Experimental analysis of fluid mechanical energy losses in aortic valve stenosis: importance of pressure recovery

Current methods for assessing the severity of aortic stenosis depend primarily on measures of maximum systolic pressure drop at the aortic valve orifice and related calculations such as valve area. It is becoming increasingly obvious, however, that the impact of the obstruction on the left ventricle is equally important in assessing its severity and could potentially be influenced by geometric factors of the valve, causing variable degrees of downstream pressure recovery. The goal of this study was to develop a method for measuring fluid mechanical energy losses in aortic stenosis that could then be directly related to the hemodynamic load placed on the left ventricle. A control volume form of conservation of energy was theoretically analyzed and modified for application to aortic valve stenosis measurements. In vitro physiological pulsatile flow experiments were conducted with different types of aortic stenosis models, including a venturi meter, a nozzle, and 21-mm Medtronic-Hall tilting disc and St. Jude bileaflet mechanical valves. The energy loss created by each model was measured for a wide range of experimental conditions, simulating physiological variation. In all cases, there was more energy lost for the nozzle (mean = 0.27 J) than for any other model for a given stroke volume. The two prosthetic valves generated approximately the same energy losses (mean = 0.18 J), which were not statistically different, whereas the venturi meter had the lowest energy loss for all conditions (mean = 0.037 J). Energy loss correlated poorly with orifice pressure drop (r2 = 0.34) but correlated well with recovered pressure drop (r2 = 0.94). However, when the valves were considered separately, orifice and recovered pressure drop were both strongly correlated with energy loss (r2 = 0.99, 0.96). The results show that recovered pressure drop, not orifice pressure drop, is directly related to the energy loss that determines pump work and therefore is a more accurate measure of the hemodynamic significance of aortic stenosis.

Quasisteady behavior of pulsatile, confined, counterflowing jets: implications for the assessment of mitral and tricuspid regurgitation

Mitral and tricuspid regurgitation create turbulent jets within the atria. Clinically, for the purpose of estimating regurgitant severity, jet size is assumed to be proportional to peak jet flow rate and regurgitant volume. Unfortunately, the relationship is more complex because the determinants of jet size include interactions between jet pulsatility, jet momentum, atrial width, and the velocity of ambient atrial counterflows. These effects on fluorescent jet penetration were measured using an in vitro simulation. Both steady and pulsatile jets were driven into an opposing counterflow velocity field peak jet length (Ljp) measurements made as a function of (1) peak orifice velocity (Ujp), (2) the time required for the jet to accelerate from zero to peak velocity and begin to decelerate (Tjp), (3) jet orifice diameter (Dj), (4) counterflow velocity (Uc), and (5) counterflow tube diameter (Dc). A compact mathematical description was developed using dimensional analysis. Results showed that peak jet length was a function of the counterflow tube diameter, the ratio of peak jet to counterflow momentum, (Mjp/Mc) = (U2jpD2j)/(U2cD2c), and a previously undescribed jet pulsatility parameter, the pulsatility index (PI), PI = D2c/(TjpUjpDj). For the same jet orifice flow conditions, jet penetration decreased as chamber diameter decreased, as the jet PI increased, and as the momentum ratio decreased. These interactions provide insight into why regurgitant jet size is not always a good estimate of regurgitant severity.

Effects of a phorbol ester and isoquinoline sulfonamides on rabbit parietal cell function

The role of protein kinase C (PKC) on gastric H+ secretion, as measured by aminopyrine (AP) uptake and other intracellular signal transduction products, was investigated in isolated rabbit parietal cells using the PKC activator 12-0-tetradecanoyl phorbol 13-acetate (TPA) and several PKC inhibitors, including isoquinoline sulfonamides (H-7, H-8, H-89 and HA-1004) and calphostin-C. TPA dose-dependently inhibited histamine (10(-4) M)- and carbachol (10(-4) M)-stimulated AP uptake without affecting the response to dibutyryl cyclic AMP (10(-3) M). H-7 and calphostin-C dose-dependently augmented secretagogue-stimulated AP uptake, whereas H-8 and H-89 inhibited the response to secretagogues, and HA-1004 had no effect. H-7 and calphostin-C-induced augmentation of AP uptake was blocked by a calcium (Ca++) antagonist, lanthanum chloride, which suggests that the enhanced AP response was regulated by extracellular Ca++. Moreover, H-7 treatment partially reversed the TPA (10(-7) M)-induced inhibition of secretagogue-stimulated AP uptake. TPA reduced histamine- and carbachol-stimulated cAMP and inositol 1,4,5-triphosphate production by 50% and 96%, respectively, with a concomitant reduction of adenylate cyclase and intracellular free Ca++ by 44% and 78%. TPA increased the distribution of membrane-associated PKC by 20% and decreased histamine-stimulated PKA by 30%. In contrast, H-7 inhibited both PKC and protein tyrosine kinase activity in vitro but had no effect on these parameters in vivo. The results indicate that TPA-induced inhibition of secretagogue-stimulated AP uptake in PC is presumably mediated by activation of PKC.

Computational simulations of mitral regurgitation quantification using the flow convergence method: comparison of hemispheric and hemielliptic formulae

Mitral regurgitation results from the incomplete closure of the mitral valve, and the noninvasive diagnosis of this disease remains an important clinical goal. In this study, steady flow computer simulations were used to evaluate flow convergence method for flow rate estimation. The hemispheric and hemielliptic formulae were compared for accuracy in the presence of complicating factors such as ventricular confinement, orifice shape, and aortic outflow. Results showed that in the absence of aortic outflow and ventricular confinement, there was a plateau zone where the hemispheric formula approximated the true flow rate, independent of orifice shape. However, in the presence of complicating factors such as aortic outflow and ventricular confinement, there was no clear zone where the hemispheric formula could be applied. The hemielliptic formula, however, worked in all cases, regardless of chamber size or magnitude of aortic outflow. Therefore, application of the hemielliptic formula should be considered in future clinical studies.

Insights from three-dimensional echocardiographic laser stereolithography. Effect of leaflet funnel geometry on the coefficient of orifice contraction, pressure loss, and the Gorlin formula in mitral stenosis

BACKGROUND

Three-dimensional echocardiography can allow us to address uniquely three-dimensional scientific questions, for example, the hypothesis that the impact of a stenotic valve depends not only on its limiting orifice area but also on its three-dimensional geometry proximal to the orifice. This can affect the coefficient of orifice contraction (Cc = effective/anatomic area), which is important because for a given flow rate and anatomic area, a lower Cc gives a higher velocity and pressure gradient, and Cc, routinely assumed constant in the Gorlin equation, may vary with valve shape (60% for a flat plate, 100% for a tube). To date, it has not been possible to study this with actual valve shapes in patients.

METHODS AND RESULTS

Three-dimensional echocardiography reconstructed valve geometries typical of the spectrum in patients with mitral stenosis: mobile doming, intermediate conical, and relatively flat immobile valves. Each geometry was constructed with orifice areas of 0.5, 1.0 and 1.5 cm2 by stereolithography (computerized laser polymerization) (total, nine valves) and studied at physiological flow rates. Cc varied prominently with shape and was larger for the longer, tapered dome (more gradual flow convergence proximal and distal to the limiting orifice): for an anatomic orifice of 1.5 cm2, Cc increased from 0.73 (flat) to 0.87 (dome), and for an area of 0.5 cm2, from 0.62 to 0.75. For each shape, Cc increased with increasing orifice size relative to the proximal funnel (more tubelike). These variations translated into important differences of up to 40% in pressure gradient for the same anatomic area and flow rate (greatest for the flattest valves), with a corresponding variation in calculated Gorlin area (an effective area) relative to anatomic values.

CONCLUSIONS

The coefficient of contraction and the related net pressure loss are importantly affected by the variations in leaflet geometry seen in patients with mitral stenosis. Three-dimensional echocardiography and stereolithography, with the use of actual information from patients, can address such uniquely three-dimensional questions to provide insight into the relations between cardiac structure, pressure, and flows.

Mode of food intake reduction in Lewis rats with indomethacin-induced ulcerative ileitis

The mechanism of anorexia in inflammatory bowel disease is poorly understood. To gain insight into possible pathophysiologic mechanisms, the feeding indices and food intake were studied in an animal model of Crohn's disease. The anorexia of indomethacin-induced ulcerative ileitis was compared with that of the well-known anorexia of total parenteral nutrition (TPN). Forty-five female Lewis rats were randomized to four groups: Control, Indomethacin, Indomethacin + TPN, and TPN. Feeding indices and food intake were continuously measured using the Automated Computerized Rat Eater Meter. Interleukin-1 alpha (IL-1 alpha), tumor necrosis factor-alpha (TNF-alpha), prostaglandin E2 (PGE2), and leukotriene B4 (LTB4) were assayed in plasma, mononuclear cell culture, or ileum to determine their role in mediating anorexia. In the TPN group, spontaneous food intake (SFI) decreased (52%; p < 0.05), primarily via reduction in meal number (MN, 54%; p < 0.05) and, to a lesser extent, meal size (MZ, 35%; p < 0.05). In comparison, in the Indomethacin group SFI decreased (74%; p < 0.05) primarily via reduction in MZ (67%, p < 0.05); MN also decreased but to a lesser extent (27%; p < 0.05). In the Indomethacin + TPN group, SFI decreased (55%; p > 0.05) primarily via reduction in MN (79%; p < 0.05), whereas MZ decreased slightly (19%; p < 0.05). Only in the Indomethacin group were IL-1 alpha and TNF-alpha detected in the mononuclear cell culture and plasma, respectively. In the Indomethacin group, an inverse correlation existed between MZ and TNF-alpha (p < 0.05). In the Indomethacin group, IL-1 alpha, PGE2, and LTB4 concentrations did not correlate with feeding indices. SFI reduction in this model was mediated primarily via a decrease in MZ. TNF-alpha is proposed to mediate this effect and TPN was shown to overcome the effect on MZ.

Doppler echocardiographic assessment of long-term progression of mitral stenosis in 103 patients: valve area and right heart disease

OBJECTIVES

The purpose of this study was to determine, in a large referral population, the rate of echocardiographic change in mitral valve area (MVA) without interim intervention, to determine which factors influence progression of narrowing and to examine associated changes in the right side of the heart.

BACKGROUND

Little information is currently available on the echocardiographic progression of mitral stenosis, particularly on progressive changes in the right side of the heart and the ability of a previously proposed algorithm to predict progression.

METHODS

We studied 103 patients (mean age 61 years; 74% female) with serial two-dimensional and Doppler echocardiography. The average interval between entry and most recent follow-up study was 3.3 +/- 2 years (range 1 to 11).

RESULTS

During the follow-up period, MVA decreased at a mean rate of 0.09 cm2/year. In 28 patients there was no decrease, in 40 there was only relatively little change (< 0.1 cm2/year) and in 35 the rate of progression of mitral valve narrowing was more rapid (> or = 0.1 cm2/year). The rate of progression was significantly greater among patients with a larger initial MVA and milder mitral stenosis (0.12 vs. 0.06 vs. 0.03 cm2/year for mild, moderate and severe stenosis, p < 0.01). Although the rate of mitral valve narrowing was a weak function of initial MVA and echocardiographic score by multivariate analysis, no set of individual values or cutoff points of these variables or pressure gradients could predict this rate in individual patients. There was a significant increase in right ventricular diastolic area (17 to 18.7 cm2) and tricuspid regurgitation grade (2 + to 3 +; p < 0.0001 between entry and follow-up studies). Progression in right heart disease occurred even in patients with minimal or no change in MVA. Patients with associated aortic regurgitation had a higher rate of decrease in MVA than did those with trace or no aortic regurgitation (0.19 vs. 0.086 cm2/year, p < 0.05).

CONCLUSIONS

The rate of mitral valve narrowing in individual patients is variable and cannot be predicted by initial MVA, mitral valve score or transmitral gradient, alone or in combination. Right heart disease can progress independent of mitral valve narrowing.

How sensitive are jet centerline velocities to an opposing flow? Implications for using the centerline method to quantify regurgitant jet flow

A method for quantifying peak mitral and tricuspid regurgitant jet flow rate that utilizes a measure of jet orifice velocity (Uo, m s-1), a distal centerline velocity (Um, m s-1), and the intervening distance (X, cm) was recently developed. This method, however, modeled the regurgitant jet as a free jet, whereas many atrial jets are counterflowing jets because of jet opposing intra-atrial flow fields (counterflows). This study evaluated the feasibility of using the free jet quantification equation in the atrium where ambient flow fields may alter jet centerline velocities and therefore reduce the accuracy of jet flow rate calculations. A 4 cm wide chamber was used to pump counterflows of 0, 4, and 22 cm s-1 against jets of 2.3, 4.8, and 6.4 s-1 originating from a 2 mm diameter orifice. For each counterflow-jet combination, jet centerline velocities were measured using laser Doppler anemometry. For free jets (no counterflow), flow rate was calculated with 98% mean accuracy. For all jets in counterflow, the calculation was less accurate as (i) the ratio of jet orifice velocity to counterflow velocity decreased (Uo/Uc, where Uc is counterflow velocity), i.e. the counterflow was relatively more intense, an (ii) centerline measurements were mad further from the orifice. But although counterflow lowered jet centerline velocities beneath free jet values, it did so only significantly in the jet's distal portion, while the initial portion (X/D < 16, where D is jet orifice diameter) of a jet in counterflow behaved essentially as a free jet. Therefore, regurgitant jets, although not classically free because of systolic atrial inflow, will decay in their initial portions as free jets and hence are candidates for quantification with the centerline technique.

Intravenous nucleosides and a nucleotide promote healing of small bowel ulcers in experimental enterocolitis

Our aim was to evaluate the possible beneficial effect of intravenous nucleosides and a nucleotide in healing small bowel ulceration in a rat model of enterocolitis. Fourteen Lewis female rats were randomized into total parenteral nutrition (TPN, N = 7) and TPN + nucleosides and a nucleotide (NS/NT, N = 7) groups. After adaptation, two doses of indomethacin (7.5 mg/kg) were administered subcutaneously 24 hr apart to each animal in both groups. Concomitant with the first dose of indomethacin, TPN or TPN + NS/NT were infused for four days. The TPN and TPN + NS/NT were isocaloric and isonitrogenous. At the end of four days, total ulcer length in the entire small bowel was measured. The mucosa surrounding ulcers was studied by optical microscopy. Immunohistochemistry was performed for proliferating cell nuclear antigen (PCNA). Ileal crypt and villus lengths were measured with an eyepiece micrometer, crypt-villus ratios were calculated, and crypt mitotic index and percentage of PCNA-labeled cells determined to assess cellular proliferation. Total ulcer length decreased significantly in the TPN + NS/NT group compared to the TPN group (42 vs 76 mm). In the TPN + NS/NT versus TPN group, the ileal mucosa surrounding ulcers showed significantly greater crypt length (21%) and there was increased crypt-villus ratio (0.53 vs 0.39), crypt mitotic index (1.2 vs 0.9), and PCNA labeling (43% vs 30%). We conclude that in rats with indomethacin-induced enterocolitis, administration of TPN + NS/NT for four days resulted in significant healing of small bowel ulcers, as indicated by decreased ulcer length. This effect of NS/NT appears to relate, in part, to increased cell proliferation, evidenced by increased crypt length, crypt-villus ratio, mitotic index, and PCNA labeling.

Quantitative assessment of stenotic aortic valve area by using intracardiac echocardiography: in vitro validation and initial in vivo illustration

Quantitative assessment of aortic stenosis (AS) is subject to the limitations of all current noninvasive and invasive methods. The ability to obtain a direct measure of aortic valve area with high resolution by intracardiac echocardiography (ICE) could be of great benefit to catheterized patients. To provide a fixed AS area as an ideal standard for comparison, we performed ICE in 12 sheep hearts with experimentally created AS and five human AS hearts from autopsies. ICE catheters were passed retrograde across the aortic valve, and the minimal orifice area on pullback was planimetered and compared with calibrated video imaging. The entire orifice circumference could be successfully recorded in 16 (94%) hearts. Orifice area from ICE correlated well with actual values (r=0.98; standard error of the estimate [SEE] = 0.06 cm2). To illustrate the applicability in vivo, two canine models and 10 patients with AS were studied. The limiting orifice could be imaged in both animals and in 8 of 10 patients, in whom values agreed well with invasive data (r= 0.95; SEE = 0.04 cm2). ICE can therefore accurately measure AS orifice area in vitro; it can be applied in vivo as well. These validation studies laid the foundation for subsequent clinical studies and applications.

Echocardiography can predict which patients will develop severe mitral regurgitation after percutaneous mitral valvulotomy

OBJECTIVES

Using two-dimensional echocardiography, we sought to identify features that are associated with severe mitral regurgitation after percutaneous mitral valvulotomy and combine them into a predictive score.

BACKGROUND

Severe mitral regurgitation after percutaneous mitral valvulotomy is a major complication carrying an adverse prognosis that, to date, has not been predictable in advance.

METHODS

In a consecutive series of 566 patients who underwent percutaneous mitral valvulotomy, 37 (6.5%) developed severe mitral regurgitation (assessed by angiography) after the procedure, 31 of whom had an echocardiogram available before percutaneous mitral valvulotomy. These 31 patients were matched by age, gender, mitral valve area and degree of mitral regurgitation before valvulotomy with 31 randomly selected patients who did not develop severe mitral regurgitation after percutaneous mitral valvulotomy. An echocardiographic score was developed on the basis of the pathologic studies of valves of patients who developed severe regurgitation after percutaneous mitral valvulotomy (leaflet rupture of relatively thin portions of nonhomogeneously thickened leaflets in the presence of commissural and subvalvular calcification) and evaluated uneven distribution of thickness in the anterior and posterior mitral leaflets, degree of commissural disease and subvalvular disease involvement, with each component graded from 0 to 4 (total, 0 to 16). Intraobserver and interobserver variability for score assessment were 6% and 7%, respectively.

RESULTS

The total mitral regurgitation echocardiographic score was significantly greater in the severe mitral regurgitation group (11.7 +/- 1.9 [mean +/- SD] vs. 8.0 +/- 1.2, p < 0.001). In addition, the component grades for the anterior leaflet (3.2 +/- 0.7 vs. 2.3 +/- 0.6, p < 0.001), commissures (2.6 +/- 0.7 vs. 1.6 +/- 0.6, p < 0.001) and subvalvular apparatus (3.2 +/- 0.6 vs. 2.3 +/- 0.7, p < 0.001) were also higher in the mitral regurgitation group. With a total score > or = 10 as a cutoff point for predicting severe mitral regurgitation after percutaneous mitral valvulotomy, a sensitivity of 90 +/- 5% and a specificity of 97 +/- 3% were obtained. Stepwise logistic regression analysis identified the mitral regurgitation echocardiographic score as the only independent predictor for developing severe mitral regurgitation after percutaneous mitral valvulotomy (p < 0.0001).

CONCLUSIONS

This new mitral regurgitation echocardiographic score can predict the development of severe mitral regurgitation after percutaneous mitral valvulotomy and can be useful in the selection of patients for this technique.

Regulation of tyrosine hydroxylase and tetrahydrobiopterin biosynthetic enzymes in PC12 cells by NGF, EGF and IFN-gamma

The regulation of catecholamine and tetrahydrobiopterin synthesis was investigated in cultured rat pheochromocytoma PC12 cells following treatments with nerve growth factor (NGF), epidermal growth factor (EGF) and interferon-gamma (IFN-gamma). NGF and EGF, but not IFN-gamma, caused an increase after 24 h in the levels of BH4 and catecholamines, and the activities of tyrosine hydroxylase and GTP cyclohydrolase, the rate-limiting enzymes in catecholamine and BH4 synthesis, respectively. Actinomycin D, a transcriptional inhibitor, blocked treatment-induced elevations in tyrosine hydroxylase and GTP cyclohydrolase activities. NGF, EGF or IFN-gamma did not affect the activity of sepiapterin reductase, the final enzyme in BH4 biosynthesis. Rp-cAMP, an inhibitor of cAMP-mediated responses, blocked the induction of tyrosine hydroxylase by NGF or EGF; inhibition of protein kinase C partially blocked the EGF effect, but not the NGF effect, NGF also induced GTP cyclohydrolase in a cAMP-dependent manner, while the EGF effect was not blocked by Rp-cAMP or protein kinase C inhibitors. Sphingosine induced GTP cyclohydrolase in a protein kinase C-independent manner without affecting tyrosine hydroxylase activity. Our results suggest that both tyrosine hydroxylase and GTP cyclohydrolase are induced in a coordinate and transcription-dependent manner by NGF and EGF, while conditions exist where the induction of tyrosine hydroxylase and GTP cyclohydrolase is not coordinately regulated.

Three-dimensional echocardiography: the influence of number of component images on accuracy of left ventricular volume quantitation

One approach to three-dimensional echocardiography is to reconstruct the surface of cardiac structures from two-dimensional images positioned in three-dimensional space. This approach has yielded accurate measures; however, the relationship between the number of nonparallel images used in three-dimensional echocardiographic reconstruction to the accuracy of the volume calculated has not been determined. With a canine model in which instantaneous left ventricular volume could be measured in vivo, images were obtained from intersecting long- and short-axis scans and stored with their spatial coordinates. The left ventricle was reconstructed and its volume calculated. The difference between three-dimensional echocardiographic and true volume was determined in 84 different cavitary volumes (4 to 85 ml). In each case, long- and short-axis images were deleted serially from the original data set (maximum of 27) until there were only three images left in the reconstruction. After each set of deletions, left ventricular volume was recalculated with the remaining images. Three-dimensional echocardiography accurately quantified ventricular volume with eight to 12 intersecting images, with a mean error of less than 1 ml and an SD of 5 ml. With a reduction of component images below eight, there were progressive increases in both absolute and mean percentage error. Accurate assessment of stroke volume and ejection fraction in this beating heart model also required eight to 12 images. Left ventricular volume and systolic function can be quantitated by three-dimensional echocardiography with as few as eight to 12 intersecting or nonparallel images.

In vitro assessment of prosthetic valve function in mitral valve replacement with chordal preservation techniques

BACKGROUND AND AIM OF THE STUDY

The importance of chordal preservation techniques in maintaining improved left ventricular function after mitral valve replacement has been well documented clinically. Currently, the choice of prosthetic valve used in chordal preservation is dependent upon the surgeon's preference. However, the transvalvular flow characteristics of common, clinically used prosthetic valves may be influenced by the mitral subvalvular apparatus, and may result in degraded valve function. The goal of this study was to perform an in vitro evaluation of the influence of chordal preservation on the transvalvular and left ventricular flow patterns of common valve prostheses.

METHODS

Tissue and mechanical valves have been evaluated under physiologic pulsatile flow with anterior and/or posterior chordal preservation. Flow patterns were assessed by 2-D planar flow visualization, pulsed wave Doppler velocity measurements, 2-D echocardiography, and selected color Doppler flow mapping. Based on changes in transvalvular and left ventricular flow patterns, favorable prosthetic valve/chordal preservation combinations were identified. Additionally, valve orientation was varied to determine optimal orientation.

RESULTS

Baseline results without chordal preservation indicate that the anti-anatomic orientation is preferred for the bileaflet valve design while the tilting disc valve should be oriented with the major axis toward the posterior (free) wall of the ventricle, corroborating published conclusions by other investigators. Some form of flow restriction is observed in all test cases with chordal preservation due to the presence of the subvalvular tissue. In general, bioprostheses showed less flow restriction then the mechanical valves, particularly with lateral flow expansion. This flow restriction may influence pressure recovery downstream of the mechanical valves tested. Increased flow constriction is observed with anterior and posterior chordal preservation.

CONCLUSIONS

This study favors the use of the St. Jude Medical bileaflet valve orientated in the anti-anatomic position, or the Carpentier-Edwards pericardial valve with chordal preservation.

Quantitative three-dimensional reconstruction of left ventricular volume with complete borders detected by acoustic quantification underestimates volume

Recently a new acoustic-quantification (AQ) technique has been developed to provide on-line automated border detection with an integrated backscatter analysis. Prior studies have largely correlated AQ areas with volumes without direct comparison of volumes for agreement. By using complete AQ-detected borders as the input to a validated method for three-dimensional echocardiographic (3DE) reconstruction, we can compare an entire cavity volume measured with the aid of AQ against a directly measured volume. This would also explore the possibility of applying AQ to 3DE reconstruction to reduce tracing time and enhance routine applicability. To compare reconstructed volumes with actual values in a stable standard allowing direct volume measurement, the left ventricles of 13 excised animal hearts were studied with a 3DE system that automatically combines two-dimensional (2D) images and their locations. Intersecting 2D views were obtained with conventional scanning and AQ imaging, with gains optimized to permit 3D reconstruction by detecting the most continuous AQ borders for each view, with maximal cavity size. Reconstruction was performed with manually traced central endocardial reflections and AQ-detected borders visually reproduced the left ventricular shapes; the AQ reconstructions, however, were consistently smaller. The reconstructed left ventricular (LV) volumes correlated well with actual values by both manual and AQ techniques (r = 0.93 and 0.88, with standard errors of 2.3 cc and 2.0 cc, p = not significant [NS]). Agreement with actual values was relatively close for the manually traced borders (y = 0.93x + 0.68, mean difference = -0.8 +/-2.2 cc). AQ-derived reconstructions consistently underestimated LV volume by 39 +/- 10% (y = 0.62x-0.09, mean difference = -7.8 +/- 3.0 cc, different from manually traced and actual volumes by analysis of variance [ANOVA], F = 69, p<0.00001). The AQ-detected threshold signal was displaced into the cavity, and volume between walls and false tendons was excluded, leading to underestimation, which increased with increasing cavity volume (r = 0.76). The AQ technique can therefore be applied to 3DE reconstruction, providing volumes that correlate well with directly measured values in a stable in vitro standard, minimizing observer decisions regarding manual border placement after image acquisition. However, when the complete borders needed for 3D reconstruction are used, absolute volumes are underestimated with current algorithms that integrate backscatter and displace the detected threshold into the ventricular cavity.

New insights into the reduction of mitral valve systolic anterior motion after ventricular septal myectomy in hypertrophic obstructive cardiomyopathy

To determine the mechanism of reduction of mitral valve systolic anterior motion by myectomy, we examined 33 patients with hypertrophic obstructive cardiomyopathy echocardiographically before and after myectomy. Measurements included outflow tract diameter, the direction of ejection streamline (the angle between the ejection flow and the mitral valve), midventricular fractional area change, and papillary muscle inward excursion in the short-axis image. After myectomy, the outflow tract was enlarged (from 1.2 +/- 0.3 cm to 2.1 +/- 0.4 cm; p < 0.001), and the ejection flow became more parallel to mitral leaflets (from 51 +/- 10 degrees to 28 +/- 8 degrees; p < 0.001), whereas hyperdynamic midventricular fractional area change was reduced (81% +/- 14% to 62% +/- 14%; p < 0.001), and papillary muscle excursion decreased (1.3 +/- 0.3 cm to 0.8 +/- 0.3 cm; p < 0.001). Outflow enlargement and reduced ventricular contraction would decrease the Venturi force. Change of ejection streamline and reduced contraction would decrease the drag force onto the mitral leaflets. Blunted papillary motion would increase the mitral leaflet tension and decrease the effect of drag force on both leaflets. Thus myectomy decreases Venturi and drag forces and appears to reduce systolic anterior motion of the mitral valve.

Intracardiac echocardiography: in vitro and in vivo validation for right ventricular volume and function

To determine the feasibility and accuracy of intracardiac ultrasonography (ICUS) for the measurement of right ventricular (RV) volumes and function, a 10 MHz ICUS catheter was used in an in vitro and in vivo model. In the in vitro study, 16 sheep hearts were imaged. Sequential cross-sectional images from RV apex to base were recorded during a calibrated pullback. Volumes were calculated by applying Simpson's algorithm. ICUS-obtained volumes correlated well with actual volumes (standard error of estimate [SEE] = 2.3 ml, r = 0.98). For the in vivo study, a beating-heart canine model was used (31 hemodynamic stages in six dogs). Actual volumes were measured by an intracavitary balloon connected to an external column. Sequential cross-sectional images were recorded during the ICUS catheter pullback from apex to base of the RV, and volumes calculated by Simpson's algorithm. Good correlations were observed between ICUS and actual values for diastolic (SEE = 4.1 ml, r = 0.97), systolic (SEE = 3.4 ml, r = 0.96), and ejection fraction (SEE = 3.1%, r = 0.87) values. This new technique can accurately quantitate RV volumes, can function both in vitro and in vivo, and has the potential for increasing applications to questions of clinical and research interest.

Mitogenic effects of tetrahydrobiopterin in PC12 cells

(6R)-5,6,7,8-Tetrahydrobiopterin (BH4), which is synthesized intracellularly from GTP, caused a concentration-dependent increase in rat pheochromocytoma (PC12) cell proliferation when added exogenously. Incubation with sepiapterin, which is converted enzymatically to BH4 within cells, also increased PC12 cell proliferation and BH4 levels concomitantly. These sepiapterin effects were mediated by BH4 as inhibition of sepiapterin conversion to BH4 by a sepiapterin reductase inhibitor, N-acetyl-serotonin, blocked the increase in proliferation and the elevation of BH4 levels. 7,8-Dihydrobiopterin (BH2) also increased BH4 levels and PC12 cell proliferation, both of which were reversed by methotrexate, which blocks the conversion of BH2 to BH4 by dihydrofolate reductase. The BH4-induced increase in PC12 cell proliferation was not related to elevated catecholamine or nitric oxide synthesis as inhibitors of tyrosine hydroxylase or nitric oxide synthase did not reduce the BH4 effect. BH4 and its precursors did not alter intracellular cAMP levels, suggesting that this second messenger is not involved in the enhancement of PC12 cell proliferation by BH4. Sepiapterin and BH4 also enhanced the proliferation of SV40-transformed human fibroblasts and rat C6 glioma cells, indicating that the stimulatory effect of BH4 on cell proliferation is not restricted to PC12 cells.

New method for accurate calculation of regurgitant flow rate based on analysis of Doppler color flow maps of the proximal flow field. Validation in a canine model of mitral regurgitation with initial application in patients

OBJECTIVES

The purpose of this study was to develop a rational and objective method for selecting a region in the proximal flow field where the hemispheric formula for calculating regurgitant flow rates by the flow convergence technique is most accurate.

BACKGROUND

A major obstacle to clinical implementation of the proximal flow convergence method is that it assumes hemispheric isovelocity contours throughout the Doppler color flow map, whereas contour shape depends critically on location in the flow field.

METHODS

Twenty mitral regurgitant flow rate stages were produced in six dogs by implanting grommet orifices into the anterior mitral leaflet and varying driving pressures so that actual peak flow rate could be determined from the known effective regurgitant orifice times the orifice velocity. Because plotting flow rate calculated by using a hemispheric formula versus alias velocities produces underestimation near the orifice and overestimation far from it, this plot was fitted to a polynomial function to allow identification of an inflection point within a relatively flat intermediate zone, where factors causing overestimation and underestimation are expected to be unimportant or balanced. The accuracy of flow rate calculation by the inflection point was compared with unselective and selective averaging techniques. Clinical relevance, initial feasibility and correlation with an independent measure were tested in 13 consecutive patients with mitral regurgitation who underwent cardiac catheterization.

RESULTS

1) The accuracy of single-point calculations was improved by selecting points in the flat portion of the curve (y = 1.15x - 3.34, r = 0.87, SEE = 22.1 ml/s vs. y = 1.34x - 1.99, r = 0.71, SEE = 45.6 ml/s, p < 0.01). 2) Selective averaging of points in the flat portion of the curve further improved accuracy and decreased scatter compared with unselective averaging (y = 1.08x + 4.8, r = 0.96, SEE = 11.6 ml/s vs. y = 1.30x + 0.6, r = 0.90, SEE = 20.9 ml/s, p < 0.01). 3) The proposed algorithm for mathematically identifying the inflection point provided the best results (y = 0.96x + 4.5, r = 0.96, SEE = 9.9 ml/s), with a mean error of 1.6 +/- 9.7 ml/s vs. 11.4 +/- 11.7 ml/s for selective averaging (p < 0.01). In patients, the proposed algorithm identified an inflection point at which calculated regurgitant volume agreed best with invasive measurements (y = 1.1x - 0.61, r = 0.93, SEE = 17 ml).

CONCLUSIONS

The accuracy of the proximal flow convergence method can be significantly improved by analyzing the flow field mathematically to identify the optimal isovelocity zone before using the hemispheric formula to calculate regurgitant flow rates. Because the proposed algorithm is objective, operator independent and, thus, suitable for automatization, it could provide the clinician with a powerful quantitative tool to assess valvular regurgitation.

The effect of aortic outflow on the quantification of mitral regurgitation by the flow convergence method

The effect of aortic outflow on the quantification of mitral regurgitation by the flow convergence method was investigated by both in vitro experiments and computational simulations. Digital analysis of the color Doppler M-mode images was compared with results obtained with laser Doppler anemometry, an engineering gold standard, and three-dimensional computational simulations. Regurgitant orifices of 3.2 and 6.4 mm in diameter were used with instantaneous aortic flow rates from 0 to 500 ml/sec, corresponding to net cardiac outputs of 0 to 5 L/min. In the absence of aortic outflow, a clear plateau was observed in plots of the calculated flow rate as a function of the distance from the orifice, indicating that there was a zone in which the hemispheric assumption was valid. As the aortic outflow was increased, the length of this plateau region decreased and then disappeared at high aortic flow rates. Farther from the orifice, beyond the plateau zone, the flow rate was overestimated and this overestimation increased with increasing aortic flow rate. Results showed excellent agreement between in vitro experiments and computational stimulations. This study demonstrated that aortic outflow has a dramatic effect on the flow convergence region and therefore must be considered in flow rate calculations.

A model based on dimensional analysis for non-invasive quantification of valvular regurgitation under confined and impinging conditions

The most descriptive measure of valvular insufficiency is the regurgitant volume. Current techniques for measuring it, however, are invasive and semi-quantitative at best. Cape and colleagues have recently developed a non-invasive technique for the quantitation of regurgitant flows corresponding to free jets cases. This technique is, unfortunately, not applicable to cases of jets constrained and/or impinging on the atrial walls as observed in many cases of mitral regurgitation. The purpose of this paper was therefore to develop an equation based on dimensional analysis, for calculating peak regurgitant flow rates from quantities than can be measured by Doppler ultrasound/echocardiography. The result is an equation for flow rate, Qo, as a function of orifice velocity, Uo, a downstream centerline velocity, Um, at a distance, x, from the orifice, the diameter of the receiving chamber, Dc, and the impingement height, H: Qo = (pi Uo/4)[a(Uo/Um)HcDdc chi e][2/(c+d+e)], where a, c, d and e can be found by multiple linear regressions on pulsed Doppler jet centerline velocity data. The assumptions made in the derivation are such that they should be physiologically applicable. The advantage of this method compared to the previous one is its theoretical justification and ability to quantify accurately peak regurgitant flow rate, and total regurgitant volume.

Three-dimensional echocardiography improves noninvasive assessment of left ventricular volume and performance

To calculate left ventricular (LV) volume by two-dimensional echocardiography (2DE), assumptions must be made about ventricular symmetry and geometry. Three-dimensional echocardiography (3DE) can quantitate LV volume without these limitations, yet its incremental value over 2DE is unknown. The purpose of this study was to compare the accuracy of LV volume determination by 3DE to standard 2DE methods. To compare the accuracy of 3DE with standard 2DE algorithms for quantitating LV volume, 28 excised canine ventricles of known volume and varying shapes (15 symmetric and 13 aneurysmal) and 10 instrumented dogs prepared so that instantaneous ventricular volume could be measured were examined by 2DE (bullet and biplane Simpson's formulas) and again by 3DE. In both excised and beating hearts, 3DE was more accurate in quantitating volume than either 2DE method (excised: error = 0.6 +/- 3.2, 2.5 +/- 10.7, and 4.0 +/- 8.5 ml by 3D, bullet, and Simpson's, respectively; beating: error = -0.5 +/- 3.5, -0.3 +/- 9.6, and -7.6 +/- 8.0 ml by 3DE, bullet, and Simpson's, respectively). This difference in accuracy between 3DE and 2DE methods was especially apparent in asymmetric ventricles distorted by ischemia or right ventricular volume overload. Stroke volume and ejection fraction calculated by 3DE also demonstrated better agreement with actual values than the bullet or Simpson methods with less variability (ejection fraction: error = -2.0% +/- 5.1%, 7.7% +/- 8.5%, and 6.8% +/- 12.3% by 3DE, bullet, and Simpson's, respectively). In both in vitro and in vivo settings, 3DE provides improved accuracy for LV volume and performance than current 2DE algorithms.

Effects of cyclic adenosine monophosphate-dependent protein kinase and calcium-dependent protein kinase modulators on stimulated gastric acid secretion in the perfused rat stomach

The effects of cyclic adenosine monophosphate-dependent protein kinase (PKA) and calcium-dependent protein kinase (PKC) modulators on secretagogue-stimulated gastric acid secretion were studied in the continuously perfused stomach of the anesthetized rat. Intravenous histamine (0.25 mg/kg/h) and pentagastrin (2 micrograms/kg/h) increased secretion above baseline by three- and fourfold, respectively. Parenteral administration of a PKC activator, 12-o-tetradecanoylphorbol-13-acetate (TPA; 0.1 nmol/h), decreased histamine- and pentagastrin-stimulated secretion by 64 and 40%, respectively. Administration of PKC inhibitors, calphostin C and 1-(5-isoquinolinyl sulfonyl)-2 methylpiperazine (H-7; 10 nmol/h, each), increased histamine- and pentagastrin-stimulated secretion by 115 and 74% and 42 and 79%, respectively, while equimolar concentrations (10 nmol/h) of three other isoquinoline sulfonamides (HA-1004, H-8, and H-89) had no effect, except for H-89 (100 nmol/h) which inhibited the histamine- and penta-gastrin-stimulated acid secretion by 44%. Basal secretion was not significantly altered by the aforementioned drugs. The TPA-induced inhibition of pentagastrin-stimulated secretion was partially reversed by treatment with H-7. These findings support a role of PKA and PKC in the modulation of stimulated gastric acid secretion in vivo.