Myocardial lesions in idiopathic and alcoholic cardiomyopathy. Study by ventricular septal biopsy

Sudden Cardiac Death in Young Individuals: A Current Review of Evaluation, Screening and Prevention

Sudden cardiac death (SCD) can affect all age groups, including young persons. While less common in the age < 35 population, the occurrence of SCD in the young raises concern, with multiple possible etiologies and often unanswered questions. While coronary artery disease is the leading cause in those > 35 years of age, the younger population faces a different subset of pathologies associated with SCD, including arrhythmias and cardiomyopathies. The tragic nature of SCD in the young entails that we explore and implement available screening methods for this population, and perform the necessary investigations such as electrocardiography (ECG) and echocardiography. In this review, we not only explore the vast etiology associated with SCD in those age < 35, but emphasize evaluation methods, who is at risk, and delve into screening of SCD in potential victims and their family members, in an attempt to prevent this traumatic event. Future research must work towards establishing preventative measures in order to reduce SCD, particularly unexplained SCD in the young.

Sudden cardiac death-update

Sudden cardiac death (SCD) is one of the most common causes of death worldwide with a higher frequency especially in the young. Therefore, SCD is represented frequently in forensic autopsy practice, whereupon pathological findings in the heart can explain acute death. These pathological changes may not only include myocardial infarction, coronary thrombosis, or all forms of myocarditis/endocarditis but also rare diseases such as hereditary structural or arrythmogenic anomalies, lesions of the cardiac conduction system, or primary cardiac tumours.

Impact of chronic alcohol ingestion on cardiac muscle protein expression

BACKGROUND

Chronic alcohol abuse contributes not only to an increased risk of health-related complications, but also to a premature mortality in adults. Myocardial dysfunction, including the development of a syndrome referred to as alcoholic cardiomyopathy, appears to be a major contributing factor. One mechanism to account for the pathogenesis of alcoholic cardiomyopathy involves alterations in protein expression secondary to an inhibition of protein synthesis. However, the full extent to which myocardial proteins are affected by chronic alcohol consumption remains unresolved.

METHODS

The purpose of this study was to examine the effect of chronic alcohol consumption on the expression of cardiac proteins. Male rats were maintained for 16 weeks on a 40% ethanol-containing diet in which alcohol was provided both in drinking water and agar blocks. Control animals were pair-fed to consume the same caloric intake. Heart homogenates from control- and ethanol-fed rats were labeled with the cleavable isotope coded affinity tags (ICAT). Following the reaction with the ICAT reagent, we applied one-dimensional gel electrophoresis with in-gel trypsin digestion of proteins and subsequent MALDI-TOF-TOF mass spectrometric techniques for identification of peptides. Differences in the expression of cardiac proteins from control- and ethanol-fed rats were determined by mass spectrometry approaches.

RESULTS

Initial proteomic analysis identified and quantified hundreds of cardiac proteins. Major decreases in the expression of specific myocardial proteins were observed. Proteins were grouped depending on their contribution to multiple activities of cardiac function and metabolism, including mitochondrial-, glycolytic-, myofibrillar-, membrane-associated, and plasma proteins. Another group contained identified proteins that could not be properly categorized under the aforementioned classification system.

CONCLUSIONS

Based on the changes in proteins, we speculate modulation of cardiac muscle protein expression represents a fundamental alteration induced by chronic alcohol consumption, consistent with changes in myocardial wall thickness measured under the same conditions.

Sex-dependent differences in the regulation of myocardial protein synthesis following long-term ethanol consumption

Chronic heavy alcohol consumption alters cardiac structure and function. Controversies remain as to whether hearts from females respond to the chronic ethanol intake in a manner analogous to males. In particular, sex differences in the myocardial response to chronic alcohol consumption remain unresolved at the molecular level. The purpose of the present set of experiments was to determine whether alterations in cardiac structure and protein metabolism show sexual dimorphism following chronic alcohol consumption for 26 wk. In control animals, hearts from female rats showed lowered heart weights and had thinner ventricular walls compared with males. The smaller heart size was associated with a lower protein content that occurred in part from a reduced rate of protein synthesis. Chronic alcohol consumption in males, but not in females, caused a thinning of the ventricular wall and intraventricular septum, as assessed by echocardiography, correlating with the loss of heart mass. The alterations in cardiac size occurred, in part, through a lowering of the protein content secondary to a diminished rate of protein synthesis. The decreased rate of protein synthesis appeared related to a reduced assembly of active eukaryotic initiation factor (eIF)4G.eIF4E complex secondary to both a diminished phosphorylation of eIF4G and increased formation of inactive 4Ebinding protein (4EBP1).eIF4E complex. The latter effects occurred as a result of decreased phosphorylation of 4EBP1. None of these ethanol-induced alterations in hearts from males were observed in hearts from females. These data suggest that chronic alcohol-induced impairments in myocardial protein synthesis results, in part, from marked decreases in eIF4E.eIF4G complex formation in males. The failure of female rats consuming ethanol to show structural changes appears related to the inability of ethanol to affect the regulation protein synthesis to the same extent as their male counterparts.

Long-term alcohol administration inhibits synthesis of both myofibrillar and sarcoplasmic proteins in heart

Alcohol decreases the rate of protein synthesis in cardiac muscle. We investigated the effects of feeding rats a diet containing alcohol for 16 weeks on the myocardial synthesis of myofibrillar and sarcoplasmic (non-myofibrillar) proteins. Alcohol administration decreased the overall rate of protein synthesis in cardiac muscle by 22% compared with controls (P < .05). The rate of synthesis of proteins in the myofibrillar and sarcoplasmic fractions was diminished proportionately after feeding a diet containing alcohol (P < .05). We examined the effects of diminished rates of protein synthesis on the expression of myofibrillar and non-myofibrillar proteins. The cellular content of actin and alpha -myosin heavy chain isoform was significantly reduced and there was an increase in the beta -myosin heavy chain isoform after feeding rats a diet containing alcohol. The reduced expression of myosin heavy chain isoform and actin did not result from a decreased abundance of messenger RNA for either of these proteins. The myocardial content of troponin C and T was unchanged whereas that of troponin I was increased. Ethanol administration reduced the expression of eEF2 and the inducible form of the 70-kDa heat shock protein, whereas the cognate form of the 70-kDa heat shock protein was unaffected in a non-myofibrillar-enriched fraction of cardiac muscle. These results suggest that (1) the reduced protein content observed in the heart after feeding a diet containing alcohol is a consequence of reduced synthesis of both myofibrillar and sarcoplasmic proteins, and (2) the expression of both actin and alpha-myosin heavy chain isoform is affected independently of the messenger RNA content of the proteins. We conclude that translational control mechanisms appear to be important in regulating the expression of myocardial proteins during long-term ethanol intoxication.

Chronic effects of ethanol on cultured myocardial cells: ultrastructural and morphometric studies

Ultrastructural alterations of the myocardium due to chronic ethanol exposure were investigated using an in vitro system-mouse ventricular myocardial cells in a monolayer culture, which were spontaneously and synchronously contracting-by chronic exposure to 12.5, 50, and 200 mM ethanol for up to 21 days. Morphometric analyses revealed that exposure to 12.5 mM ethanol for 14 days induced an increase in the number of residual bodies, which are lysosomes containing electron-dense, amorphous materials. Some cells exposed to 50 mM ethanol for 14 days contained an accumulation of glycogen granules, increasing in inverse proportion to the mitochondrial volume. The volumetric proportion of myofibrils on day 14 decreased as the ethanol dose became lower, and was in proportion to large and giant mitochondria within the limits of three ethanol groups. Dose-dependent increases in the size and volumetric proportion of mitochondria were observed after the 14-day exposure; at a low dose (12.5 mM) mitochondria of usual size tended to increase, whereas at a high dose (200 mM) giant mitochondria increased. Coincidentally with this mitochondrial increase or gigantism, all ethanol groups showed higher beat rates than the control. Consequently, it is most likely that chronic 14-day exposures to these three ethanol doses remodel the cellular function of the in vitro myocardium in different ways; the 200-mM dose induced mitochondrial hypertrophy, an adaptive response to switch myocardial energy metabolism over to some special one; the 50-mM dose was a boundary dose; and the 12.5-mM dose mostly mimicked the chronic in vivo administration of ethanol and induced slightly degenerative alterations-increased residual bodies and lysosomes, decreased myofibrils and lowered mitochondrial respiratory function.

Alcoholic cardiomyopathy versus chronic myocarditis--immunohistological investigations with LCA, CD3, CD68 and tenascin

Dilated cardiomyopathy (DCM) is a disorder of unknown aetiology characterized by the left ventricular cavity enlargement and wall thinning associated with reduced left ventricular wall motion. DCM in chronic alcoholics is supposed to be caused by alcohol induced myocardial damage (alcoholic cardiomyopathy). Nevertheless, cardiotropic viruses, such as enteroviruses have long been suspected as causative agents for at least some forms of DCM. In the present study, 13 cases of DCM in chronic alcoholics were investigated with qualification and quantification of infiltrating leucocytes using immunohistological antibodies against leucocyte common antigen (LCA), T-lymphocytes (CD3) and macrophages (CD68). In addition, the expression of tenascin, playing a role in the initiation of fibrotic changes, was examined. All antigens were known to be possibly enhanced in cases of chronic myocarditis. Using these immunohistological techniques, 2 out of 13 cases had evidence for chronic inflammatory myocardial alterations in the sense of lymphocytic infiltrates (>2.0 CD3 T-lymphocytes/visual field at 400 x (HPF); >7 CD3 T-lymphocytes per mm(2)). These cases were diagnosed as having inflammatory cardiomyopathy. The other cases without myocardial inflammation were diagnosed as idiopathic/alcoholic DCM.

Effects of chronic alcohol consumption on regulation of myocardial protein synthesis

Heart disease represents an important etiology of mortality in chronic alcoholics. The purpose of the present study was to examine potential mechanisms for the inhibitory effect of chronic alcohol exposure (16 wk) on the regulation of myocardial protein metabolism. Chronic alcohol feeding resulted in a lower heart weight and 25% loss of cardiac protein per heart compared with pair-fed controls. The loss of protein mass resulted in part from a diminished (30%) rate of protein synthesis. Ethanol exerted its inhibition of protein synthesis through diminished translational efficiency rather than lower RNA content. Chronic ethanol administration decreased the abundance of eukaryotic initiation factor (eIF)4G associated with eIF4E in the myocardium by 36% and increased the abundance of the translation response protein (4E-BP1) associated with eIF4E. In addition, chronic alcohol feeding significantly reduced the extent of p70S6 kinase (p70(S6K)) phosphorylation. The decreases in the phosphorylation of 4E-BP1 and p70(S6K) did not result from a reduced abundance of mammalian target of rapamycin (mTOR). These data suggest that a chronic alcohol-induced impairment in myocardial protein synthesis results in part from inhibition in peptide chain initiation secondary to marked changes in eIF4E availability and p70(S6K) phosphorylation.

Alcohol myopathy: impairment of protein synthesis and translation initiation

Alcohol consumption leads to numerous morphological, biochemical and functional changes in skeletal and cardiac muscle. One such change observed in both tissues after either acute alcohol intoxication or chronic alcohol consumption is a characteristic decrease in the rate of protein synthesis. A decrease in translation efficiency appears to be responsible for at least part of the reduction. This review highlights advances in determining the molecular mechanisms by which alcohol impairs protein synthesis and places these observations in context of earlier studies on alcoholic myopathy. Both acute and chronic alcohol administration impairs translational control by modulating various aspects of peptide-chain initiation. Moreover, this alcohol-induced impairment in initiation is associated with a decreased availability of eukaryotic initiation factor (eIF) 4E in striated muscle, as evidenced by an increase in the amount of the inactive eIF4E.4E-BP1 complex and decrease in the active eIF4E.eIF4G complex. In contrast, alcohol does not produce consistent alterations in the control of translation initiation by the eIF2 system. The etiology of these changes remain unresolved. However, defects in the availability or effectiveness of various anabolic hormones, particularly insulin-like growth factor-I, are consistent with the alcohol-induced decrease in protein synthesis and translation initiation.

A comparative investigation into the effect of chronic alcohol feeding on the myocardium of normotensive and hypertensive rats: an electrophoretic and biochemical study

We investigated whether the imposition of chronic alcohol in hypertension leads to greater biochemical and cellular abnormalities of the myocardium than those arising in normotension. Fifteen-week-old spontaneously hypertensive rats (SHR) and Wistar Kyoto (WKY) rats were fed ethanol-containing diets for six weeks. Particular attention was focused on the composition of contractile proteins identified by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE), fractional rate of protein synthesis, and synthesis rates relative to RNA (RNA activity) or DNA (cellular efficiency). In addition, myocardial enzymes and adenine nucleotides were measured. In both SHR and WKY rats chronic ethanol caused a general decrease in the contents of all nine contractile proteins with myosin heavy chain predominantly affected. Fractional rates of mixed (i.e., total) and myofibrillary proteins remained unaltered in both WKY rats and SHR, as were cellular efficiencies. The RNA activity was significantly reduced in ethanol-treated SHR but not in WKY rats. In ethanol-treated SHR, cardiac creatine kinase (CK) and malate dehydrogenase (MDH) activities were increased, AMP levels were elevated, whilst ATP levels and the energy charge were reduced. In WKY rats, the only significant change related to increased aspartate aminotransferase activities in response to alcohol feeding. Although there were only subtle differences between the response of the normotensive and hypertensive rats due to ethanol dosage, the reduced ATP levels and increased CK and MDH activities in SHR may reflect a greater susceptibility to ischaemic damage. Reduced contractile protein content, particularly myosin heavy chain, may contribute to contractile defects, a common feature of subclinical and clinical alcoholic cardiomyopathy.

Alcohol and the myocardium

Structural and functional abnormalities are prominent in alcoholic cardiomyopathy (ACM). Histological features in affected subjects are almost identical to the characteristics of dilated cardiomyopathy. Quantitative morphometry, however, can distinguish between ACM and dilated cardiomyopathy. Biopsies from patients with ACM show increases in the activities of some myocardial enzymes (alpha-hydroxybutyric dehydrogenase, creatine kinase, lactate dehydrogenase, malic dehydrogenase) which are correlated with the bimodal distribution of alcohol intake and may represent an adaptive response. One-third of patients with ACM have serum antibodies against cardiac acetaldehyde-protein adducts. Animal models of ethanol toxicity have shown that acutely, alcohol and acetaldehyde reduce the synthesis of cardiac contractile proteins in vivo. Two-dimensional SDS-PAGE has also shown that in rats chronically fed alcohol, the relative amounts of over 10% of heart muscle proteins are altered. The heat shock proteins (HSP) Hsp60 and Hsp70 are decreased in alcohol-fed rats, as is desmin. Reduction in HSPs may indicate reduced myocardial protection whilst a fall in desmin may indicate structural defects. In conclusion, ACM is a complex process that is due to altered protein synthesis, the formation of acetaldehyde adducts and a reduction of cardiac HSPs and desmin. Both acetaldehyde and alcohol are myocardial perturbants.

Ethanol-induced inhibition of ventricular protein synthesis in vivo and the possible role of acetaldehyde

We have determined the extent to which acute ethanol administration perturbs the synthesis of ventricular contractile and non-contractile proteins in vivo. Male Wistar rats were treated with a standard dose of ethanol (75 mmol kg-1 body weight; i.p.). Controls were treated with isovolumetric amounts of saline (0.15 mol l-1 NaCl). Two metabolic inhibitors of ethanol metabolism were also used namely 4-methylpyrazole (alcohol dehydrogenase inhibitor) and cyanamide (acetaldehyde dehydrogenase inhibitor) which in ethanol-dosed rats have been shown to either decrease or increase acetaldehyde formation, respectively. After 2.5 h, fractional rates of protein synthesis (i.e. the percentage of tissue protein renewed each day) were measured with a large (i.e. 'flooding') dose of L-[4-3H]phenylalanine (150 mumol (100 g)-1 body weight into a lateral vein). This dose of phenylalanine effectively floods all endogenous free amino acid pools so that the specific radioactivity of the free amino acid at the site of protein synthesis (i.e. the amino acyl tRNA) is reflected by the specific radioactivity of the free amino acid in acid-soluble portions of cardiac homogenates. The results showed that ethanol alone and ethanol plus 4-methylpyrazole decreased the fractional rates of mixed, myofibrillar (contractile) and sarcoplasmic (non-contractile) protein synthesis to the same extent (by approx. 25 per cent). Profound inhibition (i.e. 80 per cent) in the fractional rates of mixed, myofibrillar and sarcoplasmic protein synthesis occurred when cyanamide was used to increase acetaldehyde formation. There was also a significant decrease in cardiac DNA content. The results suggest that acute ethanol-induced cardiac injury in the rat may be mediated by both acetaldehyde and ethanol.

Myocardial levels of calcium, glycogen and triglycerides in ethanol-fed turkey poults treated with allopurinol

Effect of allopurinol treatment on myocardial levels of calcium, glycogen and triglyceride and on plasma levels of triglyceride was evaluated in turkey poults during a period of chronic ethanol consumption and following a period of ethanol abstinence. Allopurinol treatment had no significant effect on myocardial levels of calcium. Allopurinol treatment plus abstinence was slightly more effective than abstinence alone in restoring myocardial levels of glycogen and triglyceride and plasma levels of triglyceride in ethanol-fed poults to that seen in control poults.

Ethanol toxicity in primary cultures of rat myocardial cells

The potential cardiotoxicity of ethanol (EtOH) was evaluated in primary cultures of rat myocardial cells. EtOH cardiotoxicity was assessed in the cells on the basis of cell morphology, lactate dehydrogenase (LDH) leakage, succinate dehydrogenase (SDH) activity, and beating rates. Cells were treated with EtOH at concentrations of 600, 800, and 1000 mg% for duration of 1, 4, and 24 h and then evaluated for cardiotoxicity. Vacuole formation occurred 1 h after exposure to EtOH at 800 and 1000 mg%; by 4 h, cytosolic granular material appeared in these cells. Exposure for 24 h to all concentrations of EtOH resulted in vacuole, granule, and pseudopod formation and loss of cross-striations. Significant LDH leakage occurred at 1 h and 4 h with 800 and 1000 mg% EtOH. LDH release was significantly increased after 24 h with all concentrations. SDH activity was significantly depressed after 24 h with all concentrations of EtOH. Beating rates were altered as early as 1 h after exposure to 800 and 1000 mg% EtOH. After 24 h, those cells exposed to the highest concentrations of EtOH were not beating at all. These data suggest that primary myocardial cell cultures may be used to assess the in vitro cardiotoxicity of EtOH to the myocardial cell.

[Fatal poisoning by alcohol-free aniseed aperitif]

A case of chronic poisoning with alcohol-free "pastis" leading to the death of a 32 year old alcoholic patient is reported. The mean daily amount of ingested glycyrrhizinic acid was 0.35 g. "Torsades de pointes" secondary to severe hypokalemia were observed and prolonged cardiac arrest occurred. There was evidence of chronic hypokalemic myopathy and of rhabdomyolysis with acute renal failure. Furthermore, the origin of an associated cardiomyopathy is discussed.

Endomyocardial biopsy: a review of the literature

A review of the literature relating to endomyocardial biopsy (EMB) is presented. This is considered important at this time since EMB is being utilized with increasing frequency, particularly for the diagnosis of myocarditis. The development of the technique is briefly outlined. Emphasis is placed on the clinical application of EMB in the various primary cardiomyopathies (dilated, hypertrophic, restrictive, and obliterative), the infiltrative secondary cardiomyopathies (amyloidosis, sarcoidosis, hemochromatosis), myocarditis, as well as such conditions as adriamycin cardiotoxicity, cardiac transplant rejection, and Kawasaki disease. More controversial application of EMB in primary mitral valve prolapse (Barlow's syndrome), idiopathic ventricular arrhythmias, and the elucidation of the enigmatic finding of angina with angiographically normal coronary arteries is detailed. Experience with immunological and biochemical investigation of biopsy material, as well as with virus isolation and drug assays in the myocardium, is alluded to. Complications encountered with this procedure are also discussed, and its future role is contemplated.

Ultrastructural features of ethanol-induced cardiomyopathy in turkey poults

Alcoholic cardiomyopathy, characterized by cardiac hypertrophy, was induced in young turkey poults with 5% ethanol. Ultrastructural features included accumulation of glycogen, swollen mitochondria, myofibrillar lysis, increased number of lysosomes, dilated sarcoplasmic reticulum and dense myofibers. Similarity of these alterations to those described in human alcoholic cardiomyopathy confirms the usefulness of the turkey poult as an animal model for this disease syndrome.

Differentiating characteristics of myocardial nuclei in cardiomyopathy

Myocardial tissue obtained by endomyocardial biopsy was semiquantitatively evaluated for nuclear and nucleolar characteristics in six groups of patients: patients with normal cardiac function (group 1), doxorubicin-induced cardiomyopathy (group 2), idiopathic cardiomyopathy (group 3), alcoholic cardiomyopathy (group 4), post-viral cardiomyopathy (group 5), and chronic valvular heart disease (group 6). From each patient, ten nuclei containing nucleoli were examined and rated on the basis of the following characteristics: chromatin clumping, number of fibrillar centers per nucleolus, nucleolonemal structure, size of nucleolus, number of nucleoli per nucleus, and stage of nucleolar change. Mean values for the nuclear characteristics in each group were compared with normal values using the unpaired t test. In the doxorubicin treated group there were significantly increased chromatin clumping, decreased fibrillar centers, decreased nucleolonemal structure, and increased numbers of contracted nucleoli (indicating later stage). These changes may be linked to lowered nuclear and nucleolar activity. In the idiopathic and post-viral groups, characteristics were consistent with increased nuclear and nucleolar activity. There were no significant changes from normal in the nucleolar features of either the alcoholic or valvular groups. Further comparisons between groups using one-way analysis of variance and multivariate statistical analysis support the conclusion that there are significant differences in the nuclear and nucleolar characteristics of these groups.

Morphometric analysis of the rabbit myocardium after chronic ethanol feeding - early capillary changes

Male rabbits were fed with ethanol for 3 weeks. 10 ml of a 20% ethanol solution were applied daily with a stomach tube. The macroscopic, histologic and ultrastructural investigation of the hearts did not reveal and structural alterations. Morphometrically, the endothelial cells of the capillaries were changed, whereas the muscle cells did not show any abnormalities. The quantitative data indicate that the numerical density of endothelial cells is increased, whereas the volume density is not changed. This type of quantitative reaction pattern may be characterized as "proliferation" of endothelial cells. The proliferation is possibly related to ethanol-induced metabolic changes similar to chronic hypoxia. On the other hand, there is some evidence that the alteration is part of a general activation of mesenchymal cells in various organs after ethanol ingestion. The alteration is probably an early stage of the proliferation of capillaries.

Long-term benefit of dobutamine in patients with congestive cardiomyopathy

Dobutamine was given intravenously for three days to 38 patients with congestive cardiomyopathy. The patients were followed by serial determinations of functional class and by non-invasive measurements of left ventricular function-systolic time intervals (PEP/LVET) and echocardiogram (% delta D). The average PEP/LVET declined significantly (p < 0.001) at three days, four and nine weeks, and at 10 months after the discontinuation of dobutamine infusion. Also, 67% (20 of 30) of patients had improvement of the PEP/LVET by greater than -0.04 at seven days. Even two and six months after dobutamine, 58% (15 of 26) and 39% (seven of 18) were improved. Similarly, the % delta D was improved by at least 2% in 60% (18 of 30) at seven days and 55% (16 of 29) at four weeks. At two and six months, 50% (14 of 28) and 42% (10 of 24) were improved. Those patients who did not improve their FC were more likely (five of nine) to have left ventricular free wall thickness (by echocardiogram) less than 0.5 cm./M2. Those who responded usually (22 of 29) had a ventricular wall thickness greater than 0.5 cm./M2. Although the mechanism of the prolonged improvement after a three day infusion of dobutamine is not understood, this study suggests that dobutamine has a role in the therapy of chronic congestive heart failure.

Cardiac metabolsim: its contributions to alcoholic heart disease and myocardial failure

Changes in cardiac metabolism in myocardial failure and after alcohol ingestion are discussed. The main effect of alcohol ingestion is loss of cardiac contractility. Since heart muscle does not contain alcohol dehydrogenase, its toxicity is probably the result of a direct toxic effect of ethanol and acetaldehyde on the myocardial cell, possibly involving various membrane systems. Alcohol inhibits mitochondrial respiration and the activity of enzymes in the tricarboxylic acid cycle, and its interferes with both mitochondrial calcium uptake and binding. Ethanol profoundly affects myocardial lipid metabolism. Acetaldehyde diminishes myocardial protein synthesis and inhibits Ca++-activated myofibrillar ATPase. In myocardial failure, a series of possibilities may be responsible for the loss of contractility. Excitation-contraction coupling could be disturbed at the level of the sarcolemma, at the sarcoplasmic reticulum, at the mitochondria, and between calcium and the regulatory proteins. Deficiencies in Ca++ delivery systems of excitation-contraction coupling on the myosin ATPase activity could be responsible for the dimunition in cardiac contractility. Mitochondrial function may also be involved, since mitochondria from failing human hearts are defective with respect to respiratory control and calcium accumulation. Under certain conditions, the relationship of mitochondria to calcium sequestration is very important in influencing contractility. The involvement of contractile and regulatory proteins in myocardial failure cannot be excluded.

Cardiomyopathy in an adult with Bartter's syndrome and hypokalemia. Hemodynamic, angiographic and metabolic studies

A case of an adult with Bartter's syndrome (hyperplasia of the juxtaglomerular complex with hyperaldosteronism and hypokalemic alkalosis) is described; the patient had the unusual manifestation of cardiomyopathy, probably secondary to severe hypokalemia. Results of metabolic studies and kidney biopsy were consistent with Bartter's syndrome; angiographic and hemodynamic findings were abnormal. The cardiomyopathy was confirmed at autopsy after the patient's sudden death. Conclusions from this case are that severe hypokalemia can pose a serious threat both immediately in the form of dangerous arrhythmias and in the long term in the form of cardiomyopathy.

Intranuclear synthesized and native glycogen particles in human gastric cancer: ultrastructure and histochemistry

Ultrastructural and histochemical studies on human gastric cancer cells disclosed the presence of native and synthesized glycogen particles. The glycogen particles were investigated in the histochemical synthesis of glycogen particles from glucose 1-phosphate by the phosphorylase-branching glycosyltransferase system and non-incubated native glycogen in human gastric adenocarcinoma tubulare. It was observed that focal synthesis localized inthe intracytoplasmic matrix and intranucleus. Intranuclear synthesized glycogen appeared as a rosette form ranging from 1100 to 1300 A in diameter and free particles ranging from 325 to 900 A in diagmeter. The synthesis of glycogen appeared in the nucleus as well as in the cytoplasm of the human gastric cancer cells, and the synthesized glycogen was observed as a group of particles. Newly formed glycogen particles appeared occasionally in the interchromatin area as a large macromolecular structure of rosette form. Native glycogen appeared as a free-particle (250-333 A, medium =300 A) and aggregated rosette from (694-1050 A, medium=917 A) in the autophagosome of gastric cancer cells. There was not, however, a native glycogen particle in the nuclei of gastric cancer cells. Under certain conditons the nuclei of gastric cancer cells can acquire the capacity to synthesize glycogen.

Effectiveness and hazard of endomyocardial biopsy in dogs: comparison of two methods

Two different methods of endomyocardial biopsy were evaluated. Compared to the Konno bioptome, a technique using a biopsy forceps originally designed for fiberoptic bronchoscopy and bronchial biopsy, passed through a No. 9 Fr. end-hole catheter, was easier to perform. The biopsy device is smaller than the Konno bioptome, has sharper teeth, and is easier to clean. The two techniques did not differ in arrhythmogenicity, hemorrhagic changes in the myocardium, or distortion of the specimens. Ventricular tachycardia as defined by three beats in a row was observed in 34 per cent. Epicardial hemorrhage was seen in nine of 14 animals, and the specimen distortion rate was 43 per cent. In one animal, perforation of the right ventricle and hemopericardium occurred.

Severe alcoholic cardiomyopathy reversed with abstention from alcohol

In a chronic alcoholic with a severe congestive cardiomyopathy the angiographic and hemodynamic evidence of left ventricular dysfunction was completely reversed after 1 year of abstinence. At the time of initial presentation two of the traditional hallmarks of a poor prognosis were present, namely, a long exposure to alcohol before the onset of symptoms and severe diffuse left ventricular dilation and hypokinesis (ejection fraction 14.9 percent). Yet, today, 18 months later he is asymptomatic, receiving no medications and has normal left ventricular function. A reexamination of prognostic factors in alcoholic cardiomyopathy may be indicated.

Myocardial function and lipid metabolism in the chronic alcoholic animal

In view of the variables that obscure the pathogenesis of cardiomyopathy, a study was undertaken in mongrel dogs fed ethanol as 36% of calories for up to 22 mo. Both the experimental and control groups maintained body weight, hematocrit, plasma vitamin, and protein levels. Left ventricular function was evaluated in the intact anesthetized dog using indicator dilution for end-diastolic and stroke volume determinations. During increased afterload with angiotensin, the ethanol group exhibited a larger rise of end-diastolic pressure (P<0.01), whereas end-diastolic and stroke volume responses were significantly less than in controls. Preload increments with saline elicited a significantly higher end-diastolic pressure rise in the ethanol group (P<0.01). No hypertrophy, inflammation, or fibrosis was present and it was postulated that the enhanced diastolic stiffness was related to accumulation of Alcian Blue-positive material in the ventricular interstitium. To evaluate myocardial lipid metabolism, [1-(14)C]oleic acid was infused systemically. Plasma specific activity and myocardial lipid uptake were similar in both groups. There was a significantly increased incorporation of label into triglyceride, associated with a reduced (14)CO(2) production, considered the basis for a twofold increment of triglyceride content. In addition, diminished incorporation of [(14)C]oleic acid into phospholipid was observed accompanied by morphologic abnormalities of cardiac cell membranes. Potassium loss and sodium gain, like the lipid alteration, was more prominent in the subendocardium. Thus, chronic ethanol ingestion in this animal model is associated with abnormalities of ventricular function without evident malnutrition, analogous to the preclinical malfunction described in the human alcoholic.

An experimental evaluation of continuous normothermic, intermittent hypothermic, and intermittent normothermic coronary perfusion

Hedley Brown, A., Braimbridge, M. V., Darracott, Sally, Chayen, J., and Kasap, H. (1974).Thorax, 29, 38-50. An experimental evaluation of continuous normothermic, intermittent hypothermic, and intermittent normothermic coronary perfusion. Coronary perfusion and hypothermia both have disadvantages, and excellent clinical results are obtained without them, though short operations, spontaneous cooling of unperfused hearts, hyperglycaemia, heparinization, and young and cyanotic subjects may allow more tolerance of ischaemia. Functional, macroscopic, histological, ultrastructural, chemical, and metabolic evidence of the inadvisability of ischaemia, especially of hypertrophied hearts, abounds, though statistical support and histochemical proof are lacking.

Isovolumic function tests permit accurate assessment of compliance. Succinic dehydrogenase distribution is the most relevant enzyme assay of myocardial transport; freed phospholipids indicate cellular membrane disorganization. Adenosinetriphosphate response of myosin (myocardial ATP ase) is shown quantitatively by change of birefringence. Ventricular oedema may be detected by changes in weight. These tests were used to compare continuous normothermic, intermittent hypothermic, and intermittent normothermic perfusion over two hours in isolated, cross-perfused canine hearts. Isolated hearts are very sensitive to imperfections of maintenance, but cross-perfusion minimizes perfusion-induced deterioration.

Normothermic continuously perfused hearts performed significantly better than intermittently perfused hearts, among which cooled hearts functioned better than normothermic hearts after two hours. Succinic dehydrogenase and acid haematein tests showed significant benefit from cooling during intermittent perfusion. The experimental preparation and techniques of assessment proved sensitive enough to demonstrate these differences, though cooling preserved cellular enzymes better than it did function. This work gives histochemical and statistical support to existing evidence that intermittent ischaemia for two hours can be ameliorated by moderate hypothermia but is not as effective for myocardial maintenance as constant perfusion with normal blood.