The oxygen supply of the human heart∗

Revolutionizing biomedical research: The imperative need for heart-kidney-connected organoids

Organoids significantly advanced our comprehension of organ development, function, and disease modeling. This Perspective underscores the potential of heart-kidney-connected organoids in understanding the intricate relationship between these vital organs, notably the cardiorenal syndrome, where dysfunction in one organ can negatively impact the other. Conventional models fall short in replicating this complexity, necessitating an integrated approach. By co-culturing heart and kidney organoids, combined with microfluidic and 3D bioprinting technologies, a more accurate representation of in vivo conditions can be achieved. Such interconnected systems could revolutionize our grasp of multi-organ diseases, drive drug discovery by evaluating therapeutic agents on both organs simultaneously, and reduce the need for animal models. In essence, heart-kidney-connected organoids present a promising avenue to delve deeper into the pathophysiology underlying cardiorenal disorders, bridging existing knowledge gaps, and advancing biomedical research.

Targeting fatty acid and carbohydrate oxidation--a novel therapeutic intervention in the ischemic and failing heart

Cardiac ischemia and its consequences including heart failure, which itself has emerged as the leading cause of morbidity and mortality in developed countries are accompanied by complex alterations in myocardial energy substrate metabolism. In contrast to the normal heart, where fatty acid and glucose metabolism are tightly regulated, the dynamic relationship between fatty acid β-oxidation and glucose oxidation is perturbed in ischemic and ischemic-reperfused hearts, as well as in the failing heart. These metabolic alterations negatively impact both cardiac efficiency and function. Specifically there is an increased reliance on glycolysis during ischemia and fatty acid β-oxidation during reperfusion following ischemia as sources of adenosine triphosphate (ATP) production. Depending on the severity of heart failure, the contribution of overall myocardial oxidative metabolism (fatty acid β-oxidation and glucose oxidation) to adenosine triphosphate production can be depressed, while that of glycolysis can be increased. Nonetheless, the balance between fatty acid β-oxidation and glucose oxidation is amenable to pharmacological intervention at multiple levels of each metabolic pathway. This review will focus on the pathways of cardiac fatty acid and glucose metabolism, and the metabolic phenotypes of ischemic and ischemic/reperfused hearts, as well as the metabolic phenotype of the failing heart. Furthermore, as energy substrate metabolism has emerged as a novel therapeutic intervention in these cardiac pathologies, this review will describe the mechanistic bases and rationale for the use of pharmacological agents that modify energy substrate metabolism to improve cardiac function in the ischemic and failing heart. This article is part of a Special Issue entitled: Mitochondria and Cardioprotection.

THE EFFECT OF NITROGLYCERIN ON LEFT VENTRICULAR WALL TENSION IN FIXED ORIFICE AORTIC STENOSIS

Symptoms of myocardial ischemia occur in aortic stenosis in the absence of coronary artery disease. Increased left ventricular wall tension, a principal determinant of myocardial oxygen requirements, may contribute to these symptoms. This investigation was undertaken during the course of transseptal left heart catheterization in order to study the effect of nitroglycerin on left ventricular wall tension in eight patients with fixed orifice aortic stenosis. In seven of the subjects, nitroglycerin significantly reduced tension-time index per beat and per minute. In addition, left ventricular size may have diminished as a consequence of lower diastolic filling pressure. In view of the relationship between wall tension and myocardial oxygen consumption, these effects should favorably influence the balance between oxygen availability and oxygen requirements in patients with fixed obstruction to left ventricular outflow. The eighth patient experienced an appreciable increase in tension-time index, suggesting secondary hypertrophic subaortic stenosis.

Myocardial energy production and consumption remain balanced during positive inotropic stimulation when coronary flow is restricted to basal rates in rabbit heart

The effect on myocardial energy balance of increasing oxygen demand without altering basal myocardial perfusion rate was assessed in isolated, isovolumic, retrograde blood perfused rabbit hearts. Myocardial energy requirements were increased with paired stimulation. The capacity of rapid paired stimulation to increase mechanical energy consumption was demonstrated in the presence of increased perfusion with the rate X pressure product and oxygen consumption increasing 86 and 148%, respectively, compared with control values. In contrast, rapid paired stimulation under constant, basal flow conditions did not alter the rate X pressure product, while oxygen extraction and consumption increased only 40% relative to control. Myocardial ATP, creatine-phosphate, and lactate content were identical under control and constant flow-paired stimulation conditions. The results of this study indicate that no detectable energy imbalance was produced by rapid paired stimulation with flow held constant at basal rates. These results suggest that the myocardium does not increase mechanical energy expenditure in response to inotropic or rate stimulation in the presence of restricted flow reserve and are inconsistent with the concept of "demand-induced" or "relative" myocardial ischemia.

Autologous blood perfusion for myocardial protection during coronary angioplasty: a feasibility study

During coronary angioplasty, inflation of the balloon within the coronary artery produces transient arterial occlusion and frequently results in myocardial ischemia. Delivery of oxygenated autologous blood to the myocardium at risk during inflation may help mitigate this ischemia. Accordingly, we investigated the feasibility and safety of infusing blood through the central lumen of a dilatation catheter around the guidewire using both a model in vitro and clinical trials. In the tests in vitro, fresh blood was infused at flow rates up to 120 ml/min. Hemolysis was minimal at flow rates of 60 ml/min or less (less than or equal to 0.92 +/- 0.18%), but increased exponentially at higher rates (13.64 +/- 2.37% at 120 ml/min, p less than .002). A similar pattern was observed for potassium release. Platelet and leukocyte counts did not vary significantly, and beta-thromboglobulin and muramidase remained at control levels. Although mean erythrocyte volume did not change, erythrocyte histograms and light microscopy demonstrated a subpopulation of red cell fragments averaging 25 to 40 fl in size at higher rates. A randomized, crossover clinical trial was next performed by delivery of blood perfusion at 60 ml/min to 15 patients undergoing coronary angioplasty. Levels of plasma hemoglobin, beta-thromboglobulin, lactate dehydrogenase, and potassium remained constant before and after the perfusion and the control inflations. The maximum pain score was significantly lower with the perfusion inflation (4.1 +/- 0.8 vs 6.0 +/- 0.9, p less than .003). Relative to baseline, the maximum ST segment elevation during the perfusion inflation (0.5 +/- 0.3 mm) was nearly one-fourth that during the control inflation (1.9 +/- 0.6 mm, p less than .02). Thus, myocardial protection with oxygenated autologous blood perfusion at rates of 60 ml/min appears to be a safe and effective technique that may permit increased inflation time and extend the range of coronary angioplasty to include individuals at high risk for the procedure.

The coronary circulation in human septic shock

Reversible myocardial depression, manifested by ventricular dilatation and decreased ejection fraction, is common in human septic shock. A proposed mechanism, based on animal studies, is myocardial ischemia resulting from inadequate coronary blood flow. Coronary flow observations have not been reported for human septic shock. To determine whether myocardial depression in human septic shock is associated with reduced coronary flow, thermodilution coronary sinus catheters were placed in seven patients with septic shock for measurements of coronary flow and myocardial metabolism. Four of the seven patients developed myocardial depression. These patients had coronary flow similar to or higher than that of control subjects and similar to that of the other three patients, who did not develop myocardial depression. None of the patients had net myocardial lactate production. In general, compared with values in control subjects, the oxygen content difference (arterial minus coronary sinus) was narrowed, and the fractional extraction of arterial oxygen was diminished. This pattern of disordered coronary autoregulation is analogous to the pattern of arteriovenous shunting in other organs in patients with septic shock. The preservation of coronary flow, the net myocardial lactate extraction, and the increased availability of oxygen to the myocardium argue against global ischemia as the cause of myocardial depression in human septic shock.

Myocardial lactate metabolism: evidence of lactate release during net chemical extraction in man

Myocardial blood flow has been recognized to be heterogeneous in patients with coronary artery disease. Traditional arterial-coronary sinus sampling methods cannot demonstrate comparable heterogeneity of myocardial metabolism. In this study we used a tracer technique to investigate possible heterogeneity of myocardial lactate metabolism. Twenty-one patients with symptoms of ischemic heart disease were studied. We injected 14C-1-lactate intravenously as a constant infusion after a priming dose. Coronary sinus and arterial samples were obtained for chemical and radioisotopic analyses. At rest, myocardial lactate extraction by chemical analysis was 24.6 +/- 8.5% (mean +/- SD). By radioisotopic analysis, the lactate extraction was 41.0 +/- 10.2% (p less than 0.001). Thus, certain areas of the myocardium were releasing lactate despite global net extraction of lactate. In the 12 patients with significant left main or both left anterior descending (LAD) and left circumflex (LCX) lesions, the calculated amount of lactate released at rest was 0.136 +/- 0.045 mumol/ml of blood (mean +/- SD). In contrast, the amount released in the six patients with a significant lesion in only the LAD or LCX was 0.076 +/- 0.019 mumol/ml, and in the three patients without left coronary arterial lesions it was 0.039 +/- 0.004 mumol/ml. Using a tracer method, myocardial lactate metabolism was demonstrated to be heterogeneous at rest in patients with ischemic heart disease. A significant amount of lactate can be released by the myocardium at a time when chemical arterial-coronary sinus analysis indicates global myocardial extraction. The amount of lactate released appears to be related to the severity of the coronary artery disease.

The effect of adrenaline and noradrenaline on coronary vascular reserve in the dog

1. Experiments were performed on dogs, anaesthetized with pentobarbitone sodium to measure the oxygen utilization of anterior ventricular wall. The anterior interventricular vein was used for venous blood collection and flow measurement. 2. Oxygen contents of arterial blood and coronary vein were measured. 3. Intravenous (femoral vein) adrenaline infusions raised arterial blood pressure and caused an initial fall in oxygen extraction from control values of 67-45%. Noradrenaline caused an initial fall from 67 to 51%. With both, the oxygen extraction began to rise during the infusion and continued, reaching maximum levels, (mean -82%) 10 min after start of infusion. The range of maximum values for oxygen extraction ratio after noradrenaline was 76-95%. 4. An inverse linear relation was established between blood pressure and oxygen extraction; whereas a direct linear relationship was established between coronary venous blood flow and mean arterial pressure. 5. When a change in blood pressure was prevented, the oxygen extraction ratio rose. 6. In all experiments, whether extraction rose or fell, the oxygen consumption rose. 7. It is suggested that oxygen extraction is a controlled variable and, with coronary blood flow, contributes quantitatively to coronary vascular reserve. 8. The tension-time index was not directly related to oxygen consumption in these experiments. Oxygen consumption rose in response to catecholamines by about the same amount even when mean arterial blood pressure was controlled. It is suggested that cardiac adjustments to altered afterload may also involve alterations in mechanical efficiency.

The relationship between regional myocardial perfusion at rest and arteriographic lesions in patients with coronary atherosclerosis

Measurements of mean left ventricular (LV) and regional myocardial blood flow rates were made at rest in 161 patients with 133Xe and a multiplecrystal scintillation camera. Myocardial perfusion rates were correlated with assessments of the degree of coronary artery disease made from the arteriograms obtained during the same studies. In patients with normal coronary arteries without heart failure, the presence of hypertension, aortic stenosis, or aortic insufficiency was not associated with changes in mean LV perfusion from the control value of 61+/-7 ml/100 g-min. However, mean LV perfusion was significantly reduced in patients with normal coronary arteries who had cariomyopathy and impaired ventricular performance. Mean LV perfusion was not significantly different from control values in patients with "mild" coronary artery disease (less than 50% obstruction) or in patients with significant isolated disease (greater than 50% obstruction) of the left anterior descending (lad) artery. Significant reductions in mean LV perfusion were found in patients with greater than 50% obstruction of two coronary arteries (LAD + right or LAD + circumflex) and in patients with triple-vessel disease. The average perfusion rate for regions distal to LAD obstructions in patients with isolated LAD disease was not lower than the LAD perfusion in control patients, but was significantly reduced in patients with LAD + right coronary artery disease (43+/-14 ml/100 g-min). In the latter group average perfusion distal to the LAD lesion was significantly lower than the average regional perfusion rate for the remainder of the LV. However, the mean blood flow rate for the remainder of the LV was also significantly lower than control values despite the lack of significant circumflex disease. The data demonstrate that the presence of radiographically "mild" or significant isolated LAD coronary disease is not associated with reductions in mean LV perfusion at rest, but that mean LV perfusion is reduced in the presence of significant disease of two or three coronary artieries. None of the patients experienced angina during the resting studies and most had clinical evidence of ventricular failure. The observation of depressed LV perfusion in this group, as in the patients with cardiomyopathy, raises the possibility that a lowered resting blood supply may be adequate for a reduced level of performance of a diseased ventricle. The lack of selective reductions of regional perfusion at rest in the majority of the patients with LAD lesions suggests that regional myocardial blood flow must be measured during an intervention which increases myocardial oxygen consumption in order to assess the physiological significance of lesions which are observed at coronary arteriography.

[Value and limitations of coronary blood flow measurement in man (author's transl)]

Attempts to measure coronary blood flow in man have made considerable progress during the last 25 years. The major techniques are based on the direct or indirect Fick principle; coronary flow is calculated from the arterio-coronary venous difference of inert gases or from the precordial recorded disappearance curve of radioactive gases or substances. The accuracy of the techniques depends upon the properties or the indicators used and the precision of their determination. All techniques applied hitherto are intricate and unsuitable for general use. -A lot of information is obtained about coronary circulation in health and disease by coronary flow measurements in man. Further studies in this field may influence pathophysiological and clinical concepts especially concerning coronary heart disease.

Myocardial blood flow and oxygen consumption in man early after valve replacement

Twenty-one patients without demonstrable coronary artery disease have been studied in the first 48 hours after aortic or mitral valve replacement to determine the possible contribution of abnormalities of left ventricular myocardial blood flow and oxygen consumption to the impaired cardiac performance which is sometimes evident in such patients. In the 14 patients making an uneventful recovery (group A), the mean value for left ventricular coronary blood flow (Kety-Schmidt method) in each study period was between 105.9 and 111.2 ml·min –1 ·100 g –1 , and myocardial oxygen consumption between 11.1 and 12.7 ml·min –1 ·100 g –1 , both being higher than in normal resting man. Oxygen extraction was 59 to 69%, and coronary sinus oxygen tension 23 to 29 mm Hg. Lactate extraction was normal. Five patients (group B) required pharmacologic support because of low cardiac output; all had undergone mitral valve replacement. In them, left ventricular coronary blood flow and oxygen consumption were the same as in group A; however, oxygen extraction was greater (68 to 79%), coronary sinus oxygen tension lower (22 to 24 mm Hg) and lactate extraction lower. Patients in group A who underwent mitral replacement (N = 4) had systemic and coronary hemodynamics and metabolism that were as satisfactory as those undergoing aortic replacement, except that left atrial pressure was higher in the first study period. When heart rate was increased from 100 to 128 beats/minute by pacing in five patients in group A, and in two additional patients, myocardial oxygen consumption increased significantly, but in four patients coronary blood flow failed to increase, oxygen extraction increased, and coronary sinus oxygen levels decreased. We conclude that in patients such as those we studied, low cardiac output postoperatively is not the result of low total left ventricular coronary blood flow or myocardial oxygen supply, but may occur in some of these patients at this time from low or absent coronary reserve and added stresses such as those from tachycardia may be met only with the potentially detrimental mechanism of increasing oxygen extraction and reducing coronary venous and myocardial oxygen levels.

Mechanochemistry of cardiac muscle. IV. Utilization of high-energy phosphates in experimental heart failure in cats

This investigation was designed to determine whether a defect in energy utilization exists in heart failure. Accordingly, the direct conversion of chemical energy to mechanical work was studied in right ventricular papillary muscles from normal cats and cats with experimental right ventricular failure secondary to pulmonary artery constriction. Energy production was inhibited by iodoacetic acid and N 2 . After resting or performing variable amounts of internal contractile element work under isometric conditions, muscles were instantly frozen, and the total amount of chemical energy (∼ P = creatine phosphate + ATP) used was correlated with work performed and the number of contractions. The contractile properties of papillary muscles from cats with heart failure were severely depressed. There was a significant depression in initial ∼P stores in muscles from cats with heart failure, but there was no significant change in the resting rate of ∼P utilization. Although the muscles from cats with heart failure performed, on the average, 13% as much work and were activated 64% as many times, the average amount of energy used was only 7% of that used by normal muscles. It is concluded that in this form of experimentally produced heart failure the utilization of ∼P is reduced but only in relation to the reduction in contractile element work and that the direct conversion of chemical energy to mechanical work is not an inefficient process in this state.

Myocardial oxygen consumption in acute experimental cardiac depression

Myocardial oxygen consumption (MV · o 2 ) during drug-induced cardiac depression was measured in 8 anesthetized, open chest dogs in which myocardial wall tension was controlled. The right side of the heart was bypassed and myocardial contractility was reduced with procaine HCl, propranolol, or pronethalol. MV · o 2 consistently fell during cardiac depression (avg = 1.52 ml/min per 100 g left ventricle or - 11.6%). These reductions occurred despite small increases in developed tension. Changes in the tension-time index, contractile element work, and contractile element power did not correlate invariably with ΔMV · o 2 , while reductions in velocity of the contractile elements at isotension, maximum left ventricular dp/dt, and the extent of shortening of the contractile elements and circumferential fibers were associated in every experiment with the reductions in MV · o 2 . The finding that negative inotropic influences are associated with a reduction in myocardial energy utilization, when considered with earlier observations showing that positive inotropic influences induce an augmentation of MV · o 2 , provides evidence that the inotropic state and its mechanical correlates are coupled with myocardial energy utilization by a mechanism that is independent of tension development.

Effect of Exercise on Cardiac Performance in Human Subjects with Coronary Artery Disease

Cardiac performance and oxygenation have been studied in resting and exercising subjects with coronary artery disease. Disturbances exist in myocardial function and energetics, characterized by preservation of pressure development, but with impaired systolic ejection and failure to increase mechanical efficiency during exercise. Resultant elevation of myocardial oxygen need by impaired performance undoubtedly aggravates coronary reserve inadequacy during exercise.