Triiodothyronine-enhanced left ventricular function after ischemic injury

Cardioprotective effects of triiodothyronine supplementation against ischemia reperfusion injury by preserving calcium cycling proteins in isolated rat hearts

Hypothyroidism is associated with profound left ventricular dysfunction. Triiodothyronine (T₃) supplementation may improve cardiac function after ischemic reperfusion (I/R) injury. In the present study, the effect of T₃ on major calcium cycling proteins and high-energy phosphate content during I/R was evaluated. Isolated perfused rat hearts were divided into 5 groups: Sham Control (Sham, n=10), Control (n=8), T₃ 10 nM (T₃-10, n=10), T₃ 25 nM (T₃-25, n=10) and T₃ 50 nM (T₃-50, n=10). T₃ was administrated for 60 min before 30 min of ischemia and 120 min of reperfusion. The protein contents of Ca²⁺-release channels (RyR2), Ca²⁺-adenosine triphosphatase (SERCA2a), phospholamban (PLB), sarcolemmal Ca²⁺-adenosine triphosphatase (PMCA) and sodium-calcium exchanger (NCX), as well as the high-energy phosphate content in heart tissues were measured by western blot analysis. The results revealed that T₃ improved the contractile recovery (left ventricular developed pressure; +dP/dt, -dP/dt) after I/R. Western blotting assays demonstrated that I/R depressed the contents of RYR2, SERCA2a and phosphorylated RYR2 and PLB; there were no effects on the contents of PLB, PMCA and NCX. T₃ reversed I/R-induced degradation of RyR2 and SERCA2a, restored the phosphorylation of RyR2 and PLB, and preserved the high-energy phosphate contents of ATP and creatine phosphate. T₃ supplementation protected the heart against I/R injury via the preservation of Ca²⁺-cycling proteins and high-energy phosphate content.

Molecular and biochemical evidences on the protective effects of triiodothyronine against phosphine-induced cardiac and mitochondrial toxicity

AIM

Aluminum phosphide (AlP) is a widely used fumigant and rodenticide. While AlP ingestion leads to high mortality, its exact mechanism of action is unclear. There are ample evidences suggesting cardioprotective effects of triiodothyronine (T3). In this study, we aimed to examine the potential of T3 in the protection of a rat model of AlP induced cardiotoxicity.

MAIN METHODS

In order to induce AlP intoxication animals were intoxicated with AlP (12 mg/kg; LD50) by gavage. In treatment groups, T3 (1, 2 and 3 μg/kg) was administered intra-peritoneally 30 min after AlP administration. Animals were connected to the electronic cardiovascular monitoring device simultaneously after T3 administration. Then, electrocardiogram (ECG), blood pressure (BP), and heart rate (HR) were monitored for 180 min. Additionally, 24h after AlP intoxication, rats were deceased and the hearts were dissected out for evaluation of oxidative stress, cardiac mitochondrial function (complexes I, II and IV), ATP/ADP ratio, caspases 3 & 9, and apoptosis by flow cytometry.

KEY FINDINGS

The results demonstrated that AlP intoxication causes cardiac toxicity presenting with changes in ECG patterns such as decrement of HR, BP and abnormal QRS complexes, QTc and ST height. T3 at a dose of 3 μg/kg significantly improved ECG and also oxidative stress parameters. Furthermore, T3 administration could increase mitochondrial function and ATP levels within the cardiac cells. In addition, administration of T3 showed a reduction in apoptosis through diminishing the caspase activities and improving cell viability.

SIGNIFICANCE

Overall, the present data demonstrate the beneficial effects of T3 in cardiotoxicity of AlP.

Thyroid hormone and the stunned myocardium

Acute critically ill patients experience a rapid decline in plasma free thyroid hormone levels (free triiodothyronine (FT3) and free levothyroxine (FT4)), with a marked elevation of reverse T3, recognized as the euthyroid sick syndrome (ESS) or low-T3 syndrome. The ESS is also often associated with depressed myocardial function, sometimes referred to as the 'stunned myocardium'. Its clinical effects may vary from minimal hemodynamic impairment to cardiogenic shock. Medical management may range from aspirin alone to placement of a left ventricular assist device. With adequate supportive therapy, recovery usually occurs within days or weeks. The effect of T3/T4 therapy has been studied in three conditions in which the ESS and myocardial functional depression have been documented - i) transient regional myocardial ischemia and reperfusion, ii) transient global myocardial ischemia in patients undergoing cardiac surgery on cardiopulmonary bypass, and iii) transient inadequate global myocardial perfusion in brain-dead potential organ donors. Under all three conditions, myocardial ischemia leads to rapid loss of high-energy phosphates, accumulation of myocardial tissue lactate, and probably loss of homeostasis of cytosolic calcium, which may further increase cell injury. There is an inability to generate ATP through the Krebs cycle, which reduces the high-energy phosphate pool essential for all cell ATPases. Under all three conditions, following administration of T3/T4, the myocardial dysfunction was rapidly reversed. We, therefore, cautiously advocate the use of thyroid hormonal therapy to any patient with the ESS and/or a stunned myocardium.

Prediction of infarct severity from triiodothyronine levels in patients with ST-elevation myocardial infarction

BACKGROUND/AIMS

The aim of the present study was to evaluate the relationship between thyroid hormone levels and infarct severity in patients with ST-elevation myocardial infarction (STEMI).

METHODS

We retrospectively reviewed thyroid hormone levels, infarct severity, and the extent of transmurality in 40 STEMI patients evaluated via contrast-enhanced cardiac magnetic resonance imaging.

RESULTS

The high triiodothyronine (T3) group (≥ 68.3 ng/dL) exhibited a significantly higher extent of transmural involvement (late transmural enhancement > 75% after administration of gadolinium contrast agent) than did the low T3 group (60% vs. 15%; p = 0.003). However, no significant difference was evident between the high- and low-thyroid-stimulating hormone/free thyroxine (FT4) groups. When the T3 cutoff level was set to 68.3 ng/dL using a receiver operating characteristic curve, the sensitivity was 80% and the specificity 68% in terms of differentiating between those with and without transmural involvement. Upon logistic regression analysis, high T3 level was an independent predictor of transmural involvement after adjustment for the presence of diabetes mellitus (DM) and the use of glycoprotein IIb/IIIa inhibitors (odds ratio, 40.62; 95% confidence interval, 3.29 to 502; p = 0.004).

CONCLUSIONS

The T3 level predicted transmural involvement that was independent of glycoprotein IIb/IIIa inhibitor use and DM positivity.

Thyroid hormone as a therapeutic option for treating ischaemic heart disease: from early reperfusion to late remodelling

Thyroid hormone (TH), apart from its "classical" actions on cardiac contractility and heart rhythm, appears to regulate various intracellular signalling pathways related to response to stress and cardiac remodelling. There is now accumulating experimental and clinical evidence showing a beneficial effect of TH on limiting myocardial ischaemic injury, preventing/reversing post infarction cardiac remodelling and improving cardiac hemodynamics. Thyroid analogs have already been developed and may allow TH use in clinical practice. However, the efficacy of TH in the treatment of cardiac diseases is now awaiting to be tested in large clinical trials.

Thyroid hormone improves postischaemic recovery of function while limiting apoptosis: a new therapeutic approach to support hemodynamics in the setting of ischaemia-reperfusion?

Although it has long been recognized that thyroid hormone is an effective positive inotrope, its efficacy in supporting hemodynamics in the acute setting of ischaemia and reperfusion (R) without worsening reperfusion injury remains largely unknown. Thus, we investigated the effects of triiodothyronine (T3) on reperfusion injury in a Langendorff-perfused rat heart model of 30 min zero-flow ischaemia and 60 min of (R) with or without T3 (40 microg/l) at R, T3-R60, n = 11 and CNT-R60, n = 10, respectively. Furthermore, phosphorylated levels of intracellular kinases were measured at 5, 15 and 60 min of R. T3 markedly improved postischaemic recovery of left ventricular developed pressure (LVDP%); 56.0% (SEM, 4.4) in T3-R60 versus 38.8% (3.1) in CNT-R60, P < 0.05. Furthermore, LDH release was significantly lower in T3-R60. Apoptosis detection by fluorescent probe optical imaging showed increased fluorescent signal in CNT-R60 hearts, while the signal was hardly detectable in T3-R60 hearts. Similarly, caspase-3 activity was found to be 78.2 (8.2) in CNT-R60 vs 40.5 (7.1) in T3-R60 hearts, P < 0.05. This response was associated with significantly lower levels of phospho-p38 MAPK at any time point of R. No significant changes in phospho- ERK1/2 and JNK levels were observed between groups. Phospho-Akt levels were significantly lower in T3 treated group at 5 min and no change in phospho-Akt levels were observed at 15 and 60 min between groups. In conclusion, T3 administration at reperfusion can improve postischaemic recovery of function while limiting apoptosis. This may constitute a paradigm of a positive inotropic agent with anti-apoptotic action suitable for supporting hemodynamics in the clinical setting of ischaemia-reperfusion.

Thyroid hormone and myocardial ischaemia

Thyroid hormone has various effects on the cardiovascular system and its effects on cardiac contractility, heart rhythm and vascular function has long been recognized. However, new evidence is emerged on the importance of thyroid hormone in the response of the myocardium to ischaemic stress and cardiac remodelling following myocardial infarction. Based on this new information, this review highlights the role of thyroid hormone in myocardial ischaemia and cardiac remodelling, the possible underlying mechanisms and the potential therapeutic implications. Thyroid hormone or analogs may prove new therapeutic agents for treating ischaemic heart disease.

Interaction of cardiovascular risk factors with myocardial ischemia/reperfusion injury, preconditioning, and postconditioning

Therapeutic strategies to protect the ischemic myocardium have been studied extensively. Reperfusion is the definitive treatment for acute coronary syndromes, especially acute myocardial infarction; however, reperfusion has the potential to exacerbate lethal tissue injury, a process termed "reperfusion injury." Ischemia/reperfusion injury may lead to myocardial infarction, cardiac arrhythmias, and contractile dysfunction. Ischemic preconditioning of myocardium is a well described adaptive response in which brief exposure to ischemia/reperfusion before sustained ischemia markedly enhances the ability of the heart to withstand a subsequent ischemic insult. Additionally, the application of brief repetitive episodes of ischemia/reperfusion at the immediate onset of reperfusion, which has been termed "postconditioning," reduces the extent of reperfusion injury. Ischemic pre- and postconditioning share some but not all parts of the proposed signal transduction cascade, including the activation of survival protein kinase pathways. Most experimental studies on cardioprotection have been undertaken in animal models, in which ischemia/reperfusion is imposed in the absence of other disease processes. However, ischemic heart disease in humans is a complex disorder caused by or associated with known cardiovascular risk factors including hypertension, hyperlipidemia, diabetes, insulin resistance, atherosclerosis, and heart failure; additionally, aging is an important modifying condition. In these diseases and aging, the pathological processes are associated with fundamental molecular alterations that can potentially affect the development of ischemia/reperfusion injury per se and responses to cardioprotective interventions. Among many other possible mechanisms, for example, in hyperlipidemia and diabetes, the pathological increase in reactive oxygen and nitrogen species and the use of the ATP-sensitive potassium channel inhibitor insulin secretagogue antidiabetic drugs and, in aging, the reduced expression of connexin-43 and signal transducer and activator of transcription 3 may disrupt major cytoprotective signaling pathways thereby significantly interfering with the cardioprotective effect of pre- and postconditioning. The aim of this review is to show the potential for developing cardioprotective drugs on the basis of endogenous cardioprotection by pre- and postconditioning (i.e., drug applied as trigger or to activate signaling pathways associated with endogenous cardioprotection) and to review the evidence that comorbidities and aging accompanying coronary disease modify responses to ischemia/reperfusion and the cardioprotection conferred by preconditioning and postconditioning. We emphasize the critical need for more detailed and mechanistic preclinical studies that examine car-dioprotection specifically in relation to complicating disease states. These are now essential to maximize the likelihood of successful development of rational approaches to therapeutic protection for the majority of patients with ischemic heart disease who are aged and/or have modifying comorbid conditions.

Protection of the abnormal heart

Myocardial ischemia and reperfusion injury have been extensively investigated in the laboratory mainly in healthy tissues. However, in clinical settings, ischemic heart disease coexists with certain illnesses, which could potentially influence the response of the myocardium to ischemia and reperfusion. Recent research has revealed that the abnormal heart may not be always vulnerable to ischemic injury. Furthermore, the effect of powerful means of protection, such as ischemic preconditioning, may not be in operation under certain pathological conditions. With this evidence in mind, the present review will focus on the response of the abnormal heart to ischemia and reperfusion, the possible underlying mechanisms, and potential cardioprotective strategies.

Medical management to optimize donor organ potential: review of the literature

PURPOSE

Over the past two decades, the demand for donor organs continues to outpace the number of organs available for transplantation. Parallel with this has been a change in the demographics of organ donors with an increase in older donors and donors with marginal organs as a proportion of the total organ donor pool. Consequently, efforts have been made to improve the medical care delivered to potential organ donors to improve the conversion rate and graft survival of available organs. The purpose of this literature review is to provide updated recommendations for the contemporary management of organ donors after the neurological determination of death in order to maximize the probability of recipient graft survival.

SOURCES

A comprehensive review of the literature obtained through searches of MEDLINE/PubMed, and personal reference files.

PRINCIPAL FINDINGS

Contemporary management of the organ donor after neurological determination of death includes therapies to prevent the detrimental effects of the autonomic storm, the use of invasive hemodynamic monitoring and aggressive respiratory therapy including therapeutic bronchoscopy in marginal heart and lung donors, and the use of hormonal therapy including vasopressin, corticosteroids, triiodothyronine or thyroxine, and insulin for the pituitary failure and inflammation seen in brain dead organ donors. The importance of normalizing donor physiology to optimize all available organs is stressed.

CONCLUSION

Aggressive hemodynamic and respiratory management of solid organ donors, coupled with the use of hormonal therapy improves the rate of conversion and graft survival in solid organ recipients.

Triiodothyronine acutely increases blood flow in the ventricles and kidneys of anesthesized rabbits

Thyroid hormone (triiodothyronine [T(3)]) has various nongenomic effects, including alterations in glucose and fatty acid metabolism, augmentation of intracellular Ca(2+), enhancement of myocardial contractility, and vascular dilatation. However, its effect on regional blood flow remains to be established. We have measured the effect of T(3) on blood flow in major organs of anesthetized rabbits in vivo using the microsphere method. Under artificial respiration, nonradioactive microspheres (5 x 10(5)) labeled with barium were injected to measure blood flow at control level. Then, T(3) (50 microg/kg per milliliter) was administered and microspheres labeled with iodine (5 x 10(5)) were injected. The atria, ventricles, kidneys, and right upper limb were excised and their contents of microspheres were evaluated. Blood flow in the ventricles was significantly increased by T(3) (2.9 +/- 0.3 versus 3.4 +/- 0.3 mL/min per gram, vehicle versus T(3)). Similarly, blood flow in the kidneys was significantly higher after T(3) injection (4.3 +/- 0.5 versus 5.1 +/- 0.5 mL/min per, vehicle versus T(3)). The blood flow in the atria and skeletal muscles remained unchanged. These results indicate that the vasodilatory response to T(3) is not uniform and occurs preferentially in major organs such as cardiac ventricles and kidneys; this may be relevant to the T(3)-induced improvement of cardiac function.

Clinical investigation: thyroid function test abnormalities in cardiac arrest associated with acute coronary syndrome

INTRODUCTION

It is known that thyroid homeostasis is altered during the acute phase of cardiac arrest. However, it is not clear under what conditions, how and for how long these alterations occur. In the present study we examined thyroid function tests (TFTs) in the acute phase of cardiac arrest caused by acute coronary syndrome (ACS) and at the end of the first 2 months after the event.

METHOD

Fifty patients with cardiac arrest induced by ACS and 31 patients with acute myocardial infarction (AMI) who did not require cardioversion or cardiopulmonary resuscitation were enrolled in the study, as were 40 healthy volunteers. The patients were divided into three groups based on duration of cardiac arrest (<5 min, 5-10 min and >10 min). Blood samples were collected for thyroid-stimulating hormone (TSH), tri-iodothyronine (T3), free T3, thyroxine (T4), free T4, troponin-I and creatine kinase-MB measurements. The blood samples for TFTs were taken at 72 hours and at 2 months after the acute event in the cardiac arrest and AMI groups, but only once in the control group.

RESULTS

The T3 and free T3 levels at 72 hours in the cardiac arrest group were significantly lower than in both the AMI and control groups (P < 0.0001). On the other hand, there were no significant differences between T4, free T4 and TSH levels between the three groups (P > 0.05). At the 2-month evaluation, a dramatic improvement was observed in T3 and free T3 levels in the cardiac arrest group (P < 0.0001). In those patients whose cardiac arrest duration was in excess of 10 min, levels of T3, free T3, T4 and TSH were significantly lower than those in patients whose cardiac arrest duration was under 5 min (P < 0.001, P < 0.001, P < 0.005 and P < 0.05, respectively).

CONCLUSION

TFTs are significantly altered in cardiac arrest induced by ACS. Changes in TFTs are even more pronounced in patients with longer periods of resuscitation. The changes in the surviving patients were characterized by euthyroid sick syndrome, and this improved by 2 months in those patients who did not progress into a vegetative state.

The impact of cardiopulmonary bypass on selenium status, thyroid function, and oxidative defense in children

Selenium has important functions for oxidative defense and thyroid hormone metabolism. Selenium-dependent enzymes include 5'-iodothyronine deiodinase and glutathione peroxidase (GPX). The objective of this study was to investigate the relationship between plasma selenium, GPX activity, and thyroid hormone status in pediatric cardiac surgical patients. Plasma concentrations of selenium, free triiodothyronine (fT3), free thyroxin (fT4), and c-reactive protein as well as plasma activity of GPX were prospectively evaluated at anesthetic induction and 48 hours postoperatively in 59 children requiring cardiopulmonary bypass (CPB). GPX was measured at additional time points at 6, 12, and 24 hours postoperatively. There was a significant reduction in the plasma selenium concentration after cardiopulmonary bypass with obtained median measurements of 0.61 micromol/L (induction) and 0.51 micromol/L (48 hours postoperatively). The fT3/fT4 ratio decreased significantly from 0.28 at anesthetic induction to 0.22 at 48 hours postoperatively. There were no significant changes of GPX activity. 48 hours fT3 concentration, fT3/fT4 ratio, and selenium concentration were significantly negatively correlated with the time spent in intensive care. The concentration of plasma selenium in children undergoing cardiopulmonary bypass significantly decreases, resulting in diminished deiodinase activity, and a subsequent reduction in the conversion of T4 to T3.

Effects of triiodothyronine pretreatment on beta-adrenergic responses in stunned cardiac myocytes

OBJECTIVE

To investigate whether triiodothyronine pretreatment enhanced beta-adrenergic responses in stunned myocardium and whether this acute effect of triiodothyronine was mediated through the cyclic adenosine 3',5'-monophosphate (AMP) system.

DESIGN

A prospective study.

SETTING

University laboratory.

PARTICIPANTS

Rabbits.

INTERVENTIONS

Rabbit ventricular myocytes were isolated and placed in a medium equilibrated with either air (control) or with 95% N(2) and 5% CO(2) (stunned) for 15 minutes at 37 degrees C. The stunned myocytes were reoxygenated with air for 30 minutes. Triiodothyronine (10 nmol/L) and/or isoproterenol (0.1 nmol/L) was added to the myocytes. Myocyte shortening was measured by using a video-edge detector.

MEASUREMENTS AND MAIN RESULTS

In electrically stimulated cells, the basal values of the percent shortening (22%-30%) and the maximum rate of shortening (22%-25%) were significantly reduced in the stunned myocytes. Isoproterenol (5 minutes) alone significantly increased the percent shortening in the control (from 3.70 +/- 0.36 to 4.14 +/- 0.37) but not in the stunned myocytes (from 2.60 +/- 0.30 to 3.15 +/- 0.27). Triiodothyronine (5 minutes) alone significantly increased the percent shortening in the control (from 3.75 +/- 0.36 to 4.34 +/- 0.45) and in the stunned myocytes (from 2.91 +/- 0.2 to 3.85 +/- 0.26). After triiodothyronine pretreatment for 5 minutes, isoproterenol caused greater increases in the percent shortening in both the control (37%) and the stunned myocytes (62%) than either agent alone. Isoproterenol or triiodothyronine caused small increases in the maximum rate of shortening in the control (14%-16%) and the stunned myocytes (34%-49%). After triiodothyronine pretreatment, isoproterenol caused greater increases in the maximum rate of shortening in both groups (control: 41%, stunned: 73%) than either agent alone. Isoproterenol caused an increase in the level of cyclic AMP (rho;moles/10(5) myocytes) in the control (from 2.92 +/- 0.47 to 3.77 +/- 0.43) but not in the stunned myocytes (from 2.42 +/- 0.25 to 2.42 +/- 0.20). Triiodothyronine pretreatment did not cause any change in cyclic AMP levels in the control (2.50 +/- 0.29) or in the stunned myocytes (2.60 +/- 0.40). After triiodothyronine pretreatment, isoproterenol caused a small increase in the cyclic AMP level in the control but not in the stunned myocytes.

CONCLUSIONS

The data showed that the myocardial beta-adrenergic responses were more sensitive to ischemic insult than the triiodothyronine responses. Triiodothyronine pretreatment enhanced beta-adrenergic responses in both the control and the stunned myocytes. However, this acute positive inotropic effect of triiodothyronine might not be mediated through the cyclic AMP system.

Low-T3 syndrome: a strong prognostic predictor of death in patients with heart disease

BACKGROUND

Clinical and experimental data have suggested a potential negative impact of low-T3 state on the prognosis of cardiac diseases. The aim of the present prospective study was to assess the role of thyroid hormones in the prognosis of patient population with heart disease.

METHODS AND RESULTS

A total of 573 consecutive cardiac patients underwent thyroid function profile evaluation. They were divided in two subgroups: group I, 173 patients with low T3, ie, with free T3 (fT3) <3.1 pmol/L, and group II, 400 patients with normal fT3 (>or=3.1 pmol/L). We considered cumulative and cardiac death events. During the 1-year follow-up, there were 25 cumulative deaths in group I and 12 in group II (14.4% versus 3%, P<0.0001); cardiac deaths were 13 in group I and 6 in group II (7.5% versus 1.5%, P=0.0006). According to the Cox model, fT3 was the most important predictor of cumulative death (hazard ratio [HR] 3.582, P<0.0001), followed by dyslipidemia (HR 2.955, P=0.023), age (HR 1.051, P<0.005), and left ventricular ejection fraction (HR 1.037, P=0.006). At the logistic multivariate analysis, fT3 was the highest independent predictor of death (HR 0.395, P=0.003). A prevalence of low fT3 levels was found in patients with NYHA class III-IV illness compared with patients with NYHA class I-II (chi(2) 5.65, P=0.019).

CONCLUSIONS

Low-T3 syndrome is a strong predictor of death in cardiac patients and might be directly implicated in the poor prognosis of cardiac patients.

Effects of intravenous triiodothyronine during coronary artery bypass surgery

A prospective randomized and double-blind study was performed to evaluate whether perioperative triiodothyronine administration has any effect on cardiovascular performance after coronary artery bypass surgery. Sixty patients were assigned to 2 groups of 30 each. When crossclamping ended, group A received an intravenous bolus of triiodothyronine, followed by infusion for 6 hours. Group B received a placebo. Serum triiodothyronine levels and hemo-dynamic parameters were serially measured. Mean postoperative cardiac index was slightly, but not significantly, higher in group A, whereas systemic vascular resistance was significantly lower in group A. Compared with preoperative values, serum triiodothyronine levels dropped significantly in group B at the end of cardiopulmonary bypass and remained low 12 hours postoperatively, while levels rose significantly in group A. No significant differences were detected between the groups in the incidence of arrhythmia, the need for inotropic support, intensive care unit stay, mortality, and morbidity. Perioperative administration of triiodothyronine increased cardiac output slightly and decreased systemic vascular resistance, but it had no effect on operative outcome. Routine use after coronary surgery is thus not recommended.

Thyroid hormone and cardiac surgery

Thyroid hormone has important effects on the heart and peripheral vascular system. The relationship between thyroid disease states and cardiovascular hemodynamics is well recognized. Diverse clinical situations are associated with low serum triiodothyronine (T3) levels including a number of cardiovascular illnesses. In particular, cardiopulmonary bypass and open heart operations result in a low T3 state and are often complicated by significant cardiovascular dysfunction similar to that observed in clinical hypothyroidism. Multiple lines of evidence have suggested that T3 can act acutely as a positive inotrope and vasodilator agent. This recognition has prompted a number of investigators to study the effects of T3 administration to patients in the perioperative period. This paper reviews the experimental background that supported such clinical trials as well as outlines the results that have been documented in both adult and pediatric patients undergoing cardiac surgery. Low serum T3 levels resulting from cardiopulmonary bypass can be safely reversed with pharmacologic T3 supplementation. Data have suggested that T3 repletion may improve postoperative hemodynamic performance and lower the incidence of arrythmias. However, beneficial effects on major clinical outcome variables have not yet been conclusively demonstrated, and require future large-scale clinical trials.

Coronary bypass surgery in patients on thyroxin replacement therapy

The outcome of coronary bypass surgery was analyzed in 25 patients who were on thyroxin replacement therapy for chronic thyroid disorders at the time of operation. It was hypothesized that if such patients were given only their routine dose of thyroxin on the day of surgery, hemodynamic and cardiorespiratory recovery may be poor. All the patients on thyroxin replacement therapy were given their routine dose of thyroxin orally or via a nasogastric tube in the perioperative period. No supplemental dose was used. Based on preoperative levels of thyroid stimulating hormone, 68% of these patients were biochemically hypothyroid prior to surgery. Analysis of a large number of variables showed no difference in outcome against a control group who had no previous thyroid problems. We conclude that routine thyroxin administration is all that is required for a satisfactory outcome in patients undergoing coronary bypass surgery while on thyroxin replacement therapy.

Association between increased levels of reverse triiodothyronine and mortality after acute myocardial infarction

PURPOSE

The thyroid hormone system may be downregulated temporarily in patients who are severely ill. This "euthyroid sick syndrome" may be an adaptive response to conserve energy. However, thyroid hormone also has beneficial effects on the cardiovascular system, such as improving cardiac function, reducing systemic vascular resistance, and lowering serum cholesterol levels. We investigated whether thyroid hormone levels obtained at the time of myocardial infarction are associated with subsequent mortality.

PATIENTS AND METHODS

Serum levels of thyroid hormones (triiodothyronine [T3], reverse T3, free thyroxine [T4], and thyroid-stimulating hormone) were measured in 331 consecutive patients with acute myocardial infarction (mean age [+/- SD], 68 +/- 12 years), from samples obtained at the time of admission.

RESULTS

Fifty-three patients (16%) died within 1 year. Ten percent (16 of 165) of patients with reverse T3 levels (an inactive metabolite) >0.41 nmol/L (the median value) died within the first week after myocardial infarction, compared with none of the 166 patients with lower levels (P <0.0004). After 1 year, the corresponding figures were 24% (40 of 165) versus 7.8% (13 of 166; P <0.0001). Reverse T3 levels >0.41 nmol/L were associated with an increased risk of 1-year mortality (hazard ratio = 3.0; 95% confidence interval: 1.4 to 6.3; P = 0.005), independent of age, previous myocardial infarction, prior angina, heart failure, serum creatinine level, and peak serum creatine kinase-MB fraction levels.

CONCLUSION

Determination of reverse T3 levels may be a valuable and simple aid to improve identification of patients with myocardial infarction who are at high risk of subsequent mortality.

Cilazapril prevents cardiac hypertrophy and postischemic myocardial dysfunction in hyperthyroid rats

We evaluated the effects of hyperthyroidism on cardiac structural changes and postischemic myocardial function, and also studied how an angiotensin-converting enzyme (ACE) inhibitor, cilazapril, can alter these changes. Hyperthyroidism was induced by daily intraperitoneal injection of thyroxine (T4) (600 microg/kg) with or without cilazapril (10 mg/kg per day, orally), and control rats were given by vehicle. After 2 weeks of treatment, T4-treated rats showed increases in blood pressure and heart weight to body weight ratio (HW:BW). Cilazapril decreased blood pressure to control values and reduced HW:BW. In the isolated working heart preparation, T4-treated rats showed a poor postischemic recovery of left ventricular pressure-rate product (14% of baseline at 30 minutes of reperfusion vs. vehicle 85%) and cardiac work (6% vs. 71%). Cilazapril recovered both values to 49% and 43%. Propranolol (500 mg/L in drinking water) decreased blood pressure to the same extent as cilazapril in hyperthyroid rats, but changed neither HW:BW nor the postischemic myocardial dysfunction. Percent recovery of cardiac work was inversely well correlated with HW:BW (R2 = 0.998, p < 0.001). Results indicate that T4-induced cardiac hypertrophy enhances postischemic cardiac dysfunction. Results also indicate renin-angiotensin system (RAS), but not sympathetic nerve activation, is involved in cardiac hypertrophy and postischemic myocardial dysfunction in hyperthyroid rats.

Triiodothyronine supplementation in patients undergoing cardiopulmonary bypass

Patients undergoing cardiopulmonary bypass may develop clinically significant physiologic alterations in the perioperative period, including alteration of thyroid hormone concentrations. Alterations in the concentration of thyroid hormones are of concern due to the effects of these hormones on cardiac function. Hypothyroidism is associated with a decrease in cardiac performance; therefore, supplementation with the active thyroid hormone triiodothyronine (T3) in patients undergoing cardiopulmonary bypass has been investigated to improve outcomes. In addition, T3 has been studied as an agent to reduce the frequency of atrial fibrillation after cardiopulmonary bypass.

A randomized double-blind study of the effect of triiodothyronine on cardiac function and morbidity after coronary bypass surgery

BACKGROUND

Although triiodothyronine deficiency has been described after cardiopulmonary bypass, data supporting its use have been conflicting. A double-blind, randomized, placebo-controlled study was undertaken to further define the effect of triiodothyronine on hemodynamics and outcome after coronary artery bypass grafting.

METHODS

A total of 170 patients undergoing elective coronary artery bypass grafting were enrolled and completed the study from November 1996 through March 1998. On removal of the aortic crossclamp, patients were randomized to receive either intravenous triiodothyronine (0.4 microgram/kg bolus plus 0.1 microgram/kg infusion administered over a 6-hour period, n = 81) or placebo (n = 89). Outcome variables included hemodynamic profile and inotropic drug/pressor requirements at several time points (mean +/- standard error of the mean), perioperative morbidity (arrhythmia/ischemia/infarction), and mortality.

RESULTS

Despite similar baseline characteristics, patients randomized to triiodothyronine had a higher cardiac index and lower inotropic requirements after the operation. Subjects receiving triiodothyronine demonstrated a significantly lower incidence of postoperative myocardial ischemia (4% vs 18%, P =.007) and pacemaker dependence (14% vs 25%, P =.013). Seven patients in the placebo group required postoperative mechanical assistance (intra-aortic balloon pump, n = 4; left ventricular assist device, n = 3), compared with none in the triiodothyronine group (P =.01). There were 2 deaths in the placebo group and no deaths in the triiodothyronine group.

CONCLUSIONS

Parenteral triiodothyronine given after crossclamp removal during elective coronary artery bypass grafting significantly improved postoperative ventricular function, reduced the need for treatment with inotropic agents and mechanical devices, and decreased the incidence of myocardial ischemia. The incidence of atrial fibrillation was slightly decreased, and the need for postoperative pacemaker support was reduced.

[Non-thyroid indications of treatment with thyroid hormones]

INTRODUCTION

The use of thyroid hormone is currently strictly limited to thyroid diseases. Several recent papers have examined the effects of thyroid hormone in non-thyroidal diseases. These studies examined either the use of the pharmacological properties of thyroid hormone or the effect of the correction of the decrease in triiodothyronine (T3) associated with non-thyroid illnesses.

CURRENT KNOWLEDGE AND KEY POINTS

Intravenous administration of T3 improves the cardiac index during ongoing cardiac surgery, with a paradoxical decrease in the incidence of atrial fibrillation. T3 administered by the oral route also improves the cardiac index in the medium term in dilated cardiomyopathy. No benefit on survival has been demonstrated in non-thyroidal diseases when using the pharmacological properties of thyroid hormone. Other situations, such as transplantation or neural rescue after cardiac arrest, are currently under study. In non-thyroidal diseases, administration of thyroxine (T4) has no effect because of the deeply disturbed metabolism of thyroid hormones.

FUTURE PROSPECTS AND PROJECTS

Adverse metabolic effects of T4 and T3 therapy have probably been overestimated and may depend on the dose and on the time of administration in the course of the disease. Indications in cardiac surgery and cardiac diseases need to be clarified. To further understand the value of thyroid hormones in non-thyroidal diseases, placebo-controlled studies using small doses of T3 are required.

Thyroid hormone and cardiovascular disease

Thyroid hormone directly affects the heart and peripheral vascular system. The hormone can increase myocardial inotropy and heart rate and dilate peripheral arteries to increase cardiac output. An excessive deficiency of thyroid hormone can cause cardiovascular disease and aggravate many preexisting conditions. In severe systemic illness and after major surgical procedures changes in thyroid function can occur, leading to the "euthyroid sick syndrome." Patients will have normal or decreased levels of T4, decreased free and total T3, and usually normal levels of thyroid stimulating hormone. This syndrome may be an adaptive response to systemic illness that usually will revert to normal without hormone supplementation as the illness subsides. Recently, however, many investigators have explored the benefits of thyroid hormone supplementation in those diseases associated with euthyroid sick syndrome. Thyroid hormone's effects on the cardiovascular system make it an attractive therapy for those patients with impaired hemodynamics and low T3. Thyroid hormone has also been considered a treatment for patients with congestive heart failure, for patients undergoing cardiopulmonary bypass and heart transplantation, and for patients with hyperlipidemia. At present there is no evidence suggesting a favorable treatment outcome using thyroid hormone supplementation for any systemic condition except in those patients with documented hypothyroidism.

Triiodothyronine in cardiac surgery

Thyroid hormones have profound cardiovascular effects. Chronic hypothyroidism is associated with cardiovascular abnormalities that include diminished cardiac output and increased systemic vascular resistance. Acute hypothyroidism, frequently referred to as the "euthyroid sick syndrome," is present in diverse clinical situations such as brain death, sepsis, congestive heart failure, and cardiopulmonary bypass. Significant cardiovascular dysfunction often complicates each of these clinical situations. This article reviews the laboratory experiments and clinical trials that have evaluated triiodothyronine (T3) repletion in cardiac surgery. Animal experiments have shown that T3 repletion ameliorates postischemic cardiovascular dysfunction. While anecdotal clinical experience suggests that T3 repletion should be of clinical benefit, rigorous clinical trials have failed to support routine repletion of T3 in cardiac surgery. Based on the results of these clinical trials, we do not recommend routine administration of T3 to patients undergoing cardiac surgery. However, anecdotal experience suggests that T3 may help in weaning patients from cardiopulmonary bypass who are unable to be weaned from bypass despite maximal inotropic support. In use as a "rescue" agent, we administer the 0.8 microgram/kg dose that has been demonstrated to safely improve cardiac output and decrease systemic vascular resistance in the postischemic cardiopulmonary bypass patient.

Triiodothyronine: spectrum of use in heart transplantation

Triiodothyronine (T3) deficiency, present in 85% of donors, in recipients with end-stage cardiomyopathy, and in patients after cardiopulmonary bypass (CPB), may contribute to donor heart dysfunction after heart transplantation (HT). Three separate studies were performed to investigate the various potential applications of T3 in HT. In the first study, donor hearts with statistically higher filling pressures, lower EF on echocardiograms, and higher inotrope requirements were resuscitated with T3 (0.6 microgram/kg bolus) and compared to normal donors not receiving T3. All patients survived the immediate postoperative period, and at 1 week and 6 months there were no significant differences in SBP, DBP, HR, cardiac index, CVP, PCWP, or LVEF on echocardiography. The next study involved giving T3 (0.6 microgram/kg bolus) versus placebo to normal donors in a blinded randomized fashion. Although there was a trend toward less inotrope use in the T3 group, there were no other differences. In the third study, placebo (group A) or T3 (group B; 0.2 microgram/kg bolus, 0.4 microgram/kg infusion over 6 hours) was given immediately before donor heart reperfusion. The recipient groups were similar with regard to age, donor/recipient weight ratio, ischemic time, thyroid hormone levels, and pretransplant hemodynamics. Lactate from coronary sinus effluent after 10 minutes of reperfusion was higher in group A, and more group A patients required higher than baseline inotropic support. In conclusion, T3 can be used effectively to resuscitate selective donor hearts with poor function and in recipients to improve myocardial aerobic metabolism; and T3 decreases both the amount and duration of inotropic support.

The effects of triiodothyronine on hemodynamic status and cardiac function in potential heart donors

Brain death is associated with altered cardiac function and low concentrations of circulating triiodothryronine (T3). However, the effects of T3 administration on hemodynamic status and cardiac function in potential heart donors remain controversial. Thirty-seven brain-dead patients were randomly and blindly allocated to receive an intravenous bolus of either 0.2 microgram/kg T3 (n = 19) or saline placebo (n = 18). Measurements included conventional hemodynamic and echocardiographic variables of cardiac volume conditions and systolic function of the left ventricle (fractional area change [FAC], velocity of myocardial fiber shortening) using a transesophageal probe, arterial and mixed venous blood gas parameters, and serum thyroid hormone concentrations. The mean concentration of T3 was 1.86 +/- 1.55 pmol/L, and only six patients (16%) had normal values of T3 in control conditions. There was no significant correlation between T3 concentration and FAC (R = 0.17, not significant). All patients receiving T3 had normalized serum T3 concentration (7.55 +/- 2.56 pmol/L) in contrast to patients receiving saline (1.48 +/- 1.26 pmol/L). No significant differences in hemodynamic and echocardiographic parameters were observed between the placebo and T3 groups. Indeed, FAC remained unchanged after T3 (44% +/- 17% vs 46% +/- 22%) or placebo (47% +/- 18% vs 50% +/- 14%) administration. In 20 patients with impaired left ventricular function (FAC < 50%), FAC remained unchanged after T3 (n = 10; 34% +/- 12% vs 30% +/- 10%) or placebo (n = 10; 38% +/- 12% vs 35% +/- 13%) administration. In 17 patients in whom organ harvesting was delayed, transesophageal echocardiography was performed 6 h later and no significant changes in FAC were noted in the T3 group (n = 8; 49% +/- 17% vs 44% +/- 17%) and the placebo group (n = 9; 51% +/- 18% vs 47% +/- 18%). In conclusion, T3 administration did not improve hemodynamic status and myocardial function in brain-dead patients, suggesting that the euthyroid sick syndrome is not the main determinant of myocardial dysfunction in these patients.

Relations between the selenium status and the low T3 syndrome after major trauma

OBJECTIVE

Thyroxine (T4) is deiodinated to triiodothyronine (T3) by the hepatic type I iodothyronine deiodinase, a selenoprotein that is sensitive to selenium (Se) deficiency. After severe injury, T4 deiodination is decreased, leading to the low T3 syndrome. Injury increases free radical production, which inactivates the iodothyronine deiodinase. The aims were to study the Se status after major trauma and to investigate its relation to the low T3 syndrome.

DESIGN

Preliminary prospective descriptive study.

SETTING

Intensive care unit at a university teaching hospital.

PATIENTS AND METHODS

11 patients aged 41 +/- 4 years (mean +/- SEM), with severe multiple injuries (Injury Severity Score 29 +/- 2 points). A balance study was performed from day 1 to day 7. Serum and urine samples were collected from the time of admission until day 7, then on days 10, 15, 20, 25 and 30. Non-parametric tests and Pearson's correlation coefficients were used for analysis.

RESULTS

Cumulated Se losses were 0.88 +/- 0.1 mumol/24h. Serum Se was decreased from admission to day 7. T3, free T3, and the T3/T4 ratio were low until day 5, being lowest on day 2; T4 and thyroid stimulating hormone were normal. Serum Se was correlated with T3 (r = 0.55, p = 0.0001), and with free T3 (r = 0.35).

CONCLUSION

Se status is altered after trauma, with decreased Se serum levels upon admission to the ICU but with no major Se losses. Se is probably redistributed to the tissues. The correlation between Se and T3, along with the parallel decrease in T4 deiodination, indicates that reduced deiodination might be related to the transient decrease in serum Se.

Effect of sepsis and 3,5,3'-triiodothyronine replacement on myocardial integrity during oxidant challenge

OBJECTIVE

To determine whether sepsis, with or without thyroid hormonal augmentation, induces myocardial tolerance to an oxidant challenge.

DESIGN

A prospective, randomized, controlled animal trial.

SETTING

University research laboratory.

SUBJECTS

Twenty male Sprague-Dawley rats.

INTERVENTIONS

After anesthesia, animals underwent cecal ligation and puncture, with or without 3,5,3'-triiodothyronine replacement (3 ng/hr), or sham surgery. Twenty-four hours later, the heart was rapidly excised for retrograde Langendorff perfusion. Oxyradical challenge consisted of the addition of 200 microM of hydrogen peroxide to the perfusate for 60 mins.

MEASUREMENTS AND MAIN RESULTS

Myocardial contractility and relaxation were continuously recorded. Perfusate glutathione and lactate dehydrogenase concentrations were determined enzymatically at 30-min intervals for 90 mins. Oxyradical perfusion alone significantly increased glutathione efflux and decreased myocardial contractility when compared with control animals. Prior cecal ligation and puncture decreased oxidant-mediated glutathione efflux and maintained myocardial contractility. 3,5,3'-triiodothyronine supplementation appeared to increase late cardiac contractility and cellular integrity during oxidant challenge. However, this increase was not statistically significant.

CONCLUSIONS

Antecedent septic challenge appears to induce tolerance to further myocardial oxyradical exposure and improves myocardial functional and biochemical integrity. Thyroid hormonal supplementation may provide a modest additional benefit in septic animals.

Triiodothyronine therapy lowers the incidence of atrial fibrillation after cardiac operations

BACKGROUND

Cardiopulmonary bypass results in a euthyroid sick state, and recent evidence suggests that perioperative triiodothyronine (T3) supplementation may have hemodynamic benefits. In light of the known effects of thyroid hormone on atrial electrophysiology, we investigated the effects of perioperative T3 supplementation on the incidence of postoperative arrhythmias.

METHODS

One hundred forty-two patients with depressed left ventricular function (ejection fraction < 0.40) undergoing coronary artery bypass grafting were randomized to either T3 or placebo treatment groups in a prospective, double-blind fashion. Triiodothyronine was administered as a 0.8 micrograms/kg intravenous bolus at the time of aortic cross-clamp removal followed by an infusion of 0.113 micrograms.kg-1.h-1 for 6 hours. Patients were monitored for the development of arrhythmias during the first 5 postoperative days.

RESULTS

The incidence of sinus tachycardia and ventricular arrhythmias were similar between groups. Triiodothyronine-treated patients had a lower incidence of atrial fibrillation (24% versus 46%; p = 0.009), and fewer required cardioversion (0 versus 6; p = 0.012) or anticoagulation (2 versus 10; p = 0.013) during hospitalization. Six patients in the T3 group versus 16 in the placebo group required antiarrhythmic therapy at discharge (p = 0.019).

CONCLUSIONS

Perioperative T3 administration decreased the incidence and need for treatment of postoperative atrial fibrillation.

Ultrastructure changes associated with brain death in the human donor heart

Electromicroscopic examinations were carried out on 30 myocardial biopsies taken from 22 human donor hearts immediately after excision (prestorage) or immediately before transplantation (poststorage). All electron micrographs were independently examined by two morphologists. Eleven structures were examined in each micrograph, and each structure was scored according to the degree of injury. A good interobserver correlation was obtained in 84% of the structures scored. In the prestorage left ventricular biopsies (n = 11), approximately 20%-25% showed moderate to severe ultrastructural injury. The ultrastructural injury observed in the poststorage left ventricular biopsies (n = 15) was no different from that in the prestorage group, particularly injury to the sarcomere and mitochondria. A similar degree and pattern of injury was seen in the right ventricle (n = 4). There was no evidence that an ischemic storage period of less than 6 h increased the degree of injury seen. However, there was a higher incidence of moderate to severe injury in those hearts excised from donors initially dependent on high inotropic support.

Thyroid hormone therapy in cardiovascular disease

The relationship between thyroid disease states and cardiovascular hemodynamics is well recognized. Although the long-term effects of thyroid hormone are thought to result from changes in myocardial gene expression, attention has recently focused on acute, non-nuclear-mediated actions of L-triidothyronine (T3), the biologically active form of the hormone. Various lines of evidence have documented that T3 can act as a vasodilator and inotrope. With this recognition have come novel treatment strategies targeted at specific clinical conditions including heart failure and cardiac surgery that are associated with impaired cardiovascular performance and low serum T3 levels. An understanding of the mechanisms of action of thyroid hormone on the heart and peripheral vasculature is essential for the rational implementation of thyroid hormone as a therapeutic agent. As outlined in this review, initial clinical experience suggests that the ability of thyroid hormone to increase cardiac output and to lower systemic vascular resistance may provide a novel treatment option for physicians caring for patients with cardiovascular illness.

Thyroid hormone treatment after coronary-artery bypass surgery

BACKGROUND

Thyroid hormone has many effects on the cardiovascular system. During and after cardiopulmonary bypass, serum triiodothyronine concentrations decline transiently, which may contribute to postoperative hemodynamic dysfunction. We investigated whether the perioperative administration of triiodothyronine (liothyronine sodium) enhances cardiovascular performance in high-risk patients undergoing coronary-artery bypass surgery.

METHODS

We administered triiodothyronine or placebo to 142 patients with coronary artery disease and depressed left ventricular function. The hormone was administered as an intravenous bolus of 0.8 microgram per kilogram of body weight when the aortic cross-clamp was removed after the completion of bypass surgery and then as an infusion of 0.113 microgram per kilogram per hour for six hours. Clinical and hemodynamic responses were serially recorded, as was any need for inotropic or vasodilator drugs.

RESULTS

The patients' preoperative serum triiodothyronine concentrations were normal (mean [+/- SD] value, 81 +/- 22 ng per deciliter [1.2 +/- 0.3 nmol per liter]), and they decreased by 40 percent (P < 0.001) 30 minutes after the onset of cardiopulmonary bypass. The concentrations in patients given intravenous triiodothyronine became supranormal and were significantly higher than those in patients given placebo (P < 0.001). However, the concentrations were once again similar in the two groups 24 hours after surgery. The mean postoperative cardiac index was higher in the triiodothyronine group (2.97 +/- 0.72 vs. 2.67 +/- 0.61 liters per minute per square meter of body-surface area, P = 0.007), and systemic vascular resistance was lower (1073 +/- 314 vs. 1235 +/- 387 dyn.sec.cm-5, P = 0.003). The two groups did not differ significantly in the incidence of arrhythmia or the need for therapy with inotropic and vasodilator drugs during the 24 hours after surgery, or in perioperative mortality and morbidity.

CONCLUSIONS

Raising serum triiodothyronine concentrations in patients undergoing coronary-artery bypass surgery increases cardiac output and lowers systemic vascular resistance, but does not change outcome or alter the need for standard postoperative therapy.

Cardiopulmonary bypass temperature does not affect postoperative euthyroid sick syndrome?

STUDY OBJECTIVE

To determine if temperature during cardiopulmonary bypass (CPB) has an effect on perioperative and postoperative thyroid function.

DESIGN

Prospective study comparing thyroid function during and after hypothermic and normothermic CPB.

SETTING

Cardiac surgical unit at a university-affiliated hospital.

PATIENTS

Twelve patients scheduled to undergo cardiac operations with normothermic (n = 6) or hypothermic (n = 6) CPB.

INTERVENTIONS

Blood was analyzed for serum concentration of total thyroxine (TT4), total triiodothyronine (TT3), free T3 (fT3), reverse T3 (rT3), and thyroid stimulating hormone (TSH) preoperatively, 60 min after CPB was initiated, 30 min after discontinuing CPB, and on postoperative days (POD) 1, 3, and 5.

MEASUREMENTS AND RESULTS

Patients who underwent either cold (26 degrees +/- 5 degrees C) or warm (35 degrees +/- 1 degree C) CPB were comparable with regard to age, body weight, duration of CPB, cross-clamp time, use of inotropes, total heparin dose, and length of hospital stay. Incidence of postoperative myocardial infarction, congestive heart failure, and death were similar. In both groups, TT4 and TT3 were reduced below baseline values beginning with CPB and persisting for up to 5 days after CPB (p < 0.05), free T3 was reduced for up to 3 days after CPB (p < 0.05), mean serum rT3 was elevated on POD 1 and POD 3 (p < 0.05), and TSH remained unchanged.

CONCLUSION

The results of this study suggest that normothermic CPB does not prevent the development of the "euthyroid sick syndrome" during and after CPB. Despite these changes in thyroid function, most patients in both groups had a normal postoperative recovery.

The direct effects of 3,5,3'-triiodo-L-thyronine (T3) on myocyte contractile processes. Insights into mechanisms of action

Administration of 3,5,3'-triiodo-L-thyronine (T3) has recently been suggested to acutely improve left ventricular performance. However, the cellular and molecular mechanisms responsible for this improvement in left ventricular function with T3 remained unknown. Accordingly, the present study examined the direct effects of T3 administration on myocyte contractile function and the sarcolemmal systems that might potentially contribute to these effects. In isolated porcine left ventricular myocytes (n = 81), velocity of shortening increased in the presence of 80 pmol/L T3 compared with that in untreated myocytes (117.0 +/- 5.0 versus 77.3 +/- 3.3 microns/sec, p < 0.05). In a separate series of experiments (n = 29), myocyte velocity of shortening increased in the presence of both T3 and beta-adrenergic receptor stimulation (25 nmol/L isoproterenol) to greater than that with beta-adrenergic receptor stimulation alone (274.3 +/- 16.9 versus 203.7 +/- 16.2 microns/sec, p < 0.05). Cyclic adenosine monophosphate generation was next examined in isolated myocyte preparations (n = 9). In the presence of T3, no significant increase in cyclic-adenosine monophosphate generation was observed compared with that in untreated myocytes (39.1 +/- 8.3 versus 24.7 +/- 5.8 fmols/myocyte, p = 0.17). However, in the presence of both T3 and beta-adrenergic receptor stimulation, cyclic-adenosine monophosphate generation increased significantly to greater than that with beta-adrenergic receptor stimulation alone (224.4 +/- 61.1 versus 120.1 +/- 35.5 fmoles/myocyte, p < 0.05). Because cyclic-adenosine monophosphate modulates intracellular Ca2+ processes, L-type Ca+2 channel current (patch clamp methods; -picoamp/picofarad, n = 15) and peak intracellular Ca+2 levels (fura 2 ionic measurement, n = 47) were next measured. In the presence of T3, a shift in the activation voltage at peak L-type Ca+2 channel current was observed from baseline (5.5 +/- 1.4 versus 9.0 +/- 1.0 mV, p < 0.05). Furthermore, in the presence of both T3 and beta-adrenergic receptor stimulation, peak L-type Ca+2 channel current (8.9 +/- 0.7 versus 6.3 +/- 1.0 mV, p < 0.05) and peak intracellular Ca+2 levels (189.9 +/- 8.4 versus 171.7 +/- 8.3 nmol/L, p < 0.05) increased compared with values obtained with beta-adrenergic receptor stimulation alone. Important findings from the present study were twofold: (1) T3 improved myocyte contractile processes through a cyclic-adenosine monophosphate-independent mechanism and (2) T3 potentiated the effects of beta-adrenergic receptor stimulation transduction by increasing cyclic-adenosine monophosphate production, L-type Ca+2 channel current, and Ca+2 availability to the myocyte contractile apparatus.(ABSTRACT TRUNCATED AT 400 WORDS)

Interaction of thyroid hormone and heparin in postischemic myocardial recovery

BACKGROUND

Triiodothyronine (T3) administration can improve postischemic myocardial recovery. Heparin can interfere with cellular binding of T3. Introduction of heparin into an isolated heart model may interfere with this effect.

METHODS

Four groups of 8 rat hearts were placed on a modified Langendorff apparatus. All groups underwent 15 minutes of perfusion with modified Krebs-Henseleit solution (KH), followed by 20 minutes of normothermic global ischemia and 30 minutes of reperfusion. Group I underwent reperfusion with KH. Group II underwent reperfusion with KH and 1 x 10(-6) mol/L of T3. In group III, hearts underwent preischemic perfusion with heparinized KH (1,000 U/L) and reperfusion with KH containing 1 x 10(-6) mol/L of T3 and 1,000 U/L of heparin. In group IV, rats were given heparin at 2,000 IU/kg 30 minutes before sacrifice, and isolated hearts were reperfused with KH and 1 x 10(-6) mol/L of T3. A latex balloon in the left ventricle monitored hemodynamic variables.

RESULTS

Left ventricular developed pressure throughout postischemic reperfusion was greater in all the groups receiving T3 when compared with group I. Group II showed significantly greater recovery than either group III (p < 0.05) or group IV (p < 0.05).

CONCLUSIONS

Addition of T3 to the reperfusate enhances postischemic myocardial recovery in the isolated heart model, whereas addition of heparin reduces this effect.

Effect of triiodothyronine administration in experimental myocardial injury

Twelve healthy pigs were subjected to a 20-min, period of regional myocardial ischemia by snaring the left anterior descending coronary artery (LAD) between its first and second diagonal branches. The resulting myocardial injury caused significant acute hemodynamic impairments. Cardiac index declined significantly during reperfusion interval and returned to preischemic level by postoperative day 7. Plasma total triiodothyronine (TT3), free triiodothyronine (FT3) and free fatty acid (FFA) decreased gradually and reached the nadir at 6 h after LAD occlusion. In contrast, plasma reverse triiodothyronine (rT3) increased progressively after LAD occlusion and reperfusion. To investigate the effect of T3 on ischemic myocardium, T3 (0.2 microgram/kg/dose; n = 5) or saline (placebo; n = 6) was administered immediately, 30 min, 60 min, 90 min, and 120 min after reperfusion. Plasma TT3 and FT3 increased dramatically after triiodothyronine supplement but declined to presichemic level at six h after LAD occlusion. The pigs treated with T3 demonstrated a rapid improvement in cardiac index over the reperfusion interval, whereas cardiac index in the placebo group remained depressed. Myocardial oxygen consumption estimated by rate pressure product showed no difference between placebo and T3-treated groups. Oxygen extraction as O2 saturation difference between aorta and coronary sinus was less in T3-treated group. Nine pigs (four in the T3-treated group and five in the placebo group) were subjected to euthanasia with hypertonic KCl solution on postoperative day 7. Myocardial infarct size determined by triphenyltetrazolium chloride (TTC) tissue enzyme staining technique was not significantly different between T3-treated and placebo groups. We concluded that this animal model is a useful model of myocardial injury simulating "euthyroid sick syndrome" as seen in patients with cardiopulmonary bypass, and T3 supplementation after reperfusion significantly enhanced postischemic left ventricular functional recovery but did not affect myocardial oxygen consumption and myocardial infarct size.

Pretreatment with 3,5,3'triiodo-L-thyronine (T3). Effects on myocyte contractile function after hypothermic cardioplegic arrest and rewarming

Circulating levels of 3,5,3'triiodo-L-thyronine are depressed after cardiopulmonary bypass and have been implicated to play a contributory role in the alterations in left ventricular function after hypothermic cardioplegic arrest and rewarming. The central hypothesis of the present study was that pretreatment of isolated myocytes with triiodothyronine will have a direct and beneficial effect on contractile performance after hypothermic cardioplegic arrest and rewarming. Contractile function in isolated pig left ventricular myocytes was examined by video microscopy after the following treatment protocols: (1) 37 degrees C incubation in medium (normothermia) for 2 hours with triiodothyronine followed by a 2-hour normothermic incubation with no triiodothyronine, (2) 4 hours of normothermic incubation with no triiodothyronine, (3) normothermic incubation for 2 hours with triiodothyronine followed by 2 hours of hyperkalemic, hypothermic cardioplegic arrest ([K+]:24 mmol/L; 4 degrees C) and subsequent rewarming, and (4) normothermic incubation for 2 hours with no triiodothyronine followed by 2 hours of hyperkalemic, hypothermic cardioplegic arrest and rewarming. Two hours of normothermia with triiodothyronine increased myocyte contractile function by 30% compared with values in untreated control myocytes, and this increase persisted after a subsequent 2-hour incubation under normothermic conditions with no triiodothyronine. For example, myocyte velocity of shortening in triiodothyronine-pretreated myocytes was 84 +/- 4.9 microns/sec compared with 62 +/- 2.8 microns/sec in control myocytes (p < 0.05). Cardioplegic arrest and subsequent rewarming caused a significant reduction in myocyte velocity of shortening from normothermic values (37 +/- 3.4 microns/sec, p < 0.05). However, in myocytes pretreated with triiodothyronine, myocyte contractile function was significantly higher after hypothermic cardioplegic arrest and rewarming (54 +/- 2.5 microns/sec, p < 0.05). In a second series of experiments, beta-adrenergic responsiveness was examined after pretreatment with triiodothyronine. In the presence of the beta-adrenergic agonist isoproterenol (25 nmol/L), myocyte contractile function was increased by 26% in the triiodothyronine-treated myocytes compared with that in untreated control myocytes. This enhanced beta-adrenergic responsiveness with triiodothyronine pretreatment persisted with subsequent exposure to hypothermic cardioplegic arrest and rewarming. In summary, triiodothyronine pretreatment caused an increase in myocyte contractile function and beta-adrenergic responsiveness under normothermic conditions and after hypothermic cardioplegic arrest and rewarming. Thus the present study provides direct evidence to suggest that preemptive treatment with triiodothyronine may improve left ventricular contractile performance after hypothermic cardioplegic arrest and rewarming.

3,5,3' Triiodo-L-thyronine pretreatment with cardioplegic arrest and chronic left ventricular dysfunction

BACKGROUND

The active form of thyroid hormone, T3, may be an important determinant of left ventricular (LV) function after hypothermic cardioplegic arrest and rewarming, particularly in patients with preexisting LV dysfunction. Thus, the present project tested the hypothesis that T3 pretreatment will improve myocyte contractile performance after hypothermic cardioplegic arrest and rewarming in the setting of chronic LV dysfunction.

METHODS

Control LV porcine myocytes (n = 160) and cardiomyopathic LV (rapid pacing for 3 weeks at 240 beats/min) myocytes (n = 100) were treated with or without 80 pmol/L T3. Myocytes then were maintained in normothermic conditions (2 hours at 37 degrees C in media) or exposed to hypothermic cardioplegic arrest ([K+], 24 mmol/L; 2 hours at 4 degrees C) with subsequent rewarming.

RESULTS

After cardioplegic arrest and rewarming, T3 pretreatment increased myocyte velocity of shortening by 41% in control myocytes and by 35% in cardiomyopathic myocytes when compared to untreated myocytes. Furthermore, T3 pretreatment followed by beta-adrenergic receptor stimulation with isoproterenol (25 nmol/L) improved myocyte velocity of shortening by 24% in control myocytes and 90% in cardiomyopathic myocytes after hypothermic cardioplegic arrest and rewarming, as compared with untreated myocytes.

CONCLUSIONS

In summary, this study provides evidence to suggest that preemptive treatment with T3 may improve LV pump function and beta-adrenergic responsiveness after hypothermic cardioplegic arrest and rewarming in patients with underlying LV dysfunction.

Triiodothyronine improves left ventricular function without oxygen wasting effects after global hypothermic ischemia

Cardiopulmonary bypass results in a "euthyroid sick" state. Recently, interest has focused on the relationship between low serum triiodothyronine levels and postoperative cardiovascular hemodynamics. The present study was undertaken to more clearly define the acute effects of triiodothyronine on myocardial mechanics and energetics after hypothermic global ischemia using an ex-vivo canine heart preparation to model the clinical condition. Experiments were performed on isolated hearts subjected to hyperkalemic arrest with 90 minutes of hypothermic (10 degrees C) ischemia. Isolated hearts were cross-perfused by euthyroid support dogs in which triiodothyronine levels spontaneously decreased by 65% to 75% (p < 0.01) after the initiation of cross-perfusion. In nine heart preparations, triiodothyronine (Triostat) was given as a bolus dose (0.2 micrograms/kg) after 1 hour of baseline data collection with a subsequent measurable rise in serum triiodothyronine levels (p < 0.01). In six postischemic hearts, reverse triiodothyronine was given as a 0.2 micrograms/kg bolus. Triiodothyronine was also administered to a group of eight nonischemic, continuously perfused isolated hearts. Intrinsic myocardial contractility was assessed by analysis of the preload recruitable stroke work area, energetic efficiency from the myocardial oxygen consumption-pressure-volume area relationship, and coronary vascular resistance from analysis of coronary flow and perfusion pressure. Acute administration of triiodothyronine to postischemic hearts improved the preload recruitable stroke work area from 9.5 +/- 1.42 to 14.9 +/- 2.03 x 10(7) erg/ml, a 56% increase from baseline (p < 0.001), but had no effect on the preload recruitable stroke work area of the nonischemic hearts. The inotropic response resulting from triiodothyronine treatment did not alter the myocardial oxygen consumption-pressure-volume area relationship. Triiodothyronine treatment was associated with significantly decreased coronary resistance and increased coronary flow through a range of diastolic loading conditions in the postischemic hearts. The biologically inactive thyroid hormone metabolite reverse triiodothyronine was without effect on any of the measured parameters. On the basis of these results, we conclude that the low triiodothyronine state of cardiopulmonary bypass can be reproduced in this isolated heart model and that acute triiodothyronine treatment results in a unique inotropic action manifest only in the postischemic reperfused myocardium and is accomplished without oxygen wasting effects.

Thyroid hormones homeostasis in pediatric patients during and after cardiopulmonary bypass

The concentrations of thyroid hormones were measured in 14 pediatric patients before, during, and after cardiopulmonary bypass. The ages of the patients ranged between 18 months and 14 years. Patients were kept normothermic, or moderate or deep hypothermia was induced depending on the specific pathologic condition involved. A marked reduction in the levels of total triiodothyronine, total thyroxine, free triiodothyronine, and thyroid-stimulating hormone, and in the ratio of free triiodothyronine to free thyroxine was detected during the time frame of the study. The minimum levels of each hormone were reached between 12 and 48 hours after cardiopulmonary bypass, indicating that changes in thyroid function and in the conversion of thyroxine to triiodothyronine are triggered by cardiopulmonary bypass and represent specific phenomena, and that these changes are progressively exacerbated during the post-operative period. The thyroid-stimulating hormone level was markedly reduced versus its baseline values (24% +/- 0.13%), despite low levels of both total (40% +/- 18%) and free (39% +/- 20%) triiodothyronine: it returned to its preoperative level by the third postoperative day, but both the total (75% +/- 10%) and free (74% +/- 3%) triiodothyronine levels remained below their baseline values for 7 days postoperatively. Neither hemodilution nor hypothermia was responsible for the alteration observed. We conclude that pediatric patients undergoing cardiopulmonary bypass manifest changes in hormone metabolism similar to those seen in adult patients. These changes increase progressively during the postoperative period, and are still present 7 days postoperatively. The exact mechanism responsible for causing these changes is not thoroughly understood. Whether triiodothyronine replacement therapy is beneficial or deleterious remains controversial.