The role of infarct transmural extent in infarct extension: a computational study

Infarct extension, a process involving progressive extension of the infarct zone (IZ) into the normally perfused border zone (BZ), leads to continuous degradation of the myocardial function and adverse remodelling. Despite carrying a high risk of mortality, detailed understanding of the mechanisms leading to BZ hypoxia and infarct extension remains unexplored. In the present study, we developed a 3D truncated ellipsoidal left ventricular model incorporating realistic electromechanical properties and fibre orientation to examine the mechanical interaction among the remote, infarct and BZs in the presence of varying infarct transmural extent (TME). Localized highly abnormal systolic fibre stress was observed at the BZ, owing to the simultaneous presence of moderately increased stiffness and fibre strain at this region, caused by the mechanical tethering effect imposed by the overstretched IZ. Our simulations also demonstrated the greatest tethering effect and stress in BZ regions with fibre direction tangential to the BZ–remote zone boundary. This can be explained by the lower stiffness in the cross-fibre direction, which gave rise to a greater stretching of the IZ in this direction. The average fibre strain of the IZ, as well as the maximum stress in the sub-endocardial layer, increased steeply from 10% to 50% infarct TME, and slower thereafter. Based on our stress–strain loop analysis, we found impairment in the myocardial energy efficiency and elevated energy expenditure with increasing infarct TME, which we believe to place the BZ at further risk of hypoxia

Electromechanics Modelling of the Effects of Myocardial Infarction on Left Ventricular Remodelling

Myocardial infarction (MI) is one of the diseases with the highest mortality rate. Following MI, myocardium experiences abrupt changes in its loading condition due to the presence of infarct. In response to such changes, myocytes undergo adaptations to maintain homeostasis. However, maladaptation can happen and lead to remodelling, in which the left ventricle (LV) gradually loses its function and eventually turns into heart failure. Nevertheless, the mechanisms underlying LV remodelling are still poorly understood. In this study, a generic LV model was developed, incorporating realistic fibre orientation and excitable contracting myocardium. It was demonstrated that the developed model is capable of reproducing physiological LV functions, including action potential propagation, LV pressure and cavity volume, LV twisting and wall thickening. Subsequently, the generic LV model was utilised to investigate the effects of the infarct state on LV regional mechanics, including the interaction between non-contractile infarct and contractile myocardium. It was found that infarct transmural extent (TME) is more important than infarct size in determining LV regional mechanics impairments. Neighbouring contractile myocardium and non-contractile infarct induce a mechanical tethering effect, which elevates with infarct TME, at the border zone (BZ). Such mechanical tethering causes the BZ to have high systolic fibre stress, elevated energy expenditure and reduced myocardial energy efficiency, which are believed to give rise to infarct extension. The generic LV model was then modified into a patient-specific model, incorporating patient-specific infarcted LV geometry and optimised regional material properties, to study the correlation between infarct extension and myocardial mechanics impairments, including the underlying mechanisms responsible for the impairments. Among the observed myocardial mechanics impairments, only the depressed myocardial energy efficiency was found to be correlated with infarct extension. The depressed myocardial energy efficiency was due to inadequate generation of contraction force, which, at least in part, owing to inadequate stretching of myocardium at end-diastole (the Frank-Starling law). Although a stiff infarct can prevent infarct expansion, results of this study showed that it can also cause the neighbouring myocardium to be under-stretched at end-diastole, thereby depressing the generated contraction force and energy efficiency during systole, which were found to be correlated with infarct extension of the neighbouring myocardium

Perioperative Pembrolizumab for Early-Stage Non-Small-Cell Lung Cancer

BACKGROUND Among patients with resectable early-stage non-small-cell lung cancer (NSCLC), a perioperative approach that includes both neoadjuvant and adjuvant immune checkpoint inhibition may provide benefit beyond either approach alone.METHODS We conducted a randomized, double-blind, phase 3 trial to evaluate perioperative pembrolizumab in patients with early-stage NSCLC. Participants with resectable stage II, IIIA, or IIIB (N2 stage) NSCLC were assigned in a 1:1 ratio to receive neoadjuvant pembrolizumab (200 mg) or placebo once every 3 weeks, each of which was given with cisplatin-based chemotherapy for 4 cycles, followed by surgery and adjuvant pembrolizumab (200 mg) or placebo once every 3 weeks for up to 13 cycles. The dual primary end points were event-free survival (the time from randomization to the first occurrence of local progression that precluded the planned surgery, unresectable tumor, progression or recurrence, or death) and overall survival. Secondary end points included major pathological response, pathological complete response, and safety.RESULTS A total of 397 participants were assigned to the pembrolizumab group, and 400 to the placebo group. At the prespecified first interim analysis, the median follow-up was 25.2 months. Event-free survival at 24 months was 62.4% in the pembrolizumab group and 40.6% in the placebo group (hazard ratio for progression, recurrence, or death, 0.58; 95% confidence interval [CI], 0.46 to 0.72; P<0.001). The estimated 24-month overall survival was 80.9% in the pembrolizumab group and 77.6% in the placebo group (P = 0.02, which did not meet the significance criterion). A major pathological response occurred in 30.2% of the participants in the pembrolizumab group and in 11.0% of those in the placebo group (difference, 19.2 percentage points; 95% CI, 13.9 to 24.7; P<0.0001; threshold, P = 0.0001), and a pathological complete response occurred in 18.1% and 4.0%, respectively (difference, 14.2 percentage points; 95% CI, 10.1 to 18.7; P<0.0001; threshold, P = 0.0001). Across all treatment phases, 44.9% of the participants in the pembrolizumab group and 37.3% of those in the placebo group had treatment-related adverse events of grade 3 or higher, including 1.0% and 0.8%, respectively, who had grade 5 events.CONCLUSIONS Among patients with resectable, early-stage NSCLC, neoadjuvant pembrolizumab plus chemotherapy followed by resection and adjuvant pembrolizumab significantly improved event-free survival, major pathological response, and pathological complete response as compared with neoadjuvant chemotherapy alone followed by surgery. Overall survival did not differ significantly between the groups in this analysis