Right atrial ultrastructure in congenital heart disease. I. Comparison of ventricular septal defect and endocardial cushion defect

Different heart failure phenotypes of valvular heart disease: the role of mitochondrial dysfunction

Valvular heart disease (VHD)-related heart failure (HF) is a special subtype of HF with an increasingly concerned heterogeneity in pathophysiology, clinical phenotypes, and outcomes. The mechanism of VHD-related HF involves not only mechanical damage to the valve itself but also valve lesions caused by myocardial ischemia. The interactions between them will lead to the occurrence and development of VHD-related HF subtypes. Due to the spatial (combination of different valvular lesions) and temporal effects (sequence of valvular lesions) of valvular damages, it can make the patient's condition more complicated and also make the physicians deal with a dilemma when deciding on a treatment plan. This indicates that there is still lack of deep understanding on the pathogenic mechanism of VHD-related HF subtypes. On the other hand, mitochondrial dysfunction (MitD) is not only associated with the development of numerous cardiac diseases such as atherosclerosis, hypertension, diabetes, and HF but also occurs in VHD. However, the role of MitD in VHD-related HF is still not fully recognized. In this comprehensive review, we aim to discuss the current findings and challenges of different valvular damages derived from HF subtypes as well as the role of MitD in VHD-related HF subtypes.

Assessment of electrocardiographic criteria for left atrial enlargement in childhood

Ninety children, aged 1 day to 18 years (median 7 months), with electrocardiographic or echocardiographic evidence of left atrial (LA) enlargement were selected to determine if electrocardiographic criteria accurately reflected increased LA dimension as determined by echocardiography. Four cardiac defects known to produce LA enlargement were chosen: ventricular septal defect (24 patients), patient ductus arteriosus (25 patients), cardiomyopathy (27 patients) and mitral regurgitation (14 patients). Different electrocardiographic criteria for LA enlargement were assessed. The data indicated that the overall sensitivity and predictive value of the ECG to detect LA enlargement were 40 and 85%, respectively. The ECG and echocardiogram failed to agree in 62% of the patients. The most predictive variable for LA enlargement was the presence of a notched P wave in the limb leads with a large negative terminal deflection in lead V1. The sensitivity of ECG was highest in patients with chronic LA overload status, in mitral regurgitation (77%), cardiomyopathy (50%) and ventricular septal defect (54%). The results show that in the pediatric population, electrocardiographic criteria are moderately predictive for LA enlargement but not as sensitive as generally believed.

The relationship of human atrial cellular electrophysiology to clinical function and ultrastructure

Although previous studies have described the electrophysiological and ultrastructural characteristics of human cardiac fibers, no attempt has been made as yet to describe quantitatively the relationship between the ultrastructural and cellular electrophysiological derangements occurring with cardiac disease, and their clinical manifestations. In this study, we used standard microelectrode techniques to record the action potential characteristics of human atrial fibers obtained during cardiac surgery and correlated the electrophysiological parameters with clinical and ultrastructural data. Ultrastructure was studied by optical and electron microscopy. We found a multiple linear regression among maximum diastolic potential, atrial size and pressure, P wave duration and ultrastructure changes. Proliferations of Z band material, widening of intercalated discs, and degenerative changes were quantified and correlated with electrophysiological and clinical data. These studies emphasize the relationship between hemodynamic anomalies and resultant changes in both human atrial fiber structure and electrical function. Finally, the likelihood of occurrence of arrhythmias can be predicted using the analytic method described.

Effects of left atrial enlargement on atrial transmembrane potentials and structure in dogs with mitral valve fibrosis

The effects of left atrial enlargement on atrial cell electrophysiology and structure were studied in dogs with mitral valve fibrosis. Thirteen dogs (Groups I) had left atrial enlargement and intermittent atrial arrhythmias; 10 dogs (Group II) had left atrial enlargement and chronic atrial fibrillation. The resting and action potentials of cells in isolated preparations from the enlarged left atrium were found not to differ from those in the nonenlarged right atrium or in the atrium of control dogs. The resting and action potentials of cells in Group II atria did not differ significantly from those in Group I atria. Some cells (15 percent of the total studied) in the atria of dogs in Groups I and II were inexcitable, but either superfusion with acetylcholine or norepinephrine restored excitability. The structural studies showed that the left atrium of the dogs in Groups I and II had a reduced number of muscle cell layers spanning the wall with an unusually large amount of connective tissue between greatly hypertrophied cells. Very few degenerating cells were seen. Dramatic abnormalities of cell electrophysiology may not be involved in the genesis of arrhythmias in the enlarged canine atrium, and the altered morphologic features of the atrium in these dogs may be important in the genesis of persistent atrial arrhythmias.

Right atrial ultrastructural in chronic rheumatic heart disease

We studied with ultrastructure techniques portions of right atrium resected at operation from 12 patients with chronic rheumatic heart disease and 6 patients with non-rheumatic valvular heart disease. The right atrial pressures, duration of symptoms and age of the patients were comparable in both groups. Ten of the 12 rheumatic and 4 of the 6 non-rheumatic patients had atrial fibrillation. In the 12 rheumatic patients we found severe interstitial fibrosis, extensive cellular degeneration (17% of cells studied) and marked cellular hypertrophy (average cell diameter 16 micrometers). The six non-rheumatic patients showed evidence of cellular hypertrophy (average cell diameter 15 micrometers) but minimal interstitial fibrosis or cellular degeneration. The degenerative changes in the rheumatic group did not correlate with the degree of hypertrophy or the extent of the hemodynamic alterations. Atrial fibrillation, present in both rheumatic and non-rheumatic patients, did not correlate with the presence of cellular degeneration. We conclude that the structural changes in atria of patients with chronic rheumatic heart disease may be part of the rheumatic process and are not entirely secondary to altered hemodynamics.

The effects on atrial electrophysiology and structure of surgically induced right atrial enlargement in dogs

We evaluated the relationship between susceptibility to arrhythmias caused by right atrial (RA) enlargement and alterations in transmembrane potentials and ultrastructure. RA enlargement was produced in eight dogs (TI) by excising the septal cusp of the tricuspid valve through a right atriotomy and constricting the pulmonary artery. This procedure resulted in RA dilation and hypertrophy. Four sham-operated dogs (S) also were studied. Neither TI nor S dogs developed spontaneous atrial arrhythmias. Atrial overdrive (OD) and premature stimulation (PS) were used to initiate and terminate arrhythmias. At 2 weeks and for 20 to 30 weeks after surgical preparation, TI dogs were more susceptible to arrhythmias than S dogs. The duration of arrhythmias exceeded 10 minutes more often in TI dogs than in S dogs. Sixty-one percent of all arrhythmias in the TI dogs had rates of 320-450 impulses/min, and electrogram and ECG characteristics of atrial flutter (type II rhythm), whereas no S dogs developed rhythms with these slower rates. The type II rhythms were persistent, 30% lasting longer than 30 minutes, while 22% lasted more than 60 minutes. Transmembrane potentials recorded in vitro from the RA free wall of TI dogs, and responses to norepinephrine and acetylcholine were not different from control. Histological and ultrastructural studies on TI atria showed hypertrophy of fibers and some increase in connective tissue between cells. These results suggests that altered susceptibility to long-lasting arrhythmias need not be associated with significant abnormalities of cellular electrophysiology.

Myofilament-polyribosome association in muscle cells of rat left atrium after short-term hypertension

Hypertension was induced in uninephrectomized Wistar rats by administration of deoxycorticosterone acetate (DOCA) and by addition of NaCl to their drinking water. The ultrastructure of atrial and ventricular cells of left hearts was compared after short-term (2 and 6 weeks) increased blood pressure. No morphological features could distinguish cells of treated animals from cells of normotensive rats after 2 weeks of treatment. The sarcoplasm of the atrial cells of 6-week-treated hypertensive rats presented an abnormally high number of helical arrangement of ribosomes often associated with abundant unorganized thick filaments, irregular nuclear profiles showing foldings and convolutions, and enlarged mitochondria. The only fine structural changes observed in the ventricular cells of the same animals was a moderate mitochondrial enlargement. The described alterations of atrial cells probably correspond to enhanced synthesis of contractile elements associated with increased nuclear-cytoplasmic exchanges; their absence in ventricular cells suggests that short-term and moderate pressure overload induces adaptative changes in left atrial cells at a stage when ventricular cells have morphological characteristics close to normal cells.

Right atrial ultrastructure in congenital heart disease. II. Atrial septal defect: effects of volume overload

Portions of operatively resected right atrium from 15 patients with atrial septal defect were studied ultrastructurally to determine whether the cell hypertrophy in the right atrium of patients with increased right atrial blood flow and increased right atrial pressure is caused by the increased blood flow. In 12 patients with normal right atrial mean pressure but increased right atrial blood flow the atrium was dilated but no atrial arrhythmias were noted clinically. Ultrastructurally, the atrial myocardial cells in these patients were normal, measuring 6 to 10 mu in diameter, and there was no evidence of cell hypertrophy or degeneration. The remaining three patients had elevated right atrial mean pressure and increased right atrial blood flow. Ultrastructurally, the atrial myocardial cells in all three patients were hypertrophied, and two patients had evidence of focal cell degeneration; the atrium was markedly dilated, but atrial arrhythmias were not noted. The lack of cell hypertrophy in the right atrium of the 12 patients with increased blood flow but normal mean pressure suggests that in congenital heart disease volume overload alone does not lead to cell hypertrophy of the right atrial myocardium.