Complete reversal of ischemic wall motion abnormalities by combined use of gene therapy with transmyocardial laser revascularization

INTRODUCTION

Transmyocardial laser revascularization is believed to induce an angiogenic response within ischemic myocardium. We evaluated transgene expression in the setting of transmyocardial laser revascularization and hypothesized that intramyocardial injection of plasmid DNA encoding the gene for vascular endothelial growth factor could enhance the revascularization achieved by transmyocardial laser revascularization, resulting in improved cardiac function.

METHODS

Ten Yorkshire pigs had carbon dioxide-transmyocardial laser revascularization or acupuncture sites with injections of an expression plasmid encoding the gene for beta-galactosidase with or without HVJ-liposomes. Three days after transduction, transgene expression was determined by enzyme-linked immunosorbent assay. Six weeks after placement of a constrictor on the left circumflex artery, 29 pigs were randomized to ischemic controls (n = 5), transmyocardial laser revascularization (n = 4), transmyocardial laser revascularization with expression plasmid beta-galactosidase injections (n = 5), expression plasmid-vascular endothelial growth factor injections (n = 4), or transmyocardial laser revascularization with expression plasmid-vascular endothelial growth factor (n = 5) and harvested 6 weeks after therapy. Six transmyocardial laser revascularization pigs had either expression plasmid beta-galactosidase or expression plasmid-vascular endothelial growth factor injections and were harvested at 2 weeks. Normal pigs (n = 5) were included for comparison. Left ventricular free wall motion was assessed by a cardiologist in a blinded manner.

RESULTS

Transgene expression did not vary significantly with or without HVJ-liposomes in transfected transmyocardial laser revascularization myocardium. However, expression was detected in 56 of 60 (93%) transmyocardial laser revascularization-transfected sites, but in only 10 of 20 (50%) non-transmyocardial laser revascularization sites (P < .001). All (5 of 5 hearts) of the transmyocardial laser revascularization-vascular endothelial growth factor treated hearts displayed no evidence of wall motion abnormalities. Only these hearts had a statistically significantly different rate of wall motion abnormality compared with ischemic controls (P = .004).

CONCLUSION

Transfection efficiency was improved with the use of transmyocardial laser revascularization. Wall motion abnormalities were completely reversed within 6 weeks after transmyocardial laser revascularization with the direct injection of an expression plasmid encoding vascular endothelial growth factor.

Cognitive coping styles of women sexually abused in childhood: a qualitative study

OBJECTIVE

The aim was to investigate cognitive coping strategies used by a nonclinical sample of women with a history of childhood sexual abuse, to examine whether cognitive appraisals affected their current coping strategies and psychological well-being.

METHOD

Qualitative research methods were used to enable the sample to convey their own ideas about factors and meanings they attributed to their experience of child sexual abuse. The sample of 40 was drawn from one of two stratified sub samples randomly selected from electoral rolls for interview in 1989 and re-interviewed in 1995. One sub sample had reported childhood sexual abuse and the other had reported none. Inductive content analysis and coding of themes were carried out using appropriate software and supplemented by quantitative interview data.

RESULTS

Six main coping strategies were identified and then assessed to determine their mediating influence on psychiatric disorder, self-esteem and self reported difficulties experienced as adults. Overall, abuse characteristics did not predict outcome but women who "deliberately suppressed" the abuse incidents were more likely to have low self-esteem and women who "reframed" were significantly less likely to have a psychiatric diagnosis.

CONCLUSIONS

Some cognitive coping strategies employed after experiencing child sexual abuse impinge on later psychological well-being or subsequent relationships with other people. One of the more challenging findings to come out of the study was that women who "reframed" the sexual abuse event were more likely to have favorable mental health outcomes but were also more likely to report that their own child had been sexually abused.

Enhancing the family medicine curriculum in deliveries and emergency medicine as a way of developing a rural teaching site

BACKGROUND

The urban family practice residencies of Memphis were not providing sufficient training or encouragement to young physicians for practice in rural communities.

METHODS

In 1990, the Department of Family Medicine, in partnership with the State of Tennessee Health Access Act and the Baptist Health Care System, developed a teaching practice in a rural county of western Tennessee. The family practice curriculum included special skills in advanced women's health care and emergency medicine so that uniformly trained physicians could provide around-the-clock coverage in the hospital, including the delivery of babies and first-hour emergency care.

RESULTS

After 7 years, the group now includes six full-time board-certified, OB-capable family physicians. In addition, faculty members from the department's urban program in Memphis are required to contribute a "mini locum tenens" of 2-3 days of rural coverage per month. Since 1992, the practice has provided care for more than 54,000 continuity office visits, 81,000 emergency department visits, more than 3,500 hospital admissions, and 621 obstetrical deliveries. Since 1994, residents have been assigned to the site full time, with growth to 12 (4-4-4) residents assigned to this location as of 1997. Several graduates from the initial group of residents have remained in the community after graduation, and three others have established practices in rural areas. Most recently, control of the practice is being transferred from the family medicine department to the university's corporate group practice. This may result in fundamental changes in the practice's operation.

CONCLUSIONS

The approach described in this report may be useful for the expansion of urban departments of family medicine into rural and underserved communities.

HLA-B*27 subtyping by PCR-RFLP in Spanish patients with ankylosing spondylitis

We describe the use of restriction analysis on PCR-amplified DNA for detecting all B*27 subtypes except B*2710 and B*2711 (i.e. from B*2701 to B*2709). After detecting B*27 by Sty I, double digestions consisting of Sty I plus another informative enzyme led to subtype assignment. We used mismatched primers to create restriction sites when necessary. The method avoids group-specific amplifications and other laborious optimization procedures. It was successfully tested on a panel of well characterized cell lines covering different B*27 subtypes. Then, we studied a group of 57 ankylosing spondylitis patients and 746 controls from the south of Spain. B*27 showed a very strong association with the disease (OR=211.27, P=10(-7)). B*2702 and B*2705 distribution in controls (20% and 77.1%, respectively) differed from previously reported data in the Spanish population. We unexpectedly found the B*2707 allele in our population (one control).

Role of cytokines in the response to erythropoietin in hemodialysis patients

BACKGROUND

Cytokines are regulatory factors of erythropoiesis, especially in pathologic conditions. Even though a relevant role for a deranged cytokine production in the pathogenesis of dialysis anemia has been suggested, no data are available that analyze the role of cytokines in the key therapeutic issue of the needs of erythropoietin. The aim of the present study in hemodialysis patients was, therefore, to examine the relationship between the dose of recombinant human erythropoietin (EPO) and the production of cytokines by peripheral blood mononuclear cells (PBMC).

METHODS

After the exclusion of subjects with major active causes of EPO resistance, data from 34 hemodialysis patients were available for analysis. Cytokine levels were measured in the supernatants of stimulated [with bacterial lipopolysaccharide and interferon gamma (IFN-gamma)] and unstimulated PBMC. Mean yearly values of hematocrit, hemoglobin, transferrin saturation, ferritin, parathormone (PTH) and aluminum levels and EPO doses (U/kg/week) were calculated. For analysis, the 34 patients were divided according to their cutoff requirements for EPO: patients with requirements of EPO > or = 60 U/kg/week (group A1, 26 subjects) versus EPO < 60 U/kg/week (group B1, 8 subjects) and patients with requirements of EPO > or = 100 U/kg/week (group A2, 18 subjects) versus <100 U/kg/week (group B2, 16 subjects).

RESULTS

A significant direct correlation between interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-a) production values and EPO doses was found (P = 0.039 and P = 0.02 respectively). On the other hand, there was a significantly negative correlation between interleukin-12 (IL-12) production values and EPO doses (P = 0.029). Patients of groups A1 and A2 had spontaneously higher tumor necrosis factor-alpha (TNF-alpha) and lower IL-12 and IFNgamma production compared to patients from groups B1 and B2.

CONCLUSIONS

Our data disclose a previously undescribed pattern of cytokine alteration that is relevant to determine increased needs of EPO in hemodialysis patients. The present results have potential applicability in designing strategies to improve EPO resistance.

Social perception and social skill in schizophrenia

The relationship of social perception to social skill in schizophrenia was investigated. Twenty-six outpatients completed three social perception tasks (i.e. facial affect recognition, social cue recognition, and self-ratings of social skill) and participated in two role-plays. Correlational analyses revealed that the self-ratings of social skill had the most consistent relationship with social skill among the social perception measures, even after controlling for symptomatology and subject demographics. Other measures of social perception (i.e. social cue recognition) had weaker relationships with social skills. Implications for future research and psychosocial interventions are discussed.

Differential regulation of matrix metalloproteinases and their inhibitors in human glomerular epithelial cells in vitro

The present study examines the effect of transforming growth factor-beta1 (TGF-beta1) and interleukin-1beta (IL-1beta) on the regulation of gelatinase A, gelatinase B, tissue inhibitor of metalloproteinase-I (TIMP-I) and TIMP-II in human glomerular epithelial cells (GEC). The addition of TGF-beta1 resulted in the increased production and secretion of both gelatinase A (72-kD type IV collagenase) and gelatinase B (92-kD type IV collagenase), in a dose- and time-dependent manner. In contrast, the addition of IL-1beta to GEC resulted in the stimulation of secretion of gelatinase B but not gelatinase A. When the secretion of the regulatory inhibitors was examined, IL-1beta or TGF-beta1 both resulted in an increased secretion of TIMP-I, whereas the secretion of TIMP-II was downregulated. Such results demonstrate an independent and opposite regulation of the enzymes and their inhibitors. Of particular interest was the observation of the differential regulation of gelatinase A and its specific inhibitor TIMP-II (which binds to the latent form of this enzyme) in response to TGF-beta1. These results for the first time indicate that in human GEC, matrix metalloproteinases (MMP), as well as their specific inhibitors, are independently regulated by different cytokines. MMP and their regulatory tissue inhibitors (TIMP) play an important role in tissue remodeling. The results of the present study serve to emphasize both the complex regulation of matrix metabolism in the glomerulus and the potential pathologic role of an imbalance between the proteinases and their inhibitors in various forms of glomerular disease.

Sudden death due to intravenous infusion of hair conditioner

A case of sudden death in a 14-year-old girl due to self administration of hair conditioner through an intravenous infusion pump is described. This report demonstrates difficulties that may occur in determining the manner of death in such cases and outlines a specific danger that may occur when adolescents have unsupervised access to intravenous infusion equipment.

A survey of pediatric malignancy in West Virginia

The occurrence of malignancy in the pediatric age group is an uncommon but serious event. Since little data are available on the extent, nature or referral patterns of childhood cancer in West Virginia, we conducted a survey of 782 primary care physicians and 17 regional referral centers. The results showed that 249 cases of malignancy in the pediatric age group were reported and that 68% of children with newly diagnosed childhood malignancy were referred to institutions within West Virginia. We conclude that the incidence and distribution of types of malignancy in childhood in West Virginia parallels that of the nation, although there is some regional variation within the state.

Influence of mechanical ventilation on blood lactate in patients with acute respiratory failure

OBJECTIVES

To determine whether mechanical ventilation (MV) may affect blood lactate concentration in patients with acute respiratory failure.

DESIGN

Prospective observational study with follow-up to hospital discharge.

SETTING

A 17-bed medical and coronary intensive care unit in a 650-bed general hospital.

PATIENTS

55 adult patients mechanically ventilated for acute respiratory failure between May 1996 and April 1997 were recruited.

MEASUREMENTS AND RESULTS

Arterial blood samples for determination of plasma lactate and blood gas analysis were taken just before tracheal intubation on spontaneous breathing, and 20 and 60 min after the initiation of controlled MV. Cuff systemic arterial pressure was measured before tracheal intubation and every 10 min during the first h of MV. Hyperlactatemia (arterial blood lactate > or = 2 mmol/l) was present in 21 of the 55 patients studied. After 20 min of MV, there was a decrease in blood lactate from 4.74 +/- 1.78 to 3.07 +/- 1.69 mmol/l (p < 0.01); 40 min later there was a further decrease to 2.63 +/- 1.35 mmol/l (p < 0.05). The decrease in blood lactate was also observed in those patients who after starting MV developed systemic arterial hypotension (p < 0.01). In patients with a normal lactate concentration at the entry to the study, lactate remained the same after 60 min on MV (NS).

CONCLUSIONS

Controlled MV decreases substantially the severity of hyperlactatemia in patients with acute respiratory failure, and any adverse circulatory effects of MV do not alter this beneficial outcome.

3-Alkyl ethers of clocinnamox: delayed long-term mu-antagonists with variable mu efficacy

In recent years there has been considerable interest in the relationship between clocinnamox (C-CAM) and its methyl ether methoclocinnamox (MC-CAM). While C-CAM appears to be an insurmountable mu-antagonist, MC-CAM has been shown to be a potent partial agonist at mu-opioid receptors. To further investigate this relationship we prepared other ethers of C-CAM and evaluated these in opioid receptor binding assays and in vivo in mouse antinociceptive assays and in morphine-dependent monkeys. In opioid binding assays, the ethers were generally mu-selective with affinity equivalent to that of C-CAM itself. Although they displayed little or no efficacy in vitro, some of the ethers showed substantial agonist activity in the in vivo antinociceptive tests. Two of the ethers, the propargyl ether 7 and the cyclopropylmethyl ether 5, were chosen for more detailed analysis in vivo. 7 was shown to have significant mu-agonist character and was able to substitute for morphine in morphine-dependent monkeys. Interestingly, when this agonist effect abated, 7 displayed long-lasting mu-antagonism. In contrast, 5 displayed little agonist activity in vivo and was characterized as a potent, long-acting mu antagonist. Although further work is needed to determine whether metabolism is a crucial factor in determining the pharmacological profile of these ethers, it is clear that 3-O-alkylation is a useful means of varying the mu efficacy displayed by this class of acyl-substituted 14-aminomorphinones. MC-CAM itself has generated considerable interest as a potential pharmacotherapy for opiate abuse. These analogues with differing mu efficacy but retaining the long-lasting mu-antagonist effects provide further opportunities for the development of treatment drugs.

Counting of single protein molecules at interfaces and application of this technique in early-stage diagnosis

The fluorescence-based detection and counting of single protein molecules after specific binding to antibodies at interfaces is presented. A diode laser was used as the excitation source. The unspecific binding at the interface has been reduced to a level of only 0.1% of the maximum signal level. At present, the detection limit of this molecule-counting process is in the range of 10(-17) mol/L, and the dynamic range of the signal corresponds to 7 orders of magnitude of antigen concentration, but these values are not limiting. As a preliminary application in early-stage diagnosis, we have investigated the detection of a single cardiac actin molecule in human plasma, which is of interest in myocardial infarction diagnosis.

Urinary complications of Miami pouch: trend of conservative management

OBJECTIVE

Continent urinary diversions have become popular among gynecologic oncologists. Much information has been gained concerning the complications and current management of patients with continent ileocolonic reservoirs. The high mortality rate associated with reoperation has led clinicians to adopt a trend toward conservative means of management. The purpose of this study was to evaluate the applicability of conservative management of complications related to the creation of the continent ileocolonic reservoir Miami pouch.

STUDY DESIGN

Patients who underwent creation of the Miami pouch at the Division of Gynecologic Oncology, University of Miami School of Medicine, since 1988 have been included in this study. Management of complications, with particular emphasis on the conservative treatment, has been reviewed in detail for each patient. Open surgery and conservative treatment have been compared.

RESULTS

Seventy-seven patients underwent creation of the Miami pouch from February 1988 to September 1997. Sixty (77.9%) patients were affected by recurrent cervical cancer; 72 (93.5%) were previously radiated. The perioperative mortality rate was 11.7% (9 patients). Six of these patients died as a result of sepsis; all of them underwent reoperation at least once. The most common urinary complications were ureteral stricture or obstruction (22.1%), difficult catheterization (19.5%), and pyelonephritis (13%). Conservative management strategies used for these complications included percutaneous nephrostomy, stent placement, balloon dilatation, radiologically (ultrasonography, fluoroscopy, computed tomography) guided placement of catheters, and antibiotic treatment. Eighty percent of the complications associated with the ileocolonic reservoir were resolved with conservative treatment, whereas 16.9% required surgical revision.

CONCLUSION

On the basis of these findings, conservative management of urinary reservoir complications should always be considered before surgical intervention is attempted. The exact time to engage in open revision should be individualized on the basis of the clinical condition of each patient. It is our belief that the conservative approach should be instituted whenever possible but surgical intervention not be delayed when absolutely indicated.

Measurement of how well a paediatric training programme prepares graduates for their chosen career paths

To provide a sound basis for modification of our paediatric residency education programme, we surveyed graduates from the past 16 years. The questionnaire was designed to determine the adequacy of training rotations in preparing graduates for their career paths. Questionnaires were mailed to 81 graduates; 73 (90%) replied. A modified version was completed by 27 of 29 current residents (93%). For most rotations, responses were normally distributed. However, 10 or more respondents identified exposure in one area as 'excessive' and in 6 as 'inadequate'. Current residents scored many rotations as 'inadequate', likely indicative of their limited exposure to actual practice. Recommendations were consistent for subjects needing more instruction. All major issues raised by graduates had been identified by faculty, but the substantiation enabled changes to be made with widespread support. We recommend periodic survey of graduates to evaluate how well education is preparing residents for their ultimate career paths.

Associations of protein C and protein S with serum lipid concentrations

Difficulties in the laboratory measurement of protein C and protein S levels cause problems in the diagnosis of deficiency states in individual patients and may complicate estimation of the prevalence of these states in the general population. Some difficulties may be due to unappreciated influences affecting the measured levels of proteins C and S. We measured protein C activity and antigen, total and free protein S antigen, and serum total cholesterol, high-density cholesterol and triglyceride in a community-based study of 150 adults (73 male, 77 female), age range 23-80 years. Participants were identified from the list of a single general practice by stratified random sampling within sex and decade of age. Protein C activity and antigen were strongly associated with serum lipids, mean levels increasing by approximately 0.25 u/ml as total cholesterol and triglyceride concentration each rose from the 5th to 95th centile. Total protein S antigen concentration was associated with total cholesterol, the mean rising by over 0.1 u/ml as total cholesterol increased from the 5th to the 95th centile, whilst a similar rise in triglyceride was associated with an increase in mean free protein S of more than 0.3 u/ml. Overall, physiological variation in total cholesterol and triglyceride concentration was associated with significant variation in protein C and protein S levels, independent of age and sex, suggesting that it is important to take serum lipids into account when investigating patients for protein C or protein S deficiency. Failure to do so may be misleading in some circumstances.

Retroviral diversity and distribution in vertebrates

We used the PCR to screen for the presence of endogenous retroviruses within the genomes of 18 vertebrate orders across eight classes, concentrating on reptilian, amphibian, and piscine hosts. Thirty novel retroviral sequences were isolated and characterized by sequencing approximately 1 kb of their encoded protease and reverse transcriptase genes. Isolation of novel viruses from so many disparate hosts suggests that retroviruses are likely to be ubiquitous within all but the most basal vertebrate classes and, furthermore, gives a good indication of the overall retroviral diversity within vertebrates. Phylogenetic analysis demonstrated that viruses clustering with (but not necessarily closely related to) the spumaviruses and murine leukemia viruses are widespread and abundant in vertebrate genomes. In contrast, we were unable to identify any viruses from hosts outside of mammals and birds which grouped with the other five currently recognized retroviral genera: the lentiviruses, human T-cell leukemia-related viruses, avian leukemia virus-related retroviruses, type D retroviruses, and mammalian type B retroviruses. There was also some indication that viruses isolated from individual vertebrate classes tended to cluster together in phylogenetic reconstructions. This implies that the horizontal transmission of at least some retroviruses, between some vertebrate classes, occurs relatively infrequently. It is likely that many of the retroviral sequences described here are distinct enough from those of previously characterized viruses to represent novel retroviral genera.

Transrectal ultrasonography: relationship with anorectal manometry, electromyography and sensitivity tests in irritable bowel syndrome

Irritable bowel syndrome is the most frequently diagnosed disorder in gastroenterology. It has been demonstrated with specialized motility studies that these patients compared to healthy subjects show changes in rectoanal electrical and mechanical activity and in rectoanal sensitivity. However, until now no report has been published on morphological alterations in the rectum or the internal anal sphincter. Twenty-five consecutive patients with irritable bowel syndrome (mean age 32, range 17-47 years; 24 females) were evaluated prospectively by transrectal ultrasonography, rectal sensitivity studies, and recordings of both electrical and mechanical activity of the distal rectum and internal anal sphincter during a 2-h inter-digestive period. Ten healthy volunteers (mean age 34.5, range 19-50 years) served as a control group. Paired and non-paired Student's two-tailed t test and linear regression analysis were used. It was shown that muscle thickness of the rectum during rest (4.7 +/- 0.1 mm) was correlated neither with its rectal spike amplitude (0.73 +/- 0.1 mV) nor with rectal spike frequency (17.06 +/- 3.6 spike/2 h). In addition, the diameter of the internal anal sphincter (1.2 +/- 0.1 mm) was correlated neither with its resting pressure, nor with frequency (17.1 +/- 3.2/2 h), duration (14.9 +/- 1.5 s), or amplitude (14.1 +/- 1.9 mmHg), of inhibition of the spontaneous rectoanal inhibitory reflex. No correlation was found between ultrasonographic parameters and rectal distension variables (r = 0.03). This study demonstrates for the first time morphological anorectal changes in patients with irritable bowel syndrome compared to healthy subjects, in addition to showing that morphological changes are independent of physiological ones. Therefore both transrectal ultrasonography to determine anorectal morphology and electromanometry to assess anorectal function are important measures in the evaluation of patients with irritable bowel syndrome.

Large-scale taxonomic profiling of eukaryotic model organisms: a comparison of orthologous proteins encoded by the human, fly, nematode, and yeast genomes

Comparisons of DNA and protein sequences between humans and model organisms, including the yeast Saccharomyces cerevisiae, the nematode Caenorhabditis elegans, and the fruit fly Drosophila melanogaster, are a significant source of information about the function of human genes and proteins in both normal and disease states. Important questions regarding cross-species sequence comparison remain unanswered, including (1) the fraction of the metabolic, signaling, and regulatory pathways that is shared by humans and the various model organisms; and (2) the validity of functional inferences based on sequence homology. We addressed these questions by analyzing the available fractions of human, fly, nematode, and yeast genomes for orthologous protein-coding genes, applying strict criteria to distinguish between candidate orthologous and paralogous proteins. Forty-two quartets of proteins could be identified as candidate orthologs. Twenty-four Drosophila protein sequences were more similar to their human orthologs than the corresponding nematode proteins. Analysis of sequence substitutions and evolutionary distances in this data set revealed that most C. elegans genes are evolving more rapidly than Drosophila genes, suggesting that unequal evolutionary rates may contribute to the differences in similarity to human protein sequences. The available fraction of Drosophila proteins appears to lack representatives of many protein families and domains, reflecting the relative paucity of genomic data from this species.

Transmyocardial laser-revascularization: experimental studies on prolonged acute regional ischemia

OBJECTIVE

This experimental study in pigs was undertaken to answer the question whether TMLR after acute myocardial infarction may improve regional myocardial perfusion, left ventricular function and diminish myocardial necrosis in the area at risk.

METHODS

Thirty open-chest anesthetized pigs were observed for 6 h, six pigs served as controls. In 24 pigs, occlusion of the left anterior descending artery (LAD) beyond the first diagonal branch was performed: seven pigs had LAD occlusion only (ischemia group), and 17 pigs were treated by TMLR (using a CO2-laser, energy: 40 J) prior to coronary occlusion; nine pigs received one laser channel (1 mm diameter) per cm2 (laser group 1) and eight pigs two channels per cm2 in the LAD territory (laser group 2). Regional myocardial blood flow by microspheres, function (franc starling curves), histochemical assessment (triphenyl tetrazolium chloride, TTC and histology), were performed.

RESULTS

The lased pigs were less prone to ventricular fibrillation (laser group 2, 38%; laser group 1, 56%; ischemic group, 100%; P < 0.05), and showed a significant smaller area of necrosis (TTC) in the area at risk (laser group 1, 23%; laser group 2, 14%; vs. ischemia group, 31%; P < 0.01). There was no significant difference between laser-treated and ischemia hearts regarding the amount of blood flow into the infarcted LAD region and the maximal left ventricular stroke work index after 6 h (P = n.s). Regional myocardial blood flow: ischemia group, 4 +/- 5 ml/100 g/min; laser group 1, 3 +/- 10 ml/100 g/min, and laser group 2, 2 +/- 10 ml/100 g/min; maximal left ventricular stroke work index: ischemia group, 1.8 mJ/g; laser group 1, 2.1 mJ/g and laser group 2, 2.1 mJ/g.

CONCLUSIONS

This model of acute regional ischemia demonstrates that CO2-laser revascularization diminish significantly the incidence of ventricular fibrillation and necrosis in the area at risk, and does not change regional myocardial perfusion and global left ventricular function. This experiment indicates that TMLR may be an alternative in treating advanced ischemic heart disease.