index did not differ. Stockholm men had higher blood pressures, but there were more smokers among Naples men. The higher fat intake in Stockholm men may offer an explanation of the differences seen in lipoprotein and apoprotein concentrations and compositions but other factors, such as genetic influences cannot be excluded. A greater cholesterol flux through the plasma compartment in Stockholm men may be one important factor contributing to the higher incidence of ischaemic heart disease in this population.     

Very Late Relapse of Atrial Fibrillation after Pulmonary Vein Isolation: Incidence and Results of Repeat Ablation

Background: There are few data about the incidence of very late (>12 months) arrhythmia relapse after pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) and about the success rate of repeat ablation procedures in this population. Methods: All patients treated with PVI for paroxysmal AF were screened in the institution's electrophysiology database. Follow‐up data at 1, 3, 6, and 12 months and yearly thereafter including repetitive (7 days or 1 day) Holter electrocardiograms were assessed as well as the technique and success rate of repeat ablations. Results: Overall, 24 of 356 (6.7%) patients experienced their first AF recurrence more than 12 months after PVI. Of these 24 patients, 14 underwent reablation for paroxysmal (11 patients) or persistent AF (three patients). Repeat ablation included re‐PVI in all 14 patients (43 of 48 initially isolated PVs with recovered left atrial–PV conduction). Ablation of complex fractionated atrial electrograms or left/right atrial lines was performed in eight patients, including the three patients with persistent AF. During follow‐up of 15.1 ± 9 months after the second ablation, 10 of 14 (71%) reablated patients remained in sinus rhythm. Conclusions : After PVI for paroxysmal AF, very late arrhythmia recurrence occurs in less than 10% of patients. The success rate of the repeat procedure is high. (PACE 2010; 33:1258–1263)     

AV Delay Optimization and Management of DDD Paced Patients with Dilated Cardiomyopathy

Ten DDD paced patients, suffering front dilated cardiomyopathy in the NYHA functional classes III or IV were studied by means of Doppler ecbocardiography at different programmed values of atrioventricular (AV) delay (200, 150, 120, 100, and 80 msec). The following variables were evaluated: LV diameter, ejection fraction, mitral and aortic flow velocity integrals, and stroke volume. During VDD pacing, a resting AV delay associated with the best diastolic filling and systolic function was identified and programmed individually. Shortening of the AV delay to about 100 msec was associated with a gradual and progressive improvement. Further decrease caused an impairment of systolic function. The patients were clinically and beinodynamically reevaluated after 2 months of follow-up. A reduction of NYHA class and an improvement of LV function were consistently found. The reported data suggest that programming of an optimal A V delay may improve myocardial function in DDD paced patients with congestive heart failure. This result may be the consequence of an optimization of left ventricular filling and a better use of the Frank-Starling law.     

Importance of Sinus Rhythm as Endpoint of Persistent Atrial Fibrillation Ablation

Endpoint of Persistent AF Ablation . Background: The endpoint of persistent atrial fibrillation (AF) ablation is still a matter of debate. The purpose of this study was to evaluate if sinus rhythm (SR) as endpoint of persistent AF ablation has a better long‐term outcome compared to atrial tachycardia (AT) or AF at the end of the procedure. Methods and Results: Between 2008 and 2011, 191 consecutive patients undergoing de novo catheter ablation for symptomatic persistent and long‐standing persistent AF using a sequential ablation approach (including pulmonary vein isolation, ablation of complex fractionated electrograms and linear lesions) were included in the study. According to the result at the end of ablation procedure, patients were classified into 3 groups: patients with termination of AF into SR (Group 1, n = 62), patients with AT undergoing cardioversion (CV) (Group 2, n = 47), or patients with AF undergoing CV (Group 3, n = 82). The primary endpoint was freedom from any atrial tachyarrhythmia off antiarrhythmic drugs at 12 months. At 12 months, estimated proportions of patients free from any arrhythmia recurrence were 42% for Group 1, 13% for Group 2, and 25% for Group 3 (P = 0.002). In a Cox regression analysis only termination into SR was associated with a lower risk of arrhythmia recurrence (HR: 0.62; P = 0.04). Conclusion: If SR is achieved as endpoint of persistent and long‐standing persistent AF ablation using a sequential ablation approach it is associated with the highest long‐term single procedure success rate compared to AT or AF at the end of the procedure. (J Cardiovasc Electrophysiol, Vol. 24, pp. 388‐395, April 2013)     

Left Atrial Dysfunction in Patients with Patent Foramen Ovale and Atrial Septal Aneurysm Scheduled for Transcathter Closure May Play a Role in Aura Genesis

Background: It has been suggested that a left atrial (LA) dysfunction induced by large shunt and large atrial septal aneurysm (ASA) may act as a concurrent mechanism of arterial embolism in patients with patent foramen ovale (PFO) and prior stroke. We aimed to evaluate the potential contribution of this mechanism as trigger of migraine in patients with PFO. Methods: From January 2007 to September 2009, we prospectively enrolled subjects with migraine who underwent percutaneous PFO closure. Echocardiographic parameter of LA dysfunction was evaluated: pre‐ and postoperative values were compared to values of different sex and heart rate matched populations: 30 healthy patients, 21 migraine patients without PFO (MwoPFO), and a group of 25 PFO patients without migraine (PFOwoM). The Migraine Disability Assessment Score (MIDAS) was used to assess the incidence and severity of migraine. Results: Forty‐five patients (38 females, mean age 38 ± 6.7 years, mean MIDAS 35.8 ± 4.7, and 28 patients with migraine with aura) fulfilled the inclusion criteria. After successful percutaneous closure (mean follow‐up of 18.2 ± 4.8 months), PFO closure remained complete in 95%; 35 of 45 patients reported resolution or amelioration of migraine (mean MIDAS score 12.3 ± 8.8, P < 0.03). All patients with aura reported aura resolution. Preclosure values demonstrated significantly greater LA dysfunction, when compared with healthy and MwoPFO groups. Among patients in the study group, only patients with migraine with aura showed LA dysfunction comparable to PFOwoM patients. Conclusion: This study suggests that LA dysfunction probably does not contribute to migraine itself but may play a role in the genesis of aura symptoms. (J Interven Cardiol 2010;23:370–376)     

Incomplete Aneurysm Coverage after Patent Foramen Ovale Closure in Patients with Huge Atrial Septal Aneurysm: Effects on Left Atrial Functional Remodeling

Background: Large devices are often implanted to treat patent foramen ovale (PFO) and atrial septal aneurysm (ASA) with increase risk of erosion and thrombosis. Our study is aimed to assess the impact on left atrium functional remodeling and clinical outcomes of partial coverage of the approach using moderately small Amplatzer ASD Cribriform Occluder in patients with large PFO and ASA. Methods: We prospectively enrolled 30 consecutive patients with previous stroke (mean age 36 ± 9.5 years, 19 females), significant PFO, and large ASA referred to our center for catheter‐based PFO closure. Left atrium (LA) passive and active emptying, LA conduit function, and LA ejection fraction were computed before and after 6 months from the procedure by echocardiography. The preclosure values were compared to values of a normal healthy population of sex and heart rate matched 30 patients. Results: Preclosure values demonstrated significantly greater reservoir function as well as passive and active emptying, with significantly reduced conduit function and LA ejection fraction, when compared normal healthy subjects. All patients underwent successful transcatheter closure (25 mm device in 15 patients, 30 mm device in 6 patients, mean ratio device/diameter of the interatrial septum = 0.74). Incomplete ASA coverage in both orthogonal views was observed in 21 patients. Compared to patients with complete coverage, there were no differences in LA functional parameters and occlusion rates. Conclusions: This study confirmed that large ASAs are associated with LA dysfunction. The use of relatively small Amplatzer ASD Cribriform Occluder devices is probably effective enough to promote functional remodeling of the left atrium. (J Interven Cardiol 2010;23:362–367)