Reperfusion of infarcting myocardium: benefit of surgical reperfusion in a chronic model

Reduction of infarct size and preservation of endothelial function by multidose intravenous adenosine during extended reperfusion

It has been proposed that infarct extension is developed from the early to the late phase of reperfusion (R). This study compares the protective effect of single or multidose administration of adenosine (Ado) on infarct size during early and late phases of R by attenuating neutrophil (PMN) recruitment. Forty-one dogs underwent 60-min left anterior descending artery (LAD) ischemia followed by 6, 24, and 48 h of R, respectively. Infarct size (%) increased over 6 to 24 h (27 +/- 2 to 38 +/- 4; P < 0.05 24 h versus 6 h group), with a corresponding increase in creatine kinase activity. Transmural myocardial blood flow (mL/min/g) decreased from 6 to 24 h (0.47 +/- 0.02 to 0.29 +/- 0.02; P < 0.05 24 h versus 6 h group). PMN localization (mm(2) myocardium) in the perinecrotic tissue detected by immunohistochemistry with anti-CD18 antibody, and accumulation detected by myeloperoxidase (MPO, DeltaAbs/min/g) increased from 6 to 24 h (292 +/- 25 to 605 +/- 44; P < 0.05 24 h versus 6 h group; and 55 +/- 7 to 96 +/- 5; P < 0.05 24 h versus 6 h group), respectively. In in vitro analysis, PMN adherence (mm(2) endothelium) to postischemic LAD increased from 98 +/- 2 to 125 +/- 3 (P < 0.05 24 h versus 6 h group) and maximal LAD endothelium-dependent relaxation (%) impaired from 6 to 24 h (74 +/- 7 to 42 +/- 10; P < 0.05 24 h versus 6 h group). Intravenous Ado (140 microg/kg/min) for 2 h at R reduced infarct size (17 +/- 2; P < 0.05 Ado versus 6 h group), CD18 positive cells (130 +/- 10; P < 0.05 Ado versus 6 h group), MPO (14 +/- 3; P < 0.05 Ado versus 6 h group), PMN adherence (57 +/- 2; P < 0.05 Ado versus 6 h group), and augmented LAD vascular relaxation (102 +/- 5 versus 74 +/- 7; P < 0.05 Ado versus 6 h group). However, this protection by Ado was lost when R was extended to 24 h. Treatment with multiple infusion of Ado at 2, 6, 12, and 18 h R significantly preserved protective effects seen at 6 h R in the Ado group. Protection by multidose Ado was still preserved when R was extended to an additional 24 h. These data suggest that interventions aiming at permanently reducing R injury may thus need to be administered not only at early R, but also during late phase. A slow wave of PMN accumulation at late R may be involved in the extension of infarction and endothelial dysfunction.

Pressure-volume loops: a dynamic approach to the assessment of ventricular function

Analysis of ventricular function in terms of pressure-volume or pressure-dimension relationships allows global and regional ventricular dynamics to be fully analyzed. In addition, this approach allows the relationships between muscle function (contractility, stiffness, potential energy) and pump function (stroke volume, stroke work) to be determined and predicted. Alterations in ventricular loading conditions can also be examined in terms of muscle and pump function. However, this analysis is more complex than initially thought and considerable care must be taken especially when regional ischemia is concerned. Moreover, some of the early assumptions have been disproved and conclusions can only be drawn from studies in which full assessment of changes in pressure and dimensions is available.

Postcardioplegia acute cardiac dysfunction and reperfusion injury

In cardiac surgery, an obligatory period of ischemia is imposed in order to provide a convenient operative field. Brief periods of ischemia produce systolic and diastolic abnormalities related to pathology occurring during ischemia per se (ischemic injury) or expressed after the onset of reperfusion (reperfusion injury). In the surgical setting, ischemia may be encountered preoperatively with preexisting coronary disease, hypotension, or ventricular fibrillation, between intermittent infusions of cardioplegia solutions, or as a result of maldistribution of cardioplegia solution. The potential for reperfusion injury exists not only at the time of cross-clamp removal, but also with each infusion of cardioplegia solution. Infusion of cardioplegic solution is, in fact, a form of reperfusion to previously ischemic myocardium. Ischemic injury and reperfusion injury are intimately linked in that the severity of ischemia sets the stage for and determines, in part, the extent of reperfusion injury. Mild-to-moderate systolic dysfunction, which may be called "postcardioplegia stunning," remains a significant complication after cardiac surgery. More significant postoperative functional depression may occur in hearts with severe preoperative dysfunction, and in operations requiring long cross-clamp times. In addition, the failure to adequately distribute cardioplegic solution to all areas of the myocardium because of coronary stenoses, high coronary resistance or inadequate delivery pressure-flow relations, contributes to postcardioplegia dysfunction. However, the cardioplegic solution itself may also contribute to postcardioplegic dysfunction by creating temporary ionic and metabolic abnormalities. In addition, systemic hypocalcemia or hyperkalemia resulting from using large doses of cardioplegic solution may temporarily aggravate postcardioplegic mechanical dysfunction. Current formulations and strategies for delivery of cardioplegia solutions are designed to address the various contributors to both ischemic and reperfusion injury that may impact on postoperative mechanical performance. Ischemic injury is avoided by reducing myocardial oxygen demand by engaging immediate arrest and cooling the heart to approximately 10 degrees centigrade, and intermittently infusing solution to reoxygenate the myocardium, maintain hypothermia, and wash out accumulated metabolites. Reperfusion injury may be avoided by infusing hyperosmotic solutions at moderate pressures, and by incorporating oxygen radical scavengers or inhibitors to reduce membrane lipid peroxidation, myocellular and microcirculatory (endothelium) damage.(ABSTRACT TRUNCATED AT 400 WORDS)

Circulatory support with shock due to acute myocardial infarction

Cardiogenic shock after acute myocardial infarction develops according to the amount of lost myocardium, function of remote myocardium, and the phenomenon of infarct expansion. Patients treated with mechanical support alone, without additional measures, have a mortality rate of 80%, the same as patients treated medically. Emergency angioplasty and emergency coronary artery bypass grafting can reduce mortality in certain subsets of patients to 40%. Patients with more severe shock and secondary organ dysfunction may be treated with mechanical bridging to transplantation with survival rates varying between 45% and 76%. Percutaneous support systems may be used to resuscitate a patient or to temporize, allowing time to perform diagnostic studies to determine if the patient is suitable for revascularization or heart transplantation. Intravenous enoximone may improve cardiac function as well and thus allow better decision making for further therapy.