The relative importance of alkalinity, temperature, and the washout effect of bicarbonate-buffered, multidose cardioplegic solution

Recent experimental and clinical studies from our institution have shown that the administration of cold, bicarbonate-buffered, hyperkalemic crystalloid cardioplegic solution resulted in a significant rise in intramyocardial pH. This rise could theoretically be caused by (1) the alkalinity of the solution administered (pH 8.2 at 25 degrees C), (2) the washout of acid metabolites with each administration, and (3) hypothermia per se. To investigate the relative effects of each of these three factors on intramyocardial pH, dogs on cardiopulmonary bypass received crystalloid cardioplegic solution either at 10 degrees C (n = 9) or at 37 degrees C (n = 8) every 30 min during 2 hr of aortic cross-clamping. Myocardial temperature, intramyocardial pH, and CO2 tension (Pmco2) were measured continuously. Needle biopsy specimens were taken every 30 min for biochemical and ultrastructural analysis. Before aortic cross-clamping, intramyocardial pH was 7.07 +/- 0.06 in both groups (+/- SEM). Upon each administration of cardioplegic solution, hearts in the 10 degrees C group cooled to 10 degrees to 15 degrees C and intramyocardial pH increased on the average by 0.31 +/- 0.03 units (p less than .001). In the 37 degrees C group intramyocardial pH was unaffected by cardioplegic solution. At the end of the cross-clamping period, intramyocardial pH had declined to 6.49 +/- 0.13 in the 10 degrees C group and to 5.60 +/- 0.08 in the 37 degrees C group, the fall in pH being significantly greater in the 37 degrees C group than in the 10 degrees C group (p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of recurrent ischemia on myocardial high energy phosphate content in canine hearts

Successive ischemic episodes are commonly seen in clinical and experimental cardiology. Although prolonged abnormalities of the canine myocardium have been described following a single ischemic episode, it is not known whether myocardial injury is cumulative following multiple ischemic episodes. Dogs were subjected to three 15-min left anterior descending coronary artery occlusions, each followed by 30 min of reperfusion. In vivo biopsies were obtained for biochemical analysis before and during the first occlusion and 30 min into each reperfusion period. ATP and creatine phosphate (CP) fell in the endocardium during occlusion by 24% and by 69% respectively (both p less than .0001). While CP recovered during each reperfusion period, ATP remained significantly depressed. Loss of membrane-permeable purine nucleotide synthesis precursors occurred with the first reperfusion period but not with the second and third reperfusion periods. Therefore, reperfusion following one 15-min coronary occlusion is associated with severe depression of myocardial high energy phosphates; however, two additional occlusions do not cause a further decrease of these substances when intermittent reperfusion is allowed for 30 min.

First report of intramyocardial pH in man: I. Methodology and initial results

Continuous in vivo measurements of intramyocardial pH (MpH) have not been previously obtained in man. To achieve this goal, we developed in our laboratory a new, steel-jacketed, glass electrode, and circumvented temperature-related problems by recording the output in millivolts along with the adjacent myocardial temperature. A computer program was devised to calculate MpH in accordance with the Nernst equation. The need in this system for a remote, subcutaneous, reference electrode prompted two sets of experiments. The first set of experiments demonstrated in vitro that the adverse effect of varying the temperature of the reference electrode on the calibration of the pH electrode could be avoided if the reference electrode was placed in a potassium chloride (KCl) solution outside the body and connected to the subcutaneous tissues with a salt bridge. The second set of experiments, which were conducted in vivo in dogs, demonstrated that MpH measurements made with the reference electrode in the limb were not affected by ischemic electrocardiographic changes. This system was then used successfully in 10 patients undergoing coronary artery bypass surgery. Reliable, reproducible, and uniform changes were observed. Baseline MpH prior to revascularization was 6.81 +/- 0.07. Myocardial protection with cold K+ cardioplegia resulted in a significant rise in MpH to 7.45 +/- 0.06. Throughout the period of cross-clamping, MpH remained high. After revascularization and discontinuation of cardiopulmonary bypass, MpH stabilized at 6.93 +/- 0.04.(ABSTRACT TRUNCATED AT 250 WORDS)

Correlates of reperfusion ventricular fibrillation in dogs

To elucidate determinants of reperfusion ventricular fibrillation (VF), regional myocardial blood flow, ATP, creatine phosphate (CP), heart rate and blood pressure were compared in 2 groups of anesthetized dogs: those that fibrillated spontaneously upon release of a 15-minute coronary artery occlusion (VF group, n = 8) and those that did not fibrillate when reperfused (No VF group, n = 27). Arterial pressure and heart rate before and during coronary artery occlusion were similar in both groups. Ischemic endo- and epicardial ATP values, measured at the end of the occlusion period, were reduced approximately 20% of nonischemic values in both groups. In contrast, CP (nmol . mg protein-1) within the ischemic zone was significantly lower in the VF group in both the epicardium (14.3 +/- 1.6 in the VF group vs 22.8 +/- 2.5 in the No VF group, p less than 0.01) and the endocardium (9.0 +/- 2.0 in the VF group vs 18.7 +/- 1.8 in the No VF group, p less than 0.01). Furthermore, epi- and endocardial regional myocardial blood flow in the center of the ischemic zone during occlusion was significantly lower in VF dogs than in No VF dogs. Epicardial flow was 0.06 +/- 0.03 ml X min-1 X g-1 in VF dogs vs 0.44 +/- 0.06 in No VF dogs (p less than 0.001) and endocardial flow was 0.03 +/- 0.02 ml X min-1 X g-1 in VF dogs vs 0.23 +/- 0.04 ml X min-1 X g-1 in No VF dogs (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Improved intrinsic resolution: does it make a difference? Concise communication

The purpose of this study was to determine what effect further improvement in an Anger camera's intrinsic resolution has on lesion detection. We studied 52 patients undergoing bone imaging and 58 undergoing liver imaging. All patients had images performed in rapid sequence on ZLC -75 and ZLC -37 Anger cameras, both by Siemens. The two imaging systems are virtually identical except for the number of photomultiplier tubes and crystal thickness; these resulted in differences in intrinsic resolution ( ZLC -75 less than 3.8 mm FWHM at 140 keV, ZLC -37 less than 4.9 mm) and sensitivity ( ZLC -75 approximately 0.91 of ZLC -37 at 140 keV). Observer performance, measured by ROC curves, for detection of abnormalities was virtually identical with the two instruments. Subjectively, there was a trend toward preference of the ZLC -75 images, but this was not associated with any significant improvement in lesion detectability even in the subgroup in which a preference for one or the other instrument was noted.

Absence of a cumulative deterioration of regional function during three repeated 5 or 15 minute coronary occlusions

Recurrent myocardial ischemia is commonly seen in patients with coronary artery disease, in patients undergoing cardiac surgery with intermittent cross-clamping, and experimentally when multiple occlusion preparations are used to test drugs. Our study was designated to investigate whether myocardial injury is cumulative after three sequential ischemic episodes. Sixteen dogs were instrumented with ultrasonic crystals to assess percentage of segmental shortening and percentage of wall thickening in ischemic and nonischemic regions. The left anterior descending coronary artery was occluded three times for 5 min in one group (n = 8) and three times for 15 min in another group of dogs (n = 8) and each occlusion was followed by 30 min of reflow. Blood flow was determined with microspheres before coronary artery occlusion in the 5 min group and during occlusion in the 15 min group and in all dogs 25 min into the first and third reperfusion periods. During the three reperfusion periods mean segmental shortening in the ischemic zone recovered to only 60.5 +/- 8.7% (+/- SEM) of the preocclusion level (p less than .003) in the 5 min occlusion group and to 36.9 +/- 17.7% in the 15 min occlusion group (p less than .01). Mean wall thickening recovered to 61.3 +/- 16.6% (p less than .06) in the 5 min group and to 48.6 +/- 11.8% in the 15 min group (p less than .004). There were no significant differences during the reperfusion phase when mean values for the ischemic segment after the second and third occlusion were compared with the data obtained after the first occlusion in either group.(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of pindolol and metoprolol to reduce the size of non-reperfused infarcts in dogs using area at risk techniques

Recent studies have shown that long term mortality after acute myocardial infarction is reduced by chronic beta-blocker therapy, however, the mechanism is not well understood. Our objective was to determine whether the selective beta blocker, metoprolol, or the nonselective intrinsic sympathomimetic activity (ISA)-blocker pindolol, reduce infarct size as a function of an area at risk (AR) in a permanent infarction model in dogs and which blocker is preferable in regards to myocardial function. Dogs were instrumented with ultrasonic crystals to measure regional function in nonischaemic and infarct margin segments. Left ventricular (LV) pressures, LV dP/dt and heart rate (HR) were monitored. Dogs were subjected to a 6 h LAD coronary artery occlusion and were randomised to a control (n = 9), pindolol (n = 10), and metoprolol (n = 9) group. At 30 and 90 min post occlusion saline, pindolol (3 micrograms X kg-1 and 12 micrograms X kg-1) or metoprolol (12 micrograms X kg-1 and 48 micrograms X kg-1) were given intravenously. The in vivo AR was determined by autoradiography, the in vitro AR by postmortem dye infusion and the area of necrosis by tetrazolium staining. Pindolol and metoprolol decreased LV dP/dt by 20% (P less than 0.05). Metoprolol also decreased HR by 20% (P less than 0.05) and shortening of nonischaemic segments by 12% (P less than 0.05) following the 1st and 2nd dose. Function in infarct margin segments was not changed in either group. Blood flow, measured by microspheres, was similar in the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Attempted suicide by intake of pholedrine]

It is reported on an attempted suicide of a 21-year old female patient with a lethal dose of 60 to 80 tablets pholedrine longo. A pulmonary oedema could be observed in the patient. This was accompanied by hypotensive crises of blood pressure, which compelled us to use dopamin. Under therapy a stabilization of the behaviour of the patient could be achieved. Pathological liver values were diagnosed. The findings got were discussed and compared with the data of former publications.

Time course of ischemic alterations during normothermic and hypothermic arrest and its reflection by on-line monitoring of tissue pH

Currently there are no techniques available for the intraoperative on-line assessment of the adequacy of myocardial preservation during cardiac operation. The efficacy of a new intramyocardial pH electrode in quantitating myocardial ischemic damage and monitoring myocardial preservation was investigated by correlating changes in intramyocardial pH with the time course of metabolic, histologic, and ultrastructural alterations during global ischemia. Seventeen open-chest dogs were placed on cardiopulmonary bypass and the aorta was cross-clamped for 2 hours. In Group I (n = 8), aortic cross-clamping was performed under normothermia. Group II (n = 9) received 4 degrees C potassium cardioplegia immediately after cross-clamping and consecutively every 30 minutes thereafter. Intramyocardial carbon dioxide tension (Pco2) and intramyocardial pH were measured continuously. Serial transmural biopsies were obtained before and at 5, 15, 30, 60, 90, and 120 minutes after cross-clamping for biochemical and structural analysis. During the period of cross-clamping, mean myocardial temperature was 33 degrees C in Group I and 19 degrees C in Group II. Intramyocardial pH at the end of 2 hours of anoxic arrest reached 5.39 +/- 0.08 in Group I and 6.49 +/- 0.13 in Group II (both values p less than 0.01 compared to prebypass values). Intramyocardial Pco2 rose from 41 +/- 4 to 234 +/- 13 mm Hg in Group I (p less than 0.001) and did not change in Group II. Tissue content of adenosine triphosphate (ATP) decreased by 51% in Group I and by 14% in Group II (p less than 0.01 compared to prebypass value). Tissue creatine phosphate was depleted in Group I and decreased by 48% in Group II. The degree of ischemic damage assessed by a mean ischemic score was 2.15 +/- 0.06 in Group I and 0.75 +/- 0.19 in Group II (p less than 0.001). Irreversible structural damage assessed by electron microscopy occurred in Group I 60 to 90 minutes after cross-clamping and was associated with an intramyocardial pH below 6.2. No such damage was observed in Group II. Therefore, intramyocardial pH is shown to be a reliable indicator of the severity of ischemic damage during anoxic arrest under normothermic conditions and of the adequacy of preservation under hypothermic conditions. Measurement of intramyocardial pH may provide a potentially useful tool for the intraoperative on-line monitoring of the adequacy of myocardial preservation in patients undergoing cardiac operation.

Gold-195m for serial first pass radionuclide angiocardiography during upright exercise in patients with coronary artery disease

Sequential first pass radionuclide angiocardiography can be performed in rapid succession using gold-195m because of its low radiation dose and short half-life (30.5 seconds). In 25 patients with known or suspected coronary artery disease, first pass studies with gold-195m were obtained using a computerized multicrystal gamma camera at rest (n = 29), at the end of each 3 minute stage of exercise (n = 25) and immediately after exercise (n = 23). In 13 patients, assessment of left ventricular function during exercise with gold-195m was combined with thallium-201 stress scintigraphy. Left ventricular ejection fraction at rest assessed with technetium-99m and gold-195m correlated well (r = 0.93). In addition, repeat left ventricular ejection fractions at rest with gold-195m correlated closely (r = 0.96). Comparing peak exercise left ventricular ejection fraction with ejection fraction at rest, abnormal left ventricular reserve was found in 20 of 25 patients. Various abnormal patterns of left ventricular ejection fraction response were noted, showing the diagnostic potential of serial exercise angiocardiography. Thallium-201 myocardial images, obtained on a single crystal gamma camera after multiple gold-195m injections, were all of good diagnostic quality and were abnormal in 10 of 13 patients. Thus, multiple high count rate first pass studies can be obtained with gold-195m during and after exercise, allowing serial study of physiologic changes in left ventricular function during exercise. Thallium-201 myocardial imaging can be performed using the same exercise test, providing direct comparison of myocardial function and perfusion.

Studies of experimental coronary artery reperfusion. Effects on infarct size, myocardial function, biochemistry, ultrastructure and microvascular damage

The present report is a review of recent experimental studies in a canine model of acute coronary occlusion. The questions addressed were: (1) Does coronary reperfusion reduce myocardial infarct size? (2) What is the relationship between microvascular damage and hemorrhage and the development of myocardial necrosis? (3) What are the biochemical, functional and ultrastructural characteristics of reperfused tissue salvaged from necrosis? Coronary occlusion followed by reperfusion in the dog resulted in significant subepicardial salvage of myocardium if reperfusion was instituted before 6 hours of ischemia. Because ultrastructural evidence of microvascular damage was found only after irreversible damage to myocytes, and because gross hemorrhage after coronary reperfusion was confined to zones of myocardium that were already necrotic, it does not appear that hemorrhage should serve as a deterrent to reperfusing reversibly injured myocytes. Severely ischemic myocardium that had been salvaged by coronary reperfusion required several days before it returned to normal from biochemical, functional and ultrastructural standpoints.

Evaluation of antiarrhythmic activity of prostaglandin F2 alpha in man

Since prostaglandin (PG) F2 alpha had been shown to act anti-arrhythmically in various animal models and also in preliminary investigations in man, further evaluation of this effect was made in 30 patients with cardiac extrasystoles and in 2 patients with tachycardias. PGF2 alpha was infused intravenously at individually adapted consecutive rates from 5 to 100 micrograms/min each for at least 5 min. In the incidence of extrasystoles a mean maximum decrease of 41% (P less than 0.001) was obtained. One patient showed repeated short interruptions of a ventricular tachycardia. A dose-dependent significant rise in blood pressure and no significant influences on heart rate, PQ interval and QRS interval of the ECG were found. It is concluded that PGF2 alpha has probably no practical importance for the therapy of cardiac arrhythmias.

Studies by e.p.r. spectroscopy of carbon monoxide oxidases from Pseudomonas carboxydovorans and Pseudomonas carboxydohydrogena

E.p.r. spectra were obtained at 8-120 K for carbon monoxide oxidases isolated from the carboxydotrophic bacteria Pseudomonas carboxydovorans and Pseudomonas carboxydohydrogena. Spectra from the two enzymes are extremely similar to one another. Under appropriate conditions each enzyme shows signals from Mo(V) atoms in two different chemical environments, as well as showing signals from two distinct iron-sulphur centres, presumed to be [2Fe-2S] clusters, and weak FADH X free-radical signals. Parameters of most of the signals were measured, and they show considerable similarities to those of the corresponding signals from xanthine oxidase and related enzymes. Though the signals from carbon monoxide oxidases appear and disappear under reducing and oxidizing conditions, we have so far failed to demonstrate the kinetic competence of any of them. It seems likely that this was due to the presence in the enzyme preparation examined of high amounts of desulpho carbon monoxide oxidase together with another non-functional form of the enzyme giving a stable 'Resting' Mo(V) e.p.r. signal.

Kinetics of primary interaction of D-amino acid oxidase with its substrate

The formation of an initial enzyme-substrate complex of D-amino acid oxidase (D-amino acid: O2 oxidoreductase (deaminating), EC 1.4.3.3) and its substrate, D-alpha-aminobutyric acid, was studied kinetically at lower temperature and pH than their optima. The time course of the absorbance change at 516 nm in an anaerobic reaction was not exponential, but biphasic. The ratio of the rapidly reacting component to the slowly reacting one was decreased upon lowering of the temperature. The reaction rate of the rapidly reacting component depended on substrate concentration and gave a linear Arrhenius plot in the temperature range from -10 to +15 degrees C. The reaction rate of the slowly reacting component also depended on both substrate concentration and temperature. The rapidly reacting and slowly reacting components could be assigned to the substrate binding of the dimer and monomer, respectively, of this enzyme.

[The performance of ECG telemetry in the analysis of rhythm disorders]

630 outpatients and inpatients under rest as well as under conditions of physical loads and psychic stress were examined with the help of a radiobiotelemetry device of own construction, which corresponds to a combination of traditional radiotelemetry and tape storage. In 81.4% of the patients with hitherto unclarified disturbances of the cardiac rhythm telemetry obtained their qualitative clarification. In 50% of all cases with classical angina pectoris symptomatology the ischaemic heart disease was verified by determination of the usual criterias of ECG at the telemetry stripe. Of these 50% only 7 patients had no arrhythmia. In 57.5% of all examined patients with pacemakers of permanent frequency we could prove a considerable parasystoly in load by telemetry. 9 patients with R-demand-pacemakers became evident by triggering defects in load. During the psychoanalytic examination we registered extrasystoles in 25%, apart from this once developed a pancardiac asystolism. The radiobiotelemetry is a valuable completion of the well-known methods of load.