title: Bevacizumab in patients with hereditary hemorrhagic telangiectasia and severe hepatic vascular malformations and high cardiac output.
abstract: BACKGROUND
  The only treatment available to restore normal cardiac output in patients with hereditary hemorrhagic telangiectasia (HHT) and cardiac failure is liver transplant. Anti-vascular endothelial growth factor treatments such as bevacizumab may be an effective treatment.
  
  
  OBJECTIVE
  To test the efficacy of bevacizumab in reducing high cardiac output in severe hepatic forms of HHT and to assess improvement in epistaxis duration and quality of life.
  
  
  METHODS
  Single-center, phase 2 trial with national recruitment from the French HHT Network. Patients were 18 to 70 years old and had confirmed HHT, severe liver involvement, and a high cardiac index related to HHT.
  
  
  METHODS
  Bevacizumab, 5 mg per kg, every 14 days for a total of 6 injections. The total duration of the treatment was 2.5 months; patients were followed up for 6 months after the beginning of the treatment.
  
  
  METHODS
  Decrease in cardiac output at 3 months after the first injection, evaluated by echocardiography.
  
  
  RESULTS
  A total of 25 patients were included between March 2009 and November 2010. Of the 24 patients who had echocardiograms available for reread, there was a response in 20 of 24 patients with normalization of cardiac index (complete response [CR]) in 3 of 24, partial response (PR) in 17 of 24, and no response in 4 cases. Median cardiac index at beginning of the treatment was 5.05 L/min/m(2) (range, 4.1-6.2) and significantly decreased at 3 months after the beginning of the treatment with a median cardiac index of 4.2 L/min/m(2) (range, 2.9-5.2; P < .001). Median cardiac index at 6 months was significantly lower than before treatment (4.1 L/min/m(2); range, 3.0-5.1). Among 23 patients with available data at 6 months, we observed CR in 5 cases, PR in 15 cases, and no response in 3 cases. Mean duration of epistaxis, which was 221 minutes per month (range, 0-947) at inclusion, had significantly decreased at 3 months (134 minutes; range, 0-656) and 6 months (43 minutes; range, 0-310) (P = .008). Quality of life had significantly improved. The most severe adverse events were 2 cases of grade 3 systemic hypertension, which were successfully treated.
  
  
  CONCLUSIONS
  In this preliminary study of patients with HHT associated with severe hepatic vascular malformations and high cardiac output, administration of bevacizumab was associated with a decrease in cardiac output and reduced duration and number of episodes of epistaxis.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT00843440.
authors.affiliation: Hospices Civils de Lyon, Hôpital Louis Pradel, Genetic Department and National Reference Center for Rendu-Osler Disease, Bron, France. sophie.dupuis-girod@chu-lyon.fr
authors.forename: Sophie
authors.initials: S
authors.lastname: Dupuis-Girod
authors.forename: Isabelle
authors.initials: I
authors.lastname: Ginon
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Saurin
authors.forename: Denis
authors.initials: D
authors.lastname: Marion
authors.forename: Elsa
authors.initials: E
authors.lastname: Guillot
authors.forename: Evelyne
authors.initials: E
authors.lastname: Decullier
authors.forename: Adeline
authors.initials: A
authors.lastname: Roux
authors.forename: Marie-France
authors.initials: MF
authors.lastname: Carette
authors.forename: Brigitte
authors.initials: B
authors.lastname: Gilbert-Dussardier
authors.forename: Pierre-Yves
authors.initials: PY
authors.lastname: Hatron
authors.forename: Pascal
authors.initials: P
authors.lastname: Lacombe
authors.forename: Bernard
authors.initials: B
authors.lastname: Lorcerie
authors.forename: Sophie
authors.initials: S
authors.lastname: Rivière
authors.forename: Romain
authors.initials: R
authors.lastname: Corre
authors.forename: Sophie
authors.initials: S
authors.lastname: Giraud
authors.forename: Sabine
authors.initials: S
authors.lastname: Bailly
authors.forename: Gilles
authors.initials: G
authors.lastname: Paintaud
authors.forename: David
authors.initials: D
authors.lastname: Ternant
authors.forename: Pierre-Jean
authors.initials: PJ
authors.lastname: Valette
authors.forename: Henri
authors.initials: H
authors.lastname: Plauchu
authors.forename: Frédéric
authors.initials: F
authors.lastname: Faure
mesh_terms: D020533:Angiogenesis Inhibitors / Q000627:therapeutic use*; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D001165:Arteriovenous Malformations / Q000209:etiology* / Q000503:physiopathology; D000068258:Bevacizumab; D002302:Cardiac Output / Q000187:drug effects*; D004844:Epistaxis / Q000209:etiology / Q000517:prevention & control; D005260:Female; D006333:Heart Failure; D006801:Humans; D008099:Liver / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D013683:Telangiectasia, Hereditary Hemorrhagic / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology*; D016896:Treatment Outcome
chemical_list: D020533:Angiogenesis Inhibitors; D061067:Antibodies, Monoclonal, Humanized; D000068258:Bevacizumab