Long-term monotherapy with rosuvastatin prevents progressive left ventricular dysfunction and remodeling in dogs with heart failure
Baroreflex Activation for the Treatment of Heart Failure
Hani N. Sabbah, Ph.D., FACC, FCCP, FAHA
Department of Medicine, Division of Cardiovascular Medicine,
Henry Ford Hospital, Detroit, Michigan
Baroreflex Activation in HF
Word Count: 3,482
Address for Correspondence
Hani N. Sabbah, PhD
Director, Cardiovascular Research
Henry Ford Hospital
2799 West Grand Boulevard
Detroit, Michigan 48202
Office Phone: (313) 916-7360
Office Fax: (313) 916-3001
Congestive heart failure; Animal models of human disease; Heart failure - basic
studies; Baroreflex function; Ventricular Function; Ventricular dilation; mRNA expression;
Ventricular arrhythmias; Electrophysiological testing; Plasma biomarkers; Sympathetic
stimulation; Parasympathetic stimulation; Beta-adrenergic signaling; Nitric oxide; Inflammatory
Autonomic dysregulation is a feature of heart failure (HF) characterized by sustained increase of
sympathetic drive and by withdrawal of parasympathetic activity. Both maladaptations are
independent predictors of poor long-term outcome in patients with HF. Considerable evidence
exists that supports the use of pharmacologic agents that partially inhibit sympathetic activity as
an effective long-term therapy for patients with HF; the classic example being the use of
selective and non-selective beta-adrenergic receptor blockers. In contrast, modulation of
parasympathetic activation as potential therapy for HF has received only limited attention. This
review discusses the results of recent pre-clinical animal studies that provide support for the
possible use of baroreflex electrical stimulation, also know as baroreflex activation therapy
(BAT), as a long-term therapeutic approach for the treatment of patients with chronic HF. In
addition to exploring the effects of chronic BAT on left ventricular (LV) function and chamber
remodeling, the review will also address the effects of long-term BAT on ventricular arrhythmias
and on potential modifiers of the HF state that include maladaptations of both the nitric oxide
and beta-adrenergic receptor signal transduction pathways. The results of the pre-clinical studies
conducted to date have shown that in dogs with advanced HF, monotherapy with BAT improves
global LV systolic and diastolic function and partially reverses LV remodeling both globally and
at cellular and molecular levels. In addition BAT therapy was shown to markedly increase the
threshold for lethal ventricular arrhythmias in dogs with chronic HF. These benefits of BAT
support the continued exploration of this therapeutic modality for treating patients with chronic
HF and those with increased risk of sudden cardiac death.
Autonomic dysfunction occurs in heart failure (HF) and is characterized by enhanced
sympathetic activity and withdrawal of parasympathetic control. This autonomic imbalance has
long been recognized as an important mediator of increased mortality and morbidity in
myocardial infarction and HF (1, 2). Results from the Autonomic Tone and Reflexes after
Myocardial Infarction Study (ATRAMI) and the Cardiac Insufficiency Bisoprolol Study II
(CIBIS II) showed that diminished vagal activity and increased heart rate are predictors of high
mortality in these patient populations (3, 4). The sustained increase of sympathetic drive along
with reduced parasympathetic activity and activation of the renin-angiotensin-aldosterone system
(RAAS) in HF also contribute to progressive left ventricular (LV) dysfunction, progressive LV
remodeling, end-organ damage and ultimately death (5-9). The mechanisms responsible for
sustained sympathetic excitation in HF are not fully understood. It is generally believed that the
arterial reflexes, including the carotid sinus baroreflex, that are normally inhibitory to this
system, have reduced sensitivity in HF and, therefore, allow sympathetic outflow to proceed
unchecked (10-14). Several studies have shown an abnormally depressed arterial baroreflex
control in HF (11, 13, 15-20). This autonomic maladaptation in HF can lead to increased heart
rate, dysregulation of key components of the cardiac beta-adrenergic receptor signal transduction
pathway, dysregulation of nitric oxide (NO) signalling and the development of life threatening
Studies in conscious resting normal dogs have shown that activation of the carotid sinus reflex
through electrical stimulation can decrease heart rate and can also decrease sympathetic
constrictor tone during exercise (21). Studies in patients have also shown that electrical
stimulation of the carotid baroreflex can prolong the R-R interval secondary to augmented
parasympathetic activity (22). The modulation of heart rate (HR) and sympathetic tone are, at
present, recognized as important therapeutic targets in HF. Chronic carotid sinus nerve
stimulation has also been shown to be effective in the reversal of systemic arterial hypertension
(23) relief of angina pectoris (24), improvement in heart rate variability (25) and sympathetic
inhibition (26). Numerous studies in experimental animal models of HF in which the long-term
use of beta-blockers and other anti-adrenergic agents and more recently from use of specific and
selective agents that reduce HR through inhibition of the cardiac pacemaker current If
shown that these agents can prevent or attenuate progressive LV remodeling (27-30).
While much of the emphasis in treating HF over the past two decades has focused on modulation
of sympathetic activity, considerable interest has emerged recently in modulating
parasympathetic activity as a therapeutic target for treating chronic HF. It has long been
recognized that alteration in cardiac vagal efferent activity through peripheral cardiac nerve
stimulation can produce bradycardia (31), and modification in atrial (32, 33) ventricular
contractile function (34, 35). Electrical Vagus nerve stimulation (VNS) has been shown to
prevent sudden cardiac death in conscious dogs with a healed myocardial infarction (36) and
markedly improves long-term survival after chronic HF in rats (37, 38). We recently showed
that long-term electrical baroreflex activation therapy (BAT) in dogs with chronic HF can
improve LV systolic function and attenuate progressive LV remodeling (39). The discussion that
follows will focus on the beneficial consequences of restoring autonomic balance in HF through
the use of long-term BAT delivered using the Rheos System
(CVRx, Inc., Minneapolis, MN).
We will show that the reduction in sympathetic overdrive and augmentation of parasympathetic
drive with long-term BAT in animals with experimental HF can reduce HR, improve adrenergic
receptor and nitric oxide signaling, and markedly increase the threshold for lethal ventricular
arrhythmias and, in doing so, improve global LV function and partially reverse LV chamber
remodeling. The latter has been shown to correlate well with improved long-term mortality and
morbidity in patients with chronic HF.
BAT in Dogs with Coronary Microembolization-Induced HF
BAT Study Protocols in Dogs with Microembolization-Induced HF
Two separate studies were conducted in which the Rheos System
(CVRx, Inc., Minneapolis, MN)
was used to deliver BAT in dogs with microembolization-induced HF (40, 41). In the first study
dedicated primarily to hemodynamic and ventriculographic assessment of LV function and
remodeling, 14 dogs with a LV ejection fraction of approximately 25% were studied. Eight dogs
were randomized to active BAT (Rheos System ON) and 6 to no therapy at all (Sham-operated
control, Rheos System OFF). All dogs were followed for 3 months. In the second study,
dedicated primarily to electrophysiologic testing for the induction of arrhythmias, 14 dogs also
with LV ejection fraction 25% were studied. Seven dogs were randomized to active BAT
(Rheos System ON) and 7 to no therapy at all (Sham-operated control, Rheos System OFF). In
this study all dogs were followed for 6 months. In both studies, the Rheos system implant
procedure and BAT stimulation were carried out as previously described (14, 40). Briefly,
stimulating electrodes were implanted circumferentially around both carotid sinuses and
connected to the implantable pulse generator. Efficacy of the stimulation algorithm and proper
placement of the electrodes were confirmed at the time of surgery by 3 to 4 acute stimulation
runs performed 3-5 minutes apart and each confirming an acute drop of blood pressure and a
reduction of heart rate. Dogs assigned to the BAT treatment group received a predetermined
voltage with 0.5 msec square wave pulses at 50-100Hz at a duty cycle of 9 minutes ON and one
minute OFF (39).
Effects of BAT on HR Assessed from Ambulatory ECG Holter Monitoring
The effects of long-term treatment with BAT on HR and ventricular arrhythmias were evaluated
in dogs with coronary microembolization-induced HF using 24 hour ambulatory ECG Holter
monitoring (39). In sham-operated control dogs, maximum HR increased from 119 ± 40 to 158
± 32 beats/min, average HR increased from 69 ± 22 to 76 ± 15 beats/min and minimum HR
increased from 39 ± 11 to 45 ± 11 beats/min during a 3 month follow-up period. In BAT-treated
dogs, maximum HR decreased from 161 ± 40 to 122 ± 47 beats/min, average HR decreased from
92 ± 19 to 64 ± 18 beats/min and minimum HR decreased from 54 ± 18 to 38 ± 11 beats/min
(39). Even though none of these HR changes reached statistical significance, the trends support
the premise that BAT reduces HR in the setting of HF (39).
Effects of Long-term Treatment with BAT on LV Function and Remodeling in
Dogs with Microembolization-Induced HF
In dogs with advanced HF, long-term treatment with BAT significantly increased LV ejection
and stroke volume compared to untreated sham-operated controls (Fig. 1) (39). The increase in
ejection fraction was associated an increase of both stroke volume and cardiac output suggesting
a clear improvement of LV systolic function. Long-term treatment with BAT also improved
indexes of LV diastolic function as evidenced by a significant increase in early mitral inflow
deceleration time (DT), a decrease of LV end-diastolic pressure, an increase in the ratio between
peak mitral flow velocity in early diastole to peak mitral inflow velocity during left atrial
contraction (PE/PA), and a decrease in LV end-diastolic circumferential wall stress (Fig. 2) (39).
The change in these diastolic indexes with BAT support the premise that BAT may also improve
LV diastolic function in addition to improving LV systolic function. Long-term treatment with
BAT significantly decreased LV end-systolic and end-diastolic volumes suggesting that this
form of therapy can have a beneficial effect on reducing LV size (Fig. 1). BAT also improved
indices of LV shape (39) and significantly reduced functional mitral regurgitation (37). The
reduction in LV size, the restoration of ellipsoidal LV shape and the reduction in the severity of
functional mitral regurgitation suggest that this form of chronic therapy can reverse, albeit
partially, the structural changes that drive pathologic LV remodeling.
Effects of BAT on Cellular Measures of LV Remodeling
In dogs with coronary microembolization-induced HF, long-term treatment with BAT elicits
important changes in cellular and structural markers of LV remodeling. Histomorphometric
assessment performed at the end of 3 months of follow-up showed that compared to control,
treatment with BAT resulted in nearly 40% reduction in the volume fraction of replacement
fibrosis (39). This observation suggests that ongoing cardiomyocyte loss and hence their
replacement by fibrous tissue may be prevented or attenuated when long-term therapy with BAT
is implemented. Treatment with BAT was also associated with a near 22% reduction in reactive
interstitial fibrosis, a finding that can lead to improved LV relaxation and LV compliance and
hence LV filling. Heart failure is also accompanied by a reduction in myocardial capillary to
fiber ratio and by an increase in the oxygen diffusion distance (half the distance between 2
adjoining capillaries) that can lead to hypoxia of the failing myocardium (43). Studies in dogs
with HF showed that long-term treatment with BAT is associated with near normalization of
capillary density and a near 16% reduction in oxygen diffusion distance (43). Finally, long-term
treatment with BAT was associated with a near 24% reduction in cardiomyocyte cross-sectional
area, a measure of cardiomyocyte hypertrophy (43). These data suggest that BAT can attenuate
pathologic hypertrophy and in doing so, restore a near normal LV mass that is in-line with
available blood supply.
Effects of BAT on Cardiac Beta-Adrenergic Signal Transduction Pathway
In dogs with coronary microembolization-induced chronic HF, long-term treatment with BAT
resulted in partial normalization of components of the cardiac beta-adrenergic signaling pathway
(Fig. 3) (39). Compared to LV myocardium of sham-operated control dogs, the LV myocardium
of dogs treated with BAT showed up-regulation of mRNA expression of β1-adrenergic receptors
with no change in the expression of β2-adrenergic receptors. BAT-treated dogs also showed up-
regulation of mRNA expression of adenylyl cyclase and down-regulation of β-adrenergic
receptor kinase. These improvements at the molecular level were accompanied by a significant
reduction in circulating plasma norepinephrine levels (39). Long-term treatment with BAT also
resulted in down regulation of angiotensinogen, leading to a possible partial de-activation of the
vasoconstrictive influence of tissue RAAS (39). These findings suggest that delivery of BAT in
dogs with HF may restore sensitivity of the failing myocardium to adrenergic stimulation while
attenuating the detrimental action of RAAS-induced vasoconstriction.
Effects of BAT on Isoforms of Nitric Oxide Synthase
The effects of long-term treatment with BAT on the nitric oxide synthases (NOS) were also
examined in dogs with microembolization-induced HF (38). Nitric oxide (NO) is formed from
the guanidine group of L-arginine in an NADPH-dependent reaction catalyzed by a family of
NOS enzymes namely, endothelin NOS (eNOS), inducible NOS (iNOS) and neuronal NOS
(nNOS). It is well known that NO produced by eNOS plays an important role in the regulation
of cell growth, programmed cell death and vasodilation (44). Nitric oxide produced from eNOS
from cardiomyocytes can enhance myocardial relaxation and regulate contractility as well as
coronary perfusion (45, 46). In dogs with coronary microembolization-induced HF, mRNA and
protein expression of eNOS in LV myocardium is significantly down-regulated compared to
normal dogs (47). Long-term treatment with BAT significantly improves mRNA expression of
eNOS (Fig. 4) (39).
Inducible NOS is expressed by many different cell types including cardiomyocytes and is up-
regulated in HF (46). Increased expression of iNOS can lead to apoptosis (48) and can result in
peroxynitrite generation associated with fibrosis, LV hypertrophy, chamber dilation and a
cardiomyopathic phenotype (49). Increased expression of iNOS has also been shown to be
associated with increased incidence of heart block and of sudden cardiac death (49). In dogs
with coronary microembolization-induced HF, mRNA and protein expression of iNOS in LV
myocardium is significantly up-regulated compared to normal dogs (47). Long-term treatment
with BAT has been shown to normalize mRNA expression of iNOS in the failing dog LV
myocardium (Fig. 4) (39).
Recent studies have suggested that the neuronal form of NOS or nNOS is present in
cardiomyocytes (50) and may be associated with the ryanodine receptor calcium release channel
in the sarcoplasmic reticulum (51) and, therefore, may act to influence calcium cycling and
contractility (51). nNOS is up-regulated in myocardium of rats with myocardial infarctions and
in human failing hearts (52). In rats with HF, preferential inhibition of nNOS leads to increased
sensitivity of the myocardium to beta-adrenergic stimulation; a finding consistent with the
concept that nNOS-derived NO production may play a role in the autocrine regulation of
myocardial contractility (53). In dogs with coronary microembolization-induced HF, mRNA and
protein expression of nNOS in LV myocardium is significantly up-regulated compared to normal
dogs (47). Long-term treatment with BAT was shown to normalize mRNA expression of iNOS
in the failing dog LV myocardium (Fig. 4) (39).
The observation of normal physiologic balance between NOS isoforms suggest that increased
elaboration of NO occurs following treatment with BAT. It is difficult to directly assess the
level of NO due to its very short half life in the body. Measurements of the levels of NO
metabolites, specifically the pool of nitrate and nitrite, are often used as a reflection of changes
levels of NO. In the failing LV myocardium, the level of these metabolites of NO is
significantly lower than in normal myocardium. Long-term treatment with BAT in dogs with HF
has shown an increase in the total pool of nitrate and nitrite in LV myocardium (Fig. 4), thus
supporting the concept that restoration of autonomic balance in HF elicits normalization of
physiologic NO synthesis and elaboration.
Effects of BAT on Outcomes of Electrophysiologic Testing
A characteristic of patients with HF is the high incidence of malignant ventricular arrhythmias
that frequently culminate in sudden cardiac death. Patients with HF in whom these lethal
arrhythmias can be induced by electrophysiological (EP) testing carry a high risk of sudden
cardiac death. The effect of long-term treatment with BAT on EP-induced ventricular
arrhythmias was also evaluated in dogs with microembolization-induced HF described earlier.
EP testing was conducted at baseline prior to therapy and after 3 and 6 months of treatment with
BAT (n=7) or no treatment at all (control n=7). Programmed ventricular stimulation was
performed from the right ventricular apex and included delivery of up to 4 extrastimuli at
progressively shorter coupling intervals (in steps of 10 msec). The extrastimuli were delivered
following 8 ventricular paced beats with a drive cycle length between 600 and 200 msec. If a
sustained monomorphic ventricular tachycardia (VT) or ventricular fibrillation (VF) could not be
induced, then isoproterenol infusion was initiated to increase the sinus rate by 30% and the EP
stimulation protocol was repeated (Fig. 5) (54). At baseline, a sustained VT or VF was induced
in all 14 dogs (100%). After 3 and 6 months of follow-up, all control dogs (100%) were induced
into sustained VT or VF. After 3 months of BAT, only 3 of 7 dogs (43%) were induced into
sustained VT or VF. After 6 months of BAT, only 2 of 7 dogs (29%) were induced into sustained
VT or VF (Fig. 5). In addition to these findings, the arrhythmia resistance index, a measure of
the severity of stimulation needed to elicit VT or VF was significantly higher in BAT-treated
dogs at 3 months and at 6 months in comparison to controls. Finally, 6 weeks after withdrawal
of BAT (stimulation OFF) all 7 dogs assigned to the BAT group (100%) were again induced into
sustained VT or VF and the arrhythmia resistance index was returned to levels seen before
initiating BAT (Fig. 5 and 6). These results suggest that monotherapy with BAT markedly
increases the threshold for lethal ventricular arrhythmias in dogs with chronic HF. This benefit of
BAT supports the continued exploration of this device as a therapeutic modality for treating
patients with chronic HF and increased risk of sudden cardiac death.
BAT in Dogs with Rapid Pacing-Induced HF
The long-term effects of treatment with BAT were also examined in dogs with pacing-induced
HF (14). BAT electrode implantation was similar to that described earlier for dogs with
microembolization-induced HF. Of a total of 15 dogs studied, 7 received BAT and 8 were
assigned to control and did not receive BAT. Treatment with BAT was initiated 2 weeks after
initiation of right ventricular pacing at 250 beats/min and all animals were followed for up to 12
weeks. In this study, there was no difference in LV ejection fraction or LV fractional area of
shortening between treated dogs and controls. Treatment with BAT, however, significantly
lowered LV end-diastolic pressure. In addition, survival was significantly greater for dogs
undergoing BAT compared to control dogs (68.1 ± 7.4 versus 37.3 ± .2 days) (14). This
improvement in survival in BAT-treated dogs was associated with significantly lower plasma
levels of plasma norepinephrine and angiotensin-II (14). It was speculated that the beneficial
effects of BAT on survival in this animal model of HF may have been due, in part, to favorable
modulation of sympathetic overdrive and excess activation of the RAAS (14).
Conclusions and Clinical Implications
A considerable body of pre-clinical and clinical investigations exists that supports the benefits of
reducing sympathetic drive and enhancing parasympathetic drive in the management of patients
with HF. Beta-blockers as well as other drugs that selectively lower heart rate such as
ivabradine, an inhibitor of the If
current, are examples of pharmacologic interventions that
favorably modulate sympathetic and parasympathetic drive in patients with HF and, in doing so,
improve long-term outcome. In recent years, we have experienced an emergence of devices that
also target autonomic imbalance in HF. These include electrical cervical Vagus nerve
stimulators, spinal cord stimulators, and electrical baroreflex activators as described in this
review. In animals with experimental HF, long-term BAT improves LV systolic and diastolic
function and partially reverses LV remodeling. BAT normalizes mRNA expression of key
components of the β-adrenergic signal transduction pathway. Reversal of this maladaptive gene
expression is likely to restore sensitivity of the failing myocardium to catecholamines and
explains, in part, the improvement of LV function seen following chronic BAT. BAT also
normalizes mRNA expression of eNOS, nNOS and iNOS in LV myocardium of dogs with HF.
This finding provides additional insights into the possible mechanisms of action of this form of
therapy. In addition to improving LV function, long-term monotherapy with BAT markedly
increases the threshold for lethal ventricular arrhythmias in dogs with chronic HF and prolongs
survival in dogs with pacing-induced HF. These benefits of BAT strongly support the continued
exploration of this therapeutic modality for the treatment of patients with chronic HF and
increased risk of sudden cardiac death. Clinical trials employing the recently-introduced, second
generation CVRx Barostim neo
(CVRx, Inc.) are currently underway to evaluate the safety and
efficacy of BAT therapy for the treatment of patients with HF.
Supported, in part, by research grants from CVRx, Inc. and National Heart, Lung, and Blood
Institute PO1 HL074237-07
Hani N. Sabbah has received grant funding from and was a consultant to CVRx, Inc.
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HN. Long-term baroreflex activation therapy increases the threshold for the induction of
lethal ventricular arrhythmias in dogs with chronic advanced heart failure. Circulation
Treatment effect change (Δ) in left ventricular (LV) end-diastolic volume (EDV), end-
systolic volume (ESV), ejection fraction (EF) and stroke volume (SV) in sham operated
control dogs and dogs treated with baroreflex activation therapy (BAT). The figure is
based on data contained in Reference 37.
Treatment effect change (Δ) in left ventricular (LV) end-diastolic pressure (EDP),
deceleration time (DT) of early mitral valve inflow velocity, and end-diastolic
circumferential wall stress (EDWS) in sham operated control dogs and dogs treated with
baroreflex activation therapy (BAT). The figure is based on data contained in Reference
Bar graphs (mean ± SEM) depicting differences in mRNA expression of beta-1
adrenergic receptors (AR), beta-2 AR, beta-adrenergic receptor kinase-1 (BARK-1) and
adenylate cyclase-6 (AC-6) in left ventricular myocardium of normal (NL) dogs, dogs
with heart failure (HF) that were not treated (controls) and dogs with HF treated with
baroreflex activation therapy (BAT). du = densitometric units. The figure is based on
data contained in Reference 37.
Bar graphs (mean ± SEM) depicting differences in mRNA expression of neuronal nitric
oxide synthase (nNOS), inducible nitric oxide synthase (iNOS) and endothelial nitric
oxide synthase (eNOS) in left ventricular myocardium of normal (NL) dogs, dogs with
heart failure (HF) that were not treated (controls) and dogs with HF treated with
baroreflex activation therapy (BAT). Bottom right panel depicts changes in LV
myocardium levels of nitrate and nitrite, the metabolites of nitric oxide. du =
densitometric units. The figure is based on data contained in Reference 37.
Top left: recording in an untreated control dog during an electrophysiological study
showing the induction of a monomorphic ventricular tachycardia (VT) (upper tracing)
associated with hemodynamic compromise depicted by fall in systemic arterial pressure
(lower tracing) and requiring direct current (DC) cardioversion. Top right: recording in
an BAT-treated dog during an electrophysiological study showing the induction of
ventricular fibrillation (VF) (upper tracing) associated with hemodynamic compromise
depicted by fall in systemic arterial pressure (lower tracing) and requiring direct current
(DC) cardioversion. Lower panel: bar graphs (mean) depicting the proportion of dogs in
whom a VT or VF was induced at pre-treatment (PRE), 3 and 6 months (M) after
initiating BAT-treatment or no treatment and at 6 weeks after withdrawal of BAT
treatment (6 weeks starting at the end of 6 months of active treatment, POST).
Bar graphs (mean ± SEM) depicting changes in the arrhythmias resistance index, a
measure of the severity of the arrhythmia-inducing protocol, in control dogs and dogs
treated with baroreflex activation therapy (BAT). Wk = weeks; ISO – isoproterenol.
∆ LV Systolic Indexes -Treatment Effect
Figure 2∆ LV Diastolic Indexes - Treatment Effect
Beta-Adrenergic Receptor Signal Transduction Pathway
mRNA Beta-1 AR (du)
mRNA Beta-2 AR (du)
mRNA BARK-1 (du)
mRNA AC-6 (du)
Nitric Oxide Pathway
mRNA nNOS (du)
mRNA iNOS (du)
mRNA eNOS (du)
LV Nitrate+Nitrite (pmol/g)
Percent of Dogs Induced into VT or VF
Figure 6 Effects of BAT on Arrhythmia Resistance in
Experimental Heart Failure
ISO + Incremental Pacing
ISO + Burst Pacing
ISO + S1 200
ISO + S1 250
ISO + S1 300
ISO + S1 400
Arrhythmia Resistance Index
6-Month + 6 Wk
M. Weidmann A novel dermal filler with lidocaine and its applicationMichael Weidmann1 1Dermatologist, Klinik am Forsterpark Augsburg, Germany Methods and materials – how and what was performed Background – a brief discussion of the subject Patients, 18 to 80 years old, were treated and Hyaluronic acid (HA) is a polysaccharide (glycosamino-
IN THE NAME OF THE QUEEN DISTRICT COURT THE HAGUE Civil law section Judgment of July 2, 2008 in the case having case number / cause-list number 293668/ HA ZA 07-2628 of NOVARTIS AG, a legal entity under foreign law, having its registered seat and principal place of business at Basel, Switzerland, plaintiff in the main action, defendant in (partly conditional) counterclaim proceedings, procurator litis: previously mr W. Heemskerk, presently mr P.J.M. von Schmidt