Functional activation of pyruvate dehydrogenase in human brain using hyperpolarized [1-13 C]pyruvate

PURPOSE

Pyruvate, produced from either glucose, glycogen, or lactate, is the dominant precursor of cerebral oxidative metabolism. Pyruvate dehydrogenase (PDH) flux is a direct measure of cerebral mitochondrial function and metabolism. Detection of [13 C]bicarbonate in the brain from hyperpolarized [1-13 C]pyruvate using carbon-13 (13 C) MRI provides a unique opportunity for assessing PDH flux in vivo. This study is to assess changes in cerebral PDH flux in response to visual stimuli using in vivo 13 C MRS with hyperpolarized [1-13 C]pyruvate.

METHODS

From seven sedentary adults in good general health, time-resolved [13 C]bicarbonate production was measured in the brain using 90° flip angles with minimal perturbation of its precursors, [1-13 C]pyruvate and [1-13 C]lactate, to test the hypothesis that the appearance of [13 C]bicarbonate signals in the brain reflects the metabolic changes associated with neuronal activation. With a separate group of healthy participants (n = 3), the likelihood of the bolus-injected [1-13 C]pyruvate being converted to [1-13 C]lactate prior to decarboxylation was investigated by measuring [13 C]bicarbonate production with and without [1-13 C]lactate saturation.

RESULTS

In the course of visual stimulation, the measured [13 C]bicarbonate signal normalized to the total 13 C signal in the visual cortex increased by 17.1% ± 15.9% (p = 0.017), whereas no significant change was detected in [1-13 C]lactate. Proton BOLD fMRI confirmed the regional activation in the visual cortex with the stimuli. Lactate saturation decreased bicarbonate-to-pyruvate ratio by 44.4% ± 9.3% (p < 0.01).

CONCLUSION

We demonstrated the utility of 13 C MRS with hyperpolarized [1-13 C]pyruvate for assessing the activation of cerebral PDH flux via the detection of [13 C]bicarbonate production.

Dynamic 13 C MR spectroscopy as an alternative to imaging for assessing cerebral metabolism using hyperpolarized pyruvate in humans

PURPOSE

This study is to investigate time-resolved ¹³ C MR spectroscopy (MRS) as an alternative to imaging for assessing pyruvate metabolism using hyperpolarized (HP) [1-¹³ C]pyruvate in the human brain.

METHODS

Time-resolved ¹³ C spectra were acquired from four axial brain slices of healthy human participants (n = 4) after a bolus injection of HP [1-¹³ C]pyruvate. ¹³ C MRS with low flip-angle excitations and a multichannel ¹³ C/¹ H dual-frequency radiofrequency (RF) coil were exploited for reliable and unperturbed assessment of HP pyruvate metabolism. Slice-wise areas under the curve (AUCs) of ¹³ C-metabolites were measured and kinetic analysis was performed to estimate the production rates of lactate and HCO3- . Linear regression analysis between brain volumes and HP signals was performed. Region-focused pyruvate metabolism was estimated using coil-wise ¹³ C reconstruction. Reproducibility of HP pyruvate exams was presented by performing two consecutive injections with a 45-minutes interval.

RESULTS

[1-¹³ C]Lactate relative to the total ¹³ C signal (tC) was 0.21-0.24 in all slices. [¹³ C] HCO3- /tC was 0.065-0.091. Apparent conversion rate constants from pyruvate to lactate and HCO3- were calculated as 0.014-0.018 s^-1 and 0.0043-0.0056 s^-1 , respectively. Pyruvate/tC and lactate/tC were in moderate linear relationships with fractional gray matter volume within each slice. White matter presented poor linear regression fit with HP signals, and moderate correlations of the fractional cerebrospinal fluid volume with pyruvate/tC and lactate/tC were measured. Measured HP signals were comparable between two consecutive exams with HP [1-¹³ C]pyruvate.

CONCLUSIONS

Dynamic MRS in combination with multichannel RF coils is an affordable and reliable alternative to imaging methods in investigating cerebral metabolism using HP [1-¹³ C]pyruvate.

Dual-phase imaging of cardiac metabolism using hyperpolarized pyruvate

PURPOSE

Previous cardiac imaging studies using hyperpolarized (HP) [1-¹³ C]pyruvate were acquired at end-diastole (ED). Little is known about the interaction between cardiac cycle and metabolite content in the myocardium. In this study, we compared images of HP pyruvate and products at end-systole (ES) and ED.

METHODS

A dual-phase ¹³ C MRI sequence was implemented to acquire two sequential HP images within a single cardiac cycle at ES and ED during successive R-R intervals in an interleaved manner. Each healthy volunteer (N = 3) received two injections of HP [1-¹³ C]pyruvate for the dual-phase imaging on the short-axis and the vertical long-axis planes. Spatial distribution of HP ¹³ C metabolites at each cardiac phase was correlated to multiphase ¹ H MRI to confirm the mechanical changes. Ratios of myocardial HP metabolites were compared between ES and ED. Segmental analysis was performed on the midcavity short-axis plane.

RESULTS

In addition to mechanical changes, metabolic profiles of the heart detected by HP [1-¹³ C]pyruvate differed between ES and ED. The myocardial signal of [¹³ C]bicarbonate relative to [1-¹³ C]lactate was significantly smaller at ED than the ratio at ES (p < .05), particularly in mid-anterior and mid-inferoseptal segments. The distinct metabolic profiles in the myocardium likely reflect the technical aspects of the imaging approach such as the coronary flow in addition to the cyclical changes in metabolism.

CONCLUSION

The study demonstrates that metabolic profiles of the heart, measured by HP [1-¹³ C]pyruvate, are affected by the cardiac cycle in which that the data are acquired.

Preoperative imaging of glioblastoma patients using hyperpolarized 13C pyruvate: Potential role in clinical decision making

Background

Glioblastoma remains incurable despite treatment with surgery, radiation therapy, and cytotoxic chemotherapy, prompting the search for a metabolic pathway unique to glioblastoma cells.¹³C MR spectroscopic imaging with hyperpolarized pyruvate can demonstrate alterations in pyruvate metabolism in these tumors.

Methods

Three patients with diagnostic MRI suggestive of a glioblastoma were scanned at 3 T 1–2 days prior to tumor resection using a ¹³C/¹H dual-frequency RF coil and a ¹³C/¹H-integrated MR protocol, which consists of a series of ¹H MR sequences (T₂ FLAIR, arterial spin labeling and contrast-enhanced [CE] T₁) and ¹³C spectroscopic imaging with hyperpolarized [1-¹³C]pyruvate. Dynamic spiral chemical shift imaging was used for ¹³C data acquisition. Surgical navigation was used to correlate the locations of tissue samples submitted for histology with the changes seen on the diagnostic MR scans and the ¹³C spectroscopic images.

Results

Each tumor was histologically confirmed to be a WHO grade IV glioblastoma with isocitrate dehydrogenase wild type. Total hyperpolarized ¹³C signals detected near the tumor mass reflected altered tissue perfusion near the tumor. For each tumor, a hyperintense [1-¹³C]lactate signal was detected both within CE and T₂-FLAIR regions on the ¹H diagnostic images (P = .008). [¹³C]bicarbonate signal was maintained or decreased in the lesion but the observation was not significant (P = .3).

Conclusions

Prior to surgical resection, ¹³C MR spectroscopic imaging with hyperpolarized pyruvate reveals increased lactate production in regions of histologically confirmed glioblastoma.

Hyperpolarized 13C MR Spectroscopy Depicts in Vivo Effect of Exercise on Pyruvate Metabolism in Human Skeletal Muscle

Background Pyruvate dehydrogenase (PDH) and lactate dehydrogenase are essential for adenosine triphosphate production in skeletal muscle. At the onset of exercise, oxidation of glucose and glycogen is quickly enabled by dephosphorylation of PDH. However, direct measurement of PDH flux in exercising human muscle is daunting, and the net effect of covalent modification and other control mechanisms on PDH flux has not been assessed. Purpose To demonstrate the feasibility of assessing PDH activation and changes in pyruvate metabolism in human skeletal muscle after the onset of exercise using carbon 13 (¹³C) MRI with hyperpolarized (HP) [1-¹³C]-pyruvate. Materials and Methods For this prospective study, sedentary adults in good general health (mean age, 42 years ± 18 [standard deviation]; six men) were recruited from August 2019 to September 2020. Subgroups of the participants were injected with HP [1-¹³C]-pyruvate at resting, during plantar flexion exercise, or 5 minutes after exercise during recovery. In parallel, hydrogen 1 arterial spin labeling MRI was performed to estimate muscle tissue perfusion. An unpaired t test was used for comparing ¹³C data among the states. Results At rest, HP [1-¹³C]-lactate and [1-¹³C]-alanine were detected in calf muscle, but [¹³C]-bicarbonate was negligible. During moderate flexion-extension exercise, total HP ¹³C signals (tC) increased 2.8-fold because of increased muscle perfusion (P = .005), and HP [1-¹³C]-lactate-to-tC ratio increased 1.7-fold (P = .04). HP [¹³C]-bicarbonate-to-tC ratio increased 8.4-fold (P = .002) and returned to the resting level 5 minutes after exercise, whereas the lactate-to-tC ratio continued to increase to 2.3-fold as compared with resting (P = .008). Conclusion Lactate and bicarbonate production from hyperpolarized (HP) [1-carbon 13 {¹³C}]-pyruvate in skeletal muscle rapidly reflected the onset and the termination of exercise. These results demonstrate the feasibility of imaging skeletal muscle metabolism using HP [1-¹³C]-pyruvate MRI and the sensitivity of in vivo pyruvate metabolism to exercise states. © RSNA, 2021 Online supplemental material is available for this article.

Cardiac T 2 ∗ measurement of hyperpolarized 13 C metabolites using metabolite-selective multi-echo spiral imaging

PURPOSE

Noninvasive imaging with hyperpolarized (HP) pyruvate can capture in vivo cardiac metabolism. For proper quantification of the metabolites and optimization of imaging parameters, understanding MR characteristics such as T 2 ∗ s of the HP signals is critical. This study is to measure in vivo cardiac T 2 ∗ s of HP [1-¹³ C]pyruvate and the products in rodents and humans.

METHODS

A dynamic ¹³ C multi-echo spiral imaging sequence that acquires [¹³ C]bicarbonate, [1-¹³ C]lactate, and [1-¹³ C]pyruvate images in an interleaved manner was implemented for a clinical 3 Tesla system. T 2 ∗ of each metabolite was calculated from the multi-echo images by fitting the signal decay of each region of interest mono-exponentially. The performance of measuring T 2 ∗ using the sequence was first validated using a ¹³ C phantom and then with rodents following a bolus injection of HP [1-¹³ C]pyruvate. In humans, T 2 ∗ of each metabolite was calculated for left ventricle, right ventricle, and myocardium.

RESULTS

Cardiac T 2 ∗ s of HP [1-¹³ C]pyruvate, [1-¹³ C]lactate, and [¹³ C]bicarbonate in rodents were measured as 24.9 ± 5.0, 16.4 ± 4.7, and 16.9 ± 3.4 ms, respectively. In humans, T 2 ∗ of [1-¹³ C]pyruvate was 108.7 ± 22.6 ms in left ventricle and 129.4 ± 8.9 ms in right ventricle. T 2 ∗ of [1-¹³ C]lactate was 40.9 ± 8.3, 44.2 ± 5.5, and 43.7 ± 9.0 ms in left ventricle, right ventricle, and myocardium, respectively. T 2 ∗ of [¹³ C]bicarbonate in myocardium was 64.4 ± 2.5 ms. The measurements were reproducible and consistent over time after the pyruvate injection.

CONCLUSION

The proposed metabolite-selective multi-echo spiral imaging sequence reliably measures in vivo cardiac T 2 ∗ s of HP [1-¹³ C]pyruvate and products.

Characterization and compensation of f 0 inhomogeneity artifact in spiral hyperpolarized 13 C imaging of the human heart

PURPOSE

This study aimed to investigate the role of regional f 0 inhomogeneity in spiral hyperpolarized ¹³ C image quality and to develop measures to alleviate these effects.

METHODS

Field map correction of hyperpolarized ¹³ C cardiac imaging using spiral readouts was evaluated in healthy subjects. Spiral readouts with differing duration (26 and 45 ms) but similar resolution were compared with respect to off-resonance performance and image quality. An f 0 map-based image correction based on the multifrequency interpolation (MFI) method was implemented and compared to correction using a global frequency shift alone. Estimation of an unknown frequency shift was performed by maximizing a sharpness objective based on the Sobel variance. The apparent full width half at maximum (FWHM) of the myocardial wall on [¹³ C]bicarbonate was used to estimate blur.

RESULTS

Mean myocardial wall FWHM measurements were unchanged with the short readout pre-correction (14.1 ± 2.9 mm) and post-MFI correction (14.1 ± 3.4 mm), but significantly decreased in the long waveform (20.6 ± 6.6 mm uncorrected, 17.7 ± 7.0 corrected, P = .007). Bicarbonate signal-to-noise ratio (SNR) of the images acquired with the long waveform were increased by 1.4 ± 0.3 compared to those acquired with the short waveform (predicted 1.32). Improvement of image quality was observed for all metabolites with f 0 correction.

CONCLUSIONS

f 0 -map correction reduced blur and recovered signal from dropouts, particularly along the posterior myocardial wall. The low image SNR of [¹³ C]bicarbonate can be compensated with longer duration readouts but at the expense of increased f 0 artifacts, which can be partially corrected for with the proposed methods.

Imaging Acute Metabolic Changes in Patients with Mild Traumatic Brain Injury Using Hyperpolarized [1-13C]Pyruvate

Traumatic brain injury (TBI) involves complex secondary injury processes following the primary injury. The secondary injury is often associated with rapid metabolic shifts and impaired brain function immediately after the initial tissue damage. Magnetic resonance spectroscopic imaging (MRSI) coupled with hyperpolarization of ¹³C-labeled substrates provides a unique opportunity to map the metabolic changes in the brain after traumatic injury in real-time without invasive procedures. In this report, we investigated two patients with acute mild TBI (Glasgow coma scale 15) but no anatomical brain injury or hemorrhage. Patients were imaged with hyperpolarized [1-¹³C]pyruvate MRSI 1 or 6 days after head trauma. Both patients showed significantly reduced bicarbonate (HCO₃^–) production, and one showed hyperintense lactate production at the injured sites. This study reports the feasibility of imaging altered metabolism using hyperpolarized pyruvate in patients with TBI, demonstrating the translatability and sensitivity of the technology to cerebral metabolic changes after mild TBI.

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Clinical translation of hyperpolarized pyruvate to TBI was demonstrated

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Patients with mild TBI were imaged with hyperpolarized [1-¹³C]pyruvate

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Altered lactate and HCO₃^– production in the brain nearest the site of trauma

Hyperpolarized δ-[1-13 C]gluconolactone as a probe of the pentose phosphate pathway

The pentose phosphate pathway (PPP) is thought to be upregulated in trauma (to produce excess NADPH) and in cancer (to provide ribose for nucleotide biosynthesis), but simple methods for detecting changes in flux through this pathway are not available. MRI of hyperpolarized ¹³ C-enriched metabolites offers considerable potential as a rapid, non-invasive tool for detecting changes in metabolic fluxes. In this study, hyperpolarized δ-[1-¹³ C]gluconolactone was used as a probe to detect flux through the oxidative portion of the pentose phosphate pathway (PPP_ox ) in isolated perfused mouse livers. The appearance of hyperpolarized (HP) H¹³ CO₃^- within seconds after exposure of livers to HP-δ-[1-¹³ C]gluconolactone demonstrates that this probe rapidly enters hepatocytes, becomes phosphorylated, and enters the PPP_ox pathway to produce HP-H¹³ CO₃^- after three enzyme catalyzed steps (6P-gluconolactonase, 6-phosphogluconate dehydrogenase, and carbonic anhydrase). Livers perfused with octanoate as their sole energy source show no change in production of H¹³ CO₃^- after exposure to low levels of H₂ O₂ , while livers perfused with glucose and insulin showed a twofold increase in H¹³ CO₃^- after exposure to peroxide. This indicates that flux through the PPP_ox is stimulated by H₂ O₂ in glucose perfused livers but not in livers perfused with octanoate alone. Subsequent perfusion of livers with non-polarized [1,2-¹³ C]glucose followed by ¹ H NMR analysis of lactate in the perfusate verified that flux through the PPP_ox is indeed low in healthy livers and modestly higher in peroxide damaged livers. We conclude that hyperpolarized δ-[1-¹³ C]gluconolactone has the potential to serve as a metabolic imaging probe of this important biological pathway.

Citizens and scientists: toward a gendered history of scientific practice in post-revolutionary France

Because the French Revolution failed to produce a widely acceptable definition of citizenship, the limits of manhood suffrage in the early nineteenth century were uncertain. Social practices, in particular scientific activity, served as claims to the status of citizen. By engaging in scientific pastimes, bourgeois Frenchmen asserted that they possessed the rationality and autonomy that liberal theorists associated both with manliness and with civic capacity. However, bourgeois science was never a stable signifier of masculinity or of competence. As professional science emerged, the bourgeois amateur increasingly became the feminised object of satire rather than the sober and meritorious citizen-scientist.

Activin expression by cultured human retinal pigment epithelial cells

PURPOSE

To determine whether human retinal pigment epithelial (hRPE) cells produce activin, a growth factor in the transforming growth factor beta family, and to characterize growth regulatory effects of activin on retinal pigment epithelium.

METHODS

mRNA expression was examined using polymerase chain reaction with primers specific for the beta A and beta B chains of activin and by slot blot analysis with a probe specific for the beta A chain. Protein localization was determined immunocytochemically using antibodies specific for the beta A chain of activin and intact activin A. The effect of activin A on DNA synthesis was studied by measuring (3H) thymidine incorporation after cells were exposed to recombinant human activin A (rhA). Growth regulatory effects of rhA on hRPE cells were examined with cell growth assays.

RESULTS

beta A mRNA was expressed constitutively in 8/8 cells lines tested. beta B mRNA was not expressed in any of the six cell lines tested but was expressed in human ovarian granulosa cell controls. Positive immunostaining was observed for both the beta A chain and intact activin A. (3H) thymidine incorporation was inhibited 44% (P < 0.025), 45% (P < 0.025), and 44% (P < 0.015) when RPE cells were exposed to 100 ng/ml rhA and grown in serum-free medium, medium with 0.5% serum, and 1% serum, respectively. Cell growth was inhibited 33.2% (P = 0.0001) after RPE cells were exposed to 100 ng/ml rhA for 8 days.

CONCLUSIONS

These results suggest that activin A can act as an autocrine-paracrine growth regulator in RPE cells and may help control cellular growth in ocular development and proliferative eye disease.

Role of protease inhibition in myocardial preservation in prolonged hypothermic cardioplegia followed by reperfusion. Effect of aprotinin in an experimental model

The effects of aprotinin on canine myocardium subjected to cardioplegia and global ischemia for 4 hours and then reperfused for 1 hour were investigated. Lysosomal and mitochondrial enzymes and cyclic nucleotides (adenosine cyclic monophosphate and guanosine cyclic monophosphate) were measured in coronary sinus blood. Aprotinin was given intravenously before cardiopulmonary bypass at total doses of 10 X 10(3) kallikrein units per kilogram (group A, six dogs) and 20 X 10(3) KU/kg (group B, six dogs). In group A, three dogs survived but with poor cardiac function; all dogs in group B survived and had better cardiac function. Lysosomal (N-acetyl-beta-D-glucosaminidase) and mitochondrial (aspartate aminotransferase) enzymes in coronary sinus blood at 60 minutes of reperfusion were significantly (p less than 0.05) lower in group B than in group A. In both groups, guanosine cyclic monophosphate was significantly (p less than 0.01) lower during reperfusion than before cardiopulmonary bypass; however, the values were significantly (p less than 0.05) higher in group B than in group A. Serum adenosine cyclic monophosphate was lower during reperfusion than before bypass in both groups, but it recovered during reperfusion in group B. Myocardial adenosine triphosphate was well preserved in both groups but creatine phosphate was decreased (p less than 0.01) in group A. These results suggest that aprotinin at a dose of 20 X 10(3) KU/kg may be effective in preserving myocardial viability and function after prolonged cardioplegia.

Role of two-dimensional echocardiography in the prediction of in-hospital complications after acute myocardial infarction

To evaluate prospectively the prognostic value of two-dimensional echocardiography after acute myocardial infarction, two-dimensional echocardiography was performed on 61 consecutive patients who were admitted to the hospital with this condition. A left ventricular wall motion score index was derived from analysis of regional wall motion; an index of 2.0 or more within 12 hours of admission identified patients at high risk for pump failure, malignant ventricular arrhythmia or death. These complications occurred in 24 of 27 patients with an initial wall motion score index of 2.0 or more, but in only 6 of 34 with an initial index of less than 2.0 (p less than 0.0005). Of the 47 patients who were in Killip class I on admission, complications developed in 11 (79%) of the 14 with an initial index of 2.0 or more, but in only 6 (18%) of the 33 with an initial index of less than 2.0. After acute myocardial infarction, early determination of the wall motion score index by two-dimensional echocardiography is useful for identifying patients at high risk for complications and is especially valuable in the subset of patients who initially seem to be in stable condition as judged from clinical variables.

Cardiovascular hemodynamics of bicycle and handgrip exercise in normal subjects before and after administration of propranolol

Radionuclide angiography was used to study the effects of supine and upright bicycle exercise and handgrip exercise in 17 (12 well-trained) normal subjects before (control) and immediately after the administration of propranolol (160 mg/day for 4 days). Cardiac hemodynamic values were related to position in that control left ventricular volumes and the cardiac index were greater in the supine position than in the upright at rest but resting left ventricular ejection fraction was similar in both positions. The pressure volume index was greater in the upright position than in the supine. At maximal exercise before treatment, however, similar cardiovascular hemodynamic measurements were recorded in both positions. Propranolol increased left ventricular end-diastolic volume at rest and at maximal exercise. Left ventricular end-systolic volume, however, was substantially greater only in the upright position both at rest and at maximal exercise when compared with control values. Heart rate, systolic arterial pressure, cardiac index, and pressure volume index were decreased at rest and maximal exercise after treatment with propranolol. Ejection fraction was decreased in the upright position after propranolol administration but was unchanged in the supine position. Handgrip exercise primarily increased heart rate and arterial pressure and did not affect cardiac volume, and this response was unaffected by propranolol.

Reentrant tachycardia associated with atrial synchronous pacing. Report of a case with intact ventriculoatrial conduction

Reentrant tachycardia occurred after implantation of an atrial synchronous ventricular-inhibited pacemaker in a patient with bradycardia caused by second-degree (Mobitz II) atrioventricular block. Despite the presence of antegrade atrioventricular block, intact ventriculoatrial conduction was present at a cycle length that exceeded the atrial refractory period of the pacemaker. Consequently, a reentrant or "endless-loop" tachycardia occurred. Application of a magnet terminated the tachycardia. Because the episodes were frequent and could not be prevented by medication, the pacemaker was reprogrammed to a ventricular-inhibited mode. All candidates for atrial synchronous pacing should undergo an appropriate electrophysiologic study preoperatively.

Relationship between left ventricular morphology and postoperative cardiac function following valve replacement for mitral stenosis

The left ventricular myocardium excised from 14 patients who had mitral stenosis and who underwent mitral valve replacement was examined, and myocardial fibrosis was quantitated in relation to cardiac function. Conventional mitral valve replacement was performed with cold potassium-induced cardioplegia associated with systemic hypothermia (28 degrees C rectal temperature) and topical cooling. All 14 patients had perivascular fibrosis; the amounts ranged from 16% to 54% of the whole tissue excised. The mean left ventricular end-diastolic volume index (LVEDVI) determined by M-mode echocardiography increased significantly (p less than 0.001) from 66.9 +/- 4.6 ml/m2 preoperatively to 79.0 +/- 2.9 ml/m2 postoperatively. The difference between preoperative and postoperative LVEDVIs was significantly correlated (p less than 0.01) to the percentage of myocardial fibrosis (r = 0.72), in that the index increased postoperatively when myocardial fibrosis was more than 35% and decreased when fibrosis was less than 35%. After mitral valve replacement, the mean ejection fraction increased when fibrosis was less than 35% of whole tissue (+0.12 +/- 0.04) and decreased when fibrosis was greater than 35% (-0.02 +/- 0.02, p less than 0.01). No measured preoperative hemodynamic parameters were predictive of prognosis. These data suggest that the degree of myocardial fibrosis is related to left ventricular performance after mitral valve replacement.

Five-year experience with temporary pacemaker therapy in the coronary care unit

The clinical course of 1,022 consecutive patients who received a temporary transvenous pacemaker in the coronary care unit during a 5-year period between January 1976 and January 1981 was reviewed. The route of pacemaker insertion was identified in 942 patients (92.2%) and included antecubital vein cutdown in 606 patients (59.3%), subclavian venipuncture in 177 patients (17.3%), right internal jugular venipuncture in 111 patients (10.9%), and femoral venipuncture in 48 patients (4.7%). Pacemaker-related complications occurred in 140 instances (13.7% morbidity), without associated mortality. The most common complication was the development of a new pericardial rub (54 patients, 5.3%). The right internal jugular approach was associated with the lowest complication rate. On the basis of these findings, it is our practice to insert temporary pacemakers via the right internal jugular or subclavian route.

Detection of intracellular anoxia and its relationship to onset of hemodynamic dysfunction and ST-segment elevation in the intact dog heart

The temporal relationships among onset of cellular anoxia after coronary artery occlusion, contractile dysfunction, and electrocardiographic ischemia were studied in dogs with an intact circulation. Nicotinamide adenine dinucleotide (NADH) fluorescence was used to detect intracellular anoxia, using a fiber-optic method. Paired NADH concentrations from ischemic (394 +/- 10 mumol/g) and normoxic (285 +/- 11 mumol/g) regions of the heart were obtained, and the differences (delta[NADH]) were correlated with compensated fluorescence (r = 0.76, P less than 0.01). Onset of fluorescence occurred 1 to 2 sec after coronary artery occlusion, followed by hemodynamic (5 sec) and electrocardiographic (13 sec) changes. These data indicate that intracellular anoxia, with alterations in redox potential, is not synchronous with the onset of contractile failure and provide indirect support for intracellular acidosis as the likely mediator of contractile failure.

Preservation of oxidative phosphorylation by lidocaine in ischemic and reperfused myocardium

The effect of lidocaine (2 mg/kg bolus, 0.04 mg/kg per min infusion) on ischemic and reperfused myocardial respiration was assessed in 32 dogs, using indices of mitochondrial respiration (ADP:O ratio, state 3 and state 4 respiration, and respiratory control index). Heart rate, left ventricular (LV) pressure, LV dp/dt, cardiac index, epicardial ST segment, and regional myocardial blood flow, using 9 +/- 1 micron radiospheres, were measured after 40 min of constriction of the anterior descending coronary artery (N = 16) and after 20 min of reperfusion (N = 16). Results showed that lidocaine increased state 3 respiration and respiratory control in reperfused myocardium (P less than 0.05) with both glutamate and succinate-rotenone as substrate. It is concluded that lidocaine improves postischemic mitochondrial oxidative phosphorylation independent of altered hemodynamics or change in myocardial blood flow.

Protective effect of lidocaine during regional myocardial ischemia: an altered pathophysiologic response assessed by NADH fluorescence

Studies were undertaken to determine the effects of lidocaine on ischemic myocardium, which was induced by coronary artery constriction in open-chested dogs. A real-time epicardial fluorescent technique to detect in vivo-reduced nicotinamide adenine dinucleotide (NADH) during 60 seconds of ischemia was used. Blood flow of ischemic myocardium was measured by using radioactive microspheres of 9 +/- 1 micrometers (mean +/- SE) and was compared with that of normal myocardium, shown by injection of alpha-zurine blue dye. Lidocaine effectively reduced peak NADH fluorescence by 18.6%, from 93.9 +/- 7.2 to 76.4 +/-4.1 mV (p less than 0.005). Lidocaine delayed the onset of fluorescence (2.2 +/- 0.2 versus 1.3 +/- 0.1 s p less than 0.002) and facilitated the recovery from ischemia (38.4 +/- 2.9 versus 54.8 +/- 2.9 s p less than 0.001). Increase in NADH concentration during ischemia correlated (r=0.76, p less than 0.006) with ischemic fluorescence. These findings were independent of altered hemodynamics or change in myocardial blood flow. Results indicate that lidocaine provides myocardial cellular protection during transient ischemia; there is an altered NADH fluorescent response to coronary artery occlusion.

Beneficial effects of multidose coronary artery washout during elective cardiac arrest and cardiopulmonary bypass: biochemical and hemodynamic evaluation

Coronary artery washout with buffered saline (pH 7.4) during 60 and 120 minutes of elective cardiac arrest was studied in dogs during moderate hypothermic cardiopulmonary bypass. Compared with results in a group undergoing simple ischemic arrest, significantly greater myocardial adenosine triphosphate concentrations were present at 90 and 120 minutes of cardiac arrest in the coronary artery washout group. After 60 minutes of aortic cross-clamping and 60 minutes of reperfusion, left ventricular function was significantly superior in the coronary artery washout group. Coronary artery washout during the period of aortic cross-clamping preserves dynamic myocardial performance during reperfusion and is an important principle of myocardial protection during elective cardiac arrest.

Lidocaine-induced reduction in size of experimental myocardial infarction

In anesthetized open chest dogs, the effects of therapeutic doses of lidocaine on myocardial cell respiration, creatine kinase depletion, left ventricular stroke work and cardiac necrosis were assessed. The dogs were subjected to 40 minutes of occlusion of the left anterior descending coronary artery, followed by 5 hours of reperfusion. Group I (12 dogs) had infusion of saline solution; group II (8 dogs) had infusion of 0.2 mg/kg per min of lidocaine (serum level 16.8 +/- 1.4 microgram/ml); group III (5 dogs) had infusion of 0.04 mg/kg per min or lidocaine (serum level 3.6 micrograms/ml). Ischemic regional myocardial blood flow (measured by 9 micrometer spheres of strontium-85) was 6.34 +/- 1.62 ml/100 mg per min in group I, 1.48 +/- 0.59 in group II (p < 0.05) and 1.32 +/- 0.50 in group III (p < 0.05). Oxygen consumed during conversion of adenosine diphosphate to adenosine triphosphate in mitochondria from control and lidocaine-treated ischemic tissue was depressed (p < 0.05) and correlated (r = 0.63) with creatine kinase depletion. Left ventricular stroke work was not significantly different among the three groups. Infarct size (in percent of left ventricular weight) was 12.6 +/- 2.0 for group I, 4.8 +/- 1.2 for group II (p < 0.01) and 4.8 +/- 2.5 for group III (p < 0.05). The data suggest that the reduction of myocardial infarct size by lidocaine was not dependent on enhanced myocardial blood flow and was independent of left ventricular stroke work.

Failure of interventions to maintain mitochondrial function in ischemic myocardium

The purpose of this study was to investigate whether pyruvate (2.5 mmol/kg), the combination of glucose (3.9 mmol/kg) and insulin (0.13 unit/kg) with potassium (9.27 meq/kg), or sodium dichloroacetate (120 mg/kg) infused for 15 minutes before and 20 minutes after ligation of the left anterior descending coronary arterv in anesthetized dogs restricted the depression in mitochondrial respiratory function induced by ischemia. Myocardial blood flow after ligation in the three groups was o.2 ml/min per gram or less in ischemic subendocardium and was similar to that in saline-infused controls that had also undergone coronary artery ligation. The depressions induced in mitochondrial respiratory control index and state 3 respiration by ischemia in the subendocardium and subepicardium of the three treatment groups, when compared with corresponding nonischemic tissue, were not significantly improved from the control values. It was concluded that these three interventions fail to preserve mitochondrial respiration in ischemic myocardium.

Effect of betamethasone on mitochondrial oxidative phosphorylation in ischemic canine myocardium

Hemodynamics and myocardial blood flow were studied in 14 anesthetized open-chest dogs that were subjected to coronary artery occlusion followed by reperfusion. In six dogs, betamethasone was given intravenously 30 minutes before occlusion. During reperfusion, a significant increase in myocardial blood flow in nonischemic tissue was observed in the betamethasone group as compared with control (P less than 0.05). Also, the increase in myocardial blood flow in steroid-treated nonischemic tissues during reperfusion was significantly greater (P less than 0.05) than that measured in ischemic tissues in the same group. However, betamethasone failed to protect mitochondrial respiration from ischemic damage. Respiratory control indices in ischemic tissues were significantly depressed, compared with those in nonischemic tissues, even in betamethasone-treated dogs, and the degree of depression was the same in the ischemic tissues of control and treated dogs. These data suggest that betamethasone was not effective in preserving mitochondrial function in ischemia but that it increased myocardial blood flow in nonischemic tissue.

Effect of magnesium in cardioplegic solution upon hypothermic ischemic myocardial mitochondria

Twelve anesthetized mongrel dogs were subjected to systemic hypothermia and potassium-induced cardioplegia for 60 minutes with or without magnesium-1-aspartate. The effect of magnesium was assessed by indices of mitochondrial oxidative phosphorylation. Cardiac arrest was induced by potassium (20 mEq per liter) (6 dogs) or potassium (20 mEq per liter)- magnesium (8 mM per liter). The heart was reperfused for ten minutes following arrest. Dogs were supported by standard cardiopulmonary bypass with hypothermia at 20 degrees C of myocardial temperature. Mitochondria were isolated from the endocardium, the epicardium of the left ventricle and the ventricular septum. ADP: 0 ratio and state 3 respiration were well maintained in both groups following 60 minutes of ischemic arrest and 10 minutes of reperfusion. Magnesium suppressed the non-phosphorylated oxygen consumption of mitochondria, therefore, respiratory control index was signficantly enhanced in the group of potassium-magnesium-1-aspartate cardioplegia. These data suggest that magnesium protects functional capacity of mitochondrial phosphorylation in the myocardium from ischemia.

Myocardial respiration and edema following hypothermic cardioplegia and anoxic arrest

The effects of 1 and 2 hours of hypothermic anoxic arrest and cardioplegia induced by Mg-lidocaine, K-Mg, or K on left ventricular mitochondrial respiratory function, blood flow, and edema were studied in 41 mongrel dogs. Mitochondrial respiration was assessed by the indices of oxidative phosphorylation. Myocardial temperature recorded in ventricular septum was kept at 20 degrees C during ischemic arrest and 10 minutes of reperfusion. Cardioplegic solutions did not influence noncoronary blood flow during cross-clamping of the aorta. Mitochondrial respiratory function remained at control levels after 1 hour of ischemia induced by hypothermic anoxic arrest or by Mg-lidocaine or K-Mg hypothermic cardioplegia. Mitochondrial state 3 respiration after 2 hours of anoxic arrest was significantly higher in Mg-lidocaine cardioplegia than in anoxic arrest (p less than 0.05), but myocardial edema was equivalent in both groups. Mg in the cardioplegic solution suppressed mitochondrial nonphosphorylating oxygen consumption. These data suggest that mitochondrial function after 1 hour of ischemic arrest at 20 degrees C and 10 minutes of reperfusion is not significantly depressed, but at 2 hours of ischemic arrest, mitochondrial respiration is significantly impaired. However, hypothermic Mg-lidocaine cardioplegia appears to be more effective in sustaining myocardial respiration than does simple hypothermic anoxic arrest when the anoxic period is extended to 2 hours.

Quantitative evaluation of myocardial ultrastructure following hypothermic anoxic arrest

Thirty-six anesthetized mongrel dogs were subjected to systemic hypothermia and anoxic cardiac arrest while on cardiopulmonary bypass. Myocardial fine structure in the left ventricle was evaluated by quantitative analysis in the subepicardial, mid-myocardial, and subendocardial layers. The specimens were obtained by a transmural myocardial biopsy method. Graded hypothermia was employed at 36 degrees, 30 degrees, 28 degrees, 25 degrees, and 22 degrees C. The aorta was cross-clamped for 30 minutes at 36 degrees, 30 degrees, 28 degrees, and 25 degrees C. or for 45 minutes at 25 degrees and 22 degrees C. Observations indicated that pathological changes of the myocardial fine structure were significant after anoxic arrest in the normothermic group. Lesions were most extensive in the subendocardial layer after normothermic anoxic arrest, whereas hypothermia below 30 degrees C. preserved the myocardium throughout all layers without difference in pathological changes in the fine structure among the layers. Mitochondria and glycogen granules in the mid-myocardial layer and the subendocardial layer were best preserved with hypothermia at 25 degrees and 22 degrees C. after 30 minutes or 45 minutes of anoxic arrest, and dogs in these groups had a survival rate of 100 percent. Quantitative analysis of ultrastructural changes induced in these experiments suggest that a safe duration of anoxic arrest at 22 degrees to 25 degrees C. is between 30 and 45 minutes.

Myocardial ultrastructural changes after experimental ventricular fibrillation and anoxic arrest

A transmural myocardial biopsy method was used to study changed in ultrastructure after induced ventricular fibrillation or anoxic arrest in the canine heart. Interstitial edema, mitochondrial derangement, contraction bands, and swelling of capillary endothelium were more extensive in subendocardial than in subepicardial layer after anoxic arrest. Significant numbers of contraction bands were also seen in the myocardium after induced ventricular fibrillation. These changes appeared to be reversible at least in part in the group with induced ventricular fibrillation but generally not in the anoxic arrest animals. After anoxic arrest, preservation of the endocardial layer was significantly poorer than that of the epicardium; after ventricular fibrillation, there appeared to be no such difference. Myocardial mitochondria and glycogen granules were intact and more numerous after ventricular fibrillation than after anoxic arrest. The lesser damage after ventricular fibrillation than after anoxic arrest suggest that the myocardium may be affected less by the no-reflow phenomenon after normal coronary circulation is restored in ventricular fibrillation.

Intra-aortic balloon assist: initial Mayo Clinic experience and current concepts

The initial experience with intra-aortic balloon assist (IABA) at the Mayo Clinic has been with 34 desperately ill individuals; 17 survived hospitalization. Hemodynamic improvement associated with institution of IABA can be documented. An unacceptably high complication rate (26%) has resulted in extensive modification in the technique of employing IABA. Concepts of patient selection and applications of IABA have evolved from this initial experience and from a review of the literature and have resulted in less reluctant use of this cardiac-assist modality.

Partial anomalous pulmonary venous connection (intact atrial septum) associated with mitral regurgitation

The association of partial anomalous pulmonary venous connection with intact atrial septum and isolated severe nonrheumatic mitral regurgitation is rare, this combination of lesions having been reported on only one other occasion. Two such cases have been presented, with each patient having experienced an episode resembling subacute bacterial endocarditis. At operation, however, the mitral valve had a congenital cleft in one case and was normal in the other. One patient underwent mitral valvuloplasty and the second patient had mitral valve replacement. The diagnosis of associated partial anaomalous pulmonary venous connection was established at cardiac catheterization, and successful surgical correction was achieved in each case by diversion of the anamolaous pulmonary venous drainage to the left atrium via a pericardial tunnel through a surgically created atrial septal defect.

The role of Ca++ ions in the hypertrophied myocardium [proceedings]

Pressure-hypertrophied right ventricular myocardium (RVH) demonstrates paradoxically increased oxygen consumption (MVO2) related to increased in vitro energy-linked mitochondrial calcium flux. The present experiments were designed to measure mitochondrial Ca++ retention in intact RVH and relate changes in mitochondrial Ca++ metabolism to altered RVH contractile behavior and relaxation. Sixteen cats were pulmonary artery banded and their hearts plus paired controls were perfused with 45Ca Krebs-Henseleit at 30 degrees C, 120 beats/min for 10 min. At Lmax papillary muscles showed reduced active tension, a slower contraction rate, a reduced relaxation rate, a greater time to peak tension and a greater relaxation time. Retained 45Ca of mitochondria was increased from 16.75 + .96nM/mg protein in controls to 20.82 +/- .98 in RVH, (p less than 0.005). This increase in mitochondrial 45Ca retention correlated (r equal to 0.93), (P less than 0.001) with the decreased rate of papillary muscle relaxation. These data show an increased 45Ca retention of mitochondria in pressure-induced RVH and relate this biochemical abnormality to a decreased myocardial relaxation in this state.

[The calcium metabolism of myocardial mitochondria and sarcoplasmic reticulum in experimental potassium deficiency (author's transl)]

Mechanical Parameters of the whole, Langendorff-perfused cat heart and of isolated right ventricular papillary muscles are depressed in chronic potassium deficiency. 45Ca binding of sarcoplasmic reticulum (SR) was found to be diminished and correlated with a reduced contractility of the perfused hearts. 45Ca uptake of sarcoplasmic reticulum isolated from potassium deficient hearts was also reduced. The mitrochondrial 45Ca binding and endogenous Ca concentration were increased and there was a positive correlation between these two parameters. The data suggest that a reduced SR Ca binding plays a role in the depression of myocardial contractility in chronic potassium deficiency. Increased mitochondrial 45Ca binding in the presence of reduced 45Ca binding and uptake of sarcoplasmic reticulum suggests the possibility that mitochondria are an additional myocardial calcium pool in chronic potassium deficiency.

Mechanisms for the abnormal energetics of pressure-induced hypertrophy of cat myocardium

Depressed myocardial contractility with paradoxically increased oxygen consumption has been demonstrated in previous studies of pressure overload hypertrophy. To determine whether altered mitochondrial respiration participates in the abnormal energetics of this muscle, right ventricular hypertrophy (RVH) was produced in 12 cats by pulmonary artery banding. A polarographic muscle bath was used to study eight control and eight RVH papillary muscles, and the respiration of mitochondria isolated from these right ventricles was characterized. RVH muscles demonstrated depressed force-velocity and length-tension curves. The myocardial oxygen consumption per gram of peak active tension was increased from 0.65 ± 0.05 nliters/mg beat -1 (control) to 1.10±0.07 nliters/mg beat -1 (RVH) ( P <0.001). Abnormal mitochondrial respiration was shown by an increase in the rate of state 4 oxygen consumption from 12.5±0.8 natoms/mg min -1 (control) to 19.9±0.8 natoms/mg min -1 (RVH) ( P < 0.001). The altered oxygen cost of active isometric tension in the RVH muscles was linearly correlated with the altered rate of mitochondrial state 4 oxygen consumption ( r = 0.91). Ruthenium red, a compound that blocks mitochondrial calcium uptake, reduced the rate of RVH state 4 oxygen consumption to the control level. The present study suggests a mechanism for the abnormal myocardial oxygen consumption in pressure overload hypertrophy and relates it to nonphosphorylating mitochondrial respiration linked to calcium transport.

Normal myocardial function and energetics in volume-overload hypertrophy in the cat

Depressed contractility with a paradoxically increased myocardial oxygen consumption has been associated with pressure-overload hypertrophy. The present experiments investigated myocardial hypertrophy induced by volume overload. Right ventricular volume overload was produced in 19 cats by surgically creating atrial septal defects (ASD); these cats were compared with 10 sham-operated control cats. The ASD cats showed an increase in the ratio of pulmonary blood flow to systemic blood flow from 1.04 ± 0.01 ( SE ) (control) to 3.30 ± 0.28 (ASD) ( P < 0.001). Hypertrophy was evidenced by a ratio of right ventricular weight to body weight of 0.59 ± 0.03 g/kg for control cats and 0.97 ± 0.03 for ASD cats ( P < 0.001). A polarographic muscle bath was used to study papillary muscles from 8 control and 8 ASD cats. ASD muscles demonstrated normal force-velocity curves, with maximal measured preload velocities of 1.32 ± 0.05 muscle lengths/sec: control velocities were 1.33 ± 0.05 muscle lengths/sec ( P > 0.9). The myocardial oxygen consumption of isotonic contractions was normal for ASD muscles. The length-tension curves were comparable, with developed tensions at Lmax of 6.20 ± 0.31 g/mm 2 for ASD muscles and 6.34 ± 0.23 g/mm 2 for control muscles ( P > 0.7). Myocardial oxygen consumption pergram of tension development at Lmax was 0.66 ± 0.06 µliters/mg beat -1 x 10 -3 in the ASD muscles and 0.65 ± 0.05 µliters/mg beat -1 x 10 -3 in the control muscles ( P > 0.8). The mitochondrial oxidative indexes from control and hypertrophied right ventricles were similar, with respiratory control indexes of 14.3 ± 0.8 for ASD hearts and 12.8 ± 1.6 for control hearts ( P > 0.1). These data demonstrate that contractility and energetics are normal in volume-overload hypertrophy, although these same factors are abnormal in pressure-overload hypertrophy. Thus, hypertrophy alone is not a common denominator for abnormal myocardial function and energetics.