Regression of left ventricular dilation and hypertrophy after removal of volume overload. Morphological and ultrastructural study

Congenital Mitral Regurgitation Repair Based on Carpentier's Classification: Long-Term Outcomes

BACKGROUND

There are few reports of the outcomes of standardized surgical management addressing the etiologic and morphologic aspects of mitral valve malformation according to Carpentier's classification. This study aimed to evaluate the long-term outcomes of mitral valve repair in children according to Carpentier's classification.

METHODS

Patients who underwent mitral valve repair at our institution between 2000 and 2021 were retrospectively reviewed. Preoperative data, surgical techniques, and outcomes were analyzed according to Carpentier's classification. The proportion of patients free of mitral valve replacement and reoperation was estimated using Kaplan-Meier analysis.

RESULTS

Twenty-three patients (median operative age, four months) were followed up for 10 (range, 2-21) years. Preoperative mitral regurgitation was severe in 12 patients and moderate in 11 patients. Eight, five, seven, and three patients had Carpentier's type 1, 2, 3, and 4 lesions, respectively. Ventricular septal defect (N = 9) and double outlet of the great arteries from the right ventricle (N = 3) were the most commonly associated cardiac malformations. There were no cases of operative mortality or deaths during the follow-up. The overall five-year rate of freedom from mitral valve replacement was 91%, whereas the five-year rates of freedom from reoperation were 74%, 80%, 71%, and 67% in type 1, 2, 3, and 4 lesions, respectively. Postoperative mitral regurgitation at the last follow-up was moderate in three patients and less than mild in 20 patients.

CONCLUSIONS

Current surgical management of congenital mitral regurgitation is generally considered adequate; however, more complicated cases required a combination of various surgical techniques.

Nanoscale three-dimensional imaging of the human myocyte

The ventricular human myocyte is spatially organized for optimal ATP and Ca(2+) delivery to sarcomeric myosin and ionic pumps during every excitation-contraction cycle. Comprehension of three-dimensional geometry of the tightly packed ultrastructure has been derived from discontinuous two-dimensional images, but has never been precisely reconstructed or analyzed in human myocardium. Using a focused ion beam scanning electron microscope, we created nanoscale resolution serial images to quantify the three-dimensional ultrastructure of a human left ventricular myocyte. Transverse tubules (t-tubule), lipid droplets, A-bands, and mitochondria occupy 1.8, 1.9, 10.8, and 27.9% of the myocyte volume, respectively. The complex t-tubule system has a small tortuosity (1.04±0.01), and is composed of long transverse segments with diameters of 317±24nm and short branches. Our data indicates that lipid droplets located well beneath the sarcolemma are proximal to t-tubules, where 59% (13 of 22) of lipid droplet centroids are within 0.50μm of a t-tubule. This spatial association could have an important implication in the development and treatment of heart failure because it connects two independently known pathophysiological alterations, a substrate switch from fatty acids to glucose and t-tubular derangement.

Timing in resolution of left heart dilation according to the degree of mitral regurgitation in children with ventricular septal defect after surgical closure

OBJECTIVE

Children with ventricular septal defects (VSD) can have chronic volume overload, which can result in changes of left heart echocardiographic parameters. To evaluate the changes before and after surgical closure, the children were divided into three groups according to the degree of mitral regurgitation (MR), and their echocardiographic characteristics were reviewed at serial follow-up after surgical closure.

METHODS

The preoperative, and one-, three-, and 12-month postoperative echocardiographic data of 40 children who underwent surgical closure of VSD were retrospectively reviewed. Left ventricular end-diastolic volume (LVEDV), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD), mitral valvular characteristics, including degree of MR and mitral valve annulus, and left atrial (LA) characteristics, including volume and dimensions, were observed.

RESULTS

Preoperative LVEDV, LVEDD, LVESD, mitral valvular annulus, LA volume, and LA dimensions were significantly larger in children with MR. Additionally, there were significant decreases in LVEDV, LVEDD, LA volume, and LA dimensions at one, three, and 12 months postoperatively. The degree of MR also improved to a lower grade after surgical closure of the VSD without additional mitral valve repair.

CONCLUSION

The echocardiographic parameters of left heart dilation and MR in children with VSD improved within the first year after surgical closure without additional mitral valve repair. Furthermore, in all of the patients with VSD, regardless of MR, LA dilation was reduced within three months after surgical closure of the VSD; however, LV and mitral valve annular dilatation decreased within 12 months.

Outcomes of mitral regurgitation associated with large ventricular septal defect and a normal mitral valve apparatus: does intact atrial septum have an impact?

The hemodynamics of isolated large ventricular septal defect with an intact atrial septum results in greater mitral valve (MV) annular dilation and an increased incidence of mitral regurgitation (MR). MR will resolve in most patients after surgical VSD closure alone without MV repair.

FoxO transcription factors promote autophagy in cardiomyocytes

In the heart, autophagy is required for normal cardiac function and also has been implicated in cardiovascular disease. FoxO transcription factors promote autophagy in skeletal muscle and have additional roles in regulation of cell size, proliferation, and metabolism. Here we investigate the role of FoxO transcription factors in regulating autophagy and cell size in cardiomyocytes. In cultured rat neonatal cardiomyocytes, glucose deprivation leads to decreased cell size and induction of autophagy pathway genes LC3, Gabarapl1, and Atg12. Likewise, overexpression of either FoxO1 or FoxO3 reduces cardiomyocyte cell size and induces expression of autophagy pathway genes. Moreover, inhibition of FoxO activity by dominant negative FoxO1 (Delta256) blocks cardiomyocyte cell size reduction upon starvation, suggesting the necessity of FoxO function in cardiomyocyte cell size regulation. Under starvation conditions, endogenous FoxO1 and FoxO3 are localized to the nucleus and bind to promoter sequences of Gabarapl1 and Atg12. In vivo studies show that cellular stress, such as starvation or ischemia/reperfusion in mice, results in induction of autophagy in the heart with concomitant dephosphorylation of FoxO, consistent with increased activity of nuclear FoxO transcription factors. Together these results provide evidence for an important role for FoxO1 and FoxO3 in regulating autophagy and cell size in cardiomyocytes.

Atrophy-related ubiquitin ligases atrogin-1 and MuRF-1 are associated with uterine smooth muscle involution in the postpartum period

The regulation of cell size depends on a delicate balance between protein synthesis and breakdown. Skeletal and cardiac muscle adapt to hormonal and neuronal stimuli and can rapidly hypertrophy and atrophy; however, the extent to which these processes occur in smooth muscle is less clear. Atrophy in striated muscle results from enhanced protein breakdown and is associated with a common transcriptional profile and activation of the ubiquitin-proteasome pathway, including induction of the muscle-specific ubiquitin protein ligases atrogin-1 and muscle ring-finger protein 1 (MuRF-1). Here we show that atrogin-1 is also expressed in smooth muscle, and that both atrogin-1 and MuRF-1 are upregulated in the uterus following delivery, as rapid involution occurs. While these two genes are similarly induced in all types of muscle during rapid loss of cell mass, other striated muscle atrophy-specific transcriptional changes are not observed during uterine involution, suggesting different underlying molecular mechanisms. These results raise the possibility that activation of atrogin-1 and MuRF-1 may be a common general adaptation in cells undergoing a rapid reduction in size.

The FOXO3a transcription factor regulates cardiac myocyte size downstream of AKT signaling

Although signaling mechanisms inducing cardiac hypertrophy have been extensively studied, little is known about the mechanisms that reverse cardiac hypertrophy. Here, we describe the existence of a similar Akt/forkhead signaling axis in cardiac myocytes in vitro and in vivo, which is regulated by insulin, insulin-like growth factor (IGF), stretch, pressure overload, and angiotensin II stimulation. FOXO3a gene transfer prevented both IGF and stretch-induced hypertrophy in rat neonatal cardiac myocyte cultures in vitro. Transduction with FOXO3a also caused a significant reduction in cardiomyocyte size in mouse hearts in vivo. Akt/FOXO signaling regulated the expression of multiple atrophy-related genes "atrogenes," including the ubiquitin ligase atrogin-1 (MAFbx). In cardiac myocyte cultures, transduction with constitutively active Akt or treatment with IGF suppressed atrogin-1 mRNA expression, whereas transduction with FOXO3a stimulated its expression. FOXO3a transduction activated the atrogin-1 promoter in both cultured myocytes and mouse heart. Thus, in cardiomyocytes, as in skeletal muscle, FOXO3a activates an atrogene transcriptional program, which retards or prevents hypertrophy and is down-regulated by multiple physiological and pathological stimuli of myocyte growth.

Time-dependent remodeling of transmural architecture underlying abnormal ventricular geometry in chronic volume overload heart failure

To test the hypothesis that the abnormal ventricular geometry in failing hearts may be accounted for by regionally selective remodeling of myocardial laminae or sheets, we investigated remodeling of the transmural architecture in chronic volume overload induced by an aortocaval shunt. We determined three-dimensional finite deformation at apical and basal sites in left ventricular anterior wall of six dogs with the use of biplane cineradiography of implanted markers. Myocardial strains at end diastole were measured at a failing state referred to control to describe remodeling of myofibers and sheet structures over time. After 9 +/- 2 wk (means +/- SE) of volume overload, the myocardial volume within the marker sets increased by >20%. At 2 wk, the basal site had myofiber elongation (0.099 +/- 0.030; P <0.05), whereas the apical site did not [P=not significant (NS)]. Sheet shear at the basal site increased progressively toward the final study (0.040 +/- 0.003 at 2 wk and 0.054 +/- 0.021 at final; both P <0.05), which contributed to a significant increase in wall thickness at the final study (0.181 +/- 0.047; P < 0.05), whereas the apical site did not (P=NS). We conclude that the remodeling of the transmural architecture is regionally heterogeneous in chronic volume overload. The early differences in fiber elongation seem most likely due to a regional gradient in diastolic wall stress, whereas the late differences in wall thickness are most likely related to regional differences in the laminar architecture of the wall. These results suggest that the temporal progression of ventricular remodeling may be anatomically designed at the level of regional laminar architecture.

Reverse structural and gap-junctional remodeling after prolonged atrial fibrillation in the goat

BACKGROUND

Prolonged atrial fibrillation (AF) results in electrical, structural, and gap-junctional remodeling. We examined the reversibility of the changes in (ultra)structure and gap junctions.

METHODS AND RESULTS

Four groups of goats were used: (1) sinus rhythm (SR), (2) 4 months' AF (4 mo AF), (3) 2 months' SR after 4 mo AF (2 mo post-AF), and (4) 4 months' SR after 4 mo AF (4 mo post-AF). Atria were characterized electrophysiologically, (ultra)structure was studied by light and electron microscopy, and structural and gap-junctional protein expression was studied by immunohistochemistry or Western blotting. The atrial effective refractory period had completely returned to normal values 2 mo post-AF. Induced AF episodes still lasted for minutes at 2 and 4 mo post-AF, compared with seconds in the SR group. Structural abnormalities were still present at 2 and 4 mo post-AF, although to a lesser extent. The increased atrial myocyte diameter was back to normal at 4 mo post-AF. The number of myocytes with severe myolysis had almost normalized 4 mo post-AF, whereas myocytes with mild myolysis remained significantly increased. Extracellular matrix area fraction after 4 mo AF was similar to SR. However, the extracellular matrix fraction per myocyte had increased after 4 mo AF and remained higher post-AF. Changes in expression of structural proteins were partially restored post-AF. The reduction of connexin 40 that was observed during AF was completely reversed at 4 mo post-AF.

CONCLUSIONS

Recovery from structural remodeling after 4 mo AF is a slow process and is still incomplete 4 mo post-AF. Several months post-AF, the duration of AF episodes is still prolonged (minutes).

Preserved contractile function despite atrophic remodeling in unloaded rat hearts

The present study was designed to determine whether myocardial atrophy is necessarily associated with changes in cardiac contractility. Myocardial unloading of normal hearts was produced via heterotopic transplantation in rats. Contractions of isolated myocytes (1.2 mM Ca2+; 37 degrees C) were assessed during field stimulation (0.5, 1.0, and 2.0 Hz), and papillary muscle contractions were assessed during direct stimulation (2.0 mM Ca2+; 37 degrees C; 0.5 Hz). Hemodynamic unloading was associated with a 41% decrease in median myocyte volume and proportional decreases in myocyte length and width. Nevertheless, atrophic myocytes had normal fractional shortening, time to peak contraction, and relaxation times. Despite decreases in absolute maximal force generation (F(max)), there were no differences in F(max)/ area in papillary muscles isolated from unloaded transplanted hearts. Therefore, atrophic remodeling after unloading is associated with intact contractile function in isolated myocytes and papillary muscles when contractile indexes are normalized to account for reductions in cell length and cross-sectional area, respectively. Nevertheless, in the absence of compensatory increases in contractile function, reductions in myocardial mass will lead to impaired overall work capacity.

Contribution of ventricular remodeling to pathogenesis of heart failure in rats

We previously reported an approximately 50% incidence of rats with symptoms of congestive heart failure (CHF) at 8 wk postinfrarenal aorto-caval fistula. However, it was not clear whether compensatory ventricular remodeling could continue beyond 8 wk or whether the remaining animals would have developed CHF or died. Therefore, the intent of this study was to complete the characterization of this model of sustained volume overload by determining the morbidity and mortality and the temporal response of left ventricular (LV) remodeling and function beyond 8 wk. The findings demonstrate an upper limit to LV hypertrophy and substantial increases in LV volume and compliance, matrix metalloproteinase activity, and collagen volume fraction associated with the development of CHF. There was an 80% incidence of morbidity and mortality following 21 wk of chronic volume overload. These findings indicate that the development of CHF is triggered by marked ventricular dilatation and increased compliance occurring once the myocardial hypertrophic response is exhausted.

Effects of arteriovenous shunt on ventricular function in dog

BACKGROUND

The bidirectional cavopulmonary shunt has been increasingly accepted as an interim step to the Fontan operation. However, the effect(s) of chronic volume overload on ventricular function are not yet well understood.

METHODS

Twelve mongrel dogs, with (chronic volume overload group), or without (control group) a femoral arteriovenous shunt created 8 weeks before the assessment, were subjected to a right heart bypass from the right atrium to the proximal pulmonary trunk. Nonpulsatile perfusion via the bypass was achieved using a centrifugal pump and cross-clamping of the pulmonary trunk. Left ventricular function was evaluated using the end-systolic elastance and the Doppler flow pattern on echocardiograms (epicardiac and transesophageal, simultaneously) during acute volume loading.

RESULTS

The left ventricular weight and the left ventricular weight/end-diastolic volume ratio showed no change from control values. The sum of the isovolumetric contraction time and the isovolumetric relaxation time divided by the ejection time remained constant during acute volume loading in the chronic volume overload group, while an increase was demonstrated in the control group. The chronic volume overload group showed a lower Ees (30.8 +/- 16.4 mmHg/cm2 vs. 107.6 +/- 70.3 mmHg/cm2, p = 0.03) than the control group.

CONCLUSIONS

The global ventricular performance changed with chronic adaptation to the arteriovenous shunt, and became resistant to acute volume loading. Left ventricular contractility under nonpulsatile pulmonary perfusion was impaired by chronic volume overload, which is deleterious to the Fontan operation.

Acute changes in left ventricular geometry after volume reduction operation

BACKGROUND

After surgical removal of a volume load, regression of myocardial mass proceeds slowly relative to diminution in ventricular cavity size, resulting in increased wall thickness and decreased cavity dimensions, which may affect the filling properties and performance of the heart. We investigated the acute changes in ventricular geometry that occur after the Fontan operation and hemi-Fontan operation for tricuspid atresia, and compared them with closure of a ventricular septal defect in a two-ventricle heart.

METHODS

We reviewed the results of echocardiography performed before and 8 +/- 7 days after (1) Fontan operation for tricuspid atresia (n = 9), (2) hemi-Fontan operation for tricuspid atresia (n = 10), and (3) closure of a ventricular septal defect (n = 13). Measurements were made from images of the left ventricle at end-diastole: (1) apical, septal, and posterior wall thickness; and (2) long- and short-axis cavity diameters, cross-sectional areas, and ventricular volume. Posterior wall thickness to cavity dimension ratio was calculated.

RESULTS

Wall thickness increased in all groups, with the greatest degree of increase after the Fontan operation. Cavity measures decreased most dramatically after the Fontan operation, with less dramatic and equivalent changes noted after the hemi-Fontan operation and ventricular septal defect closure. Posterior wall thickness to cavity diameter ratios were equivalent in all before operation, increased after operation, and were greatest after the Fontan operation.

CONCLUSIONS

Changes in ventricular geometry identified as an increase in wall thickness and a decrease in cavity dimension are most dramatic after the Fontan operation. Changes seen after the hemi-Fontan operation are of a milder degree, which may in part explain the excellent clinical course after this operation.

Changes in diastolic function during development and correction of chronic LV volume overload produced by mitral regurgitation

BACKGROUND

Mitral regurgitation (MR) causes an augmentation in left ventricular (LV) diastolic function, increasing early diastolic filling rate and decreasing LV stiffness. Whether these changes in diastolic function persist, return to normal, or become abnormal after mitral valve replacement (MVR) is unknown.

METHODS AND RESULTS

Simultaneous LV echocardiography and catheterization studies were performed in six dogs in the baseline state (baseline), 3 months after creation of MR (chronic MR), and 3 months after MVR. Chronic MR caused LV dilation (end-diastolic dimension increased from 4.5 +/- 0.1 cm in baseline to 5.8 +/- 0.1 cm in chronic MR, p < 0.05) and eccentric LV hypertrophy (LV-to-body weight ratio increased from 3.6 +/- 0.2 g/kg in baseline to 4.9 +/- 0.4 g/kg in chronic MR, p < 0.05). Chronic MR caused an increase in LV early diastolic filling rate (peak rate of increase in minor-axis dimension increased from 11 +/- 1 cm/sec in baseline to 18 +/- 1 cm/sec in chronic MR, p < 0.05), did not change the time constant of myocardial relaxation (tau was 31 +/- 4 msec in baseline and 30 +/- 2 msec in chronic MR), and caused a decrease in the modulus of regional chamber stiffness from 7.7 +/- 1.2 in baseline to 2.4 +/- 0.03 in chronic MR, p < 0.05. MVR caused the resolution of LV dilation (end-diastolic dimension returned to normal [4.8 +/- 0.2 cm]), but three months after MVR, regression of LV hypertrophy was incomplete (LV-to-body weight ratio remained elevated [4.4 +/- 0.5 g/kg]). After MVR, LV early diastolic filling rate (8 +/- 1 cm/sec), the relaxation time constant (31 +/- 2 msec), chamber stiffness (7.1 +/- 1.8), myocardial stiffness (11.2 +/- 3.1), and LV end-diastolic pressure (8 +/- 1 mm Hg) returned to normal.

CONCLUSIONS

The enhanced diastolic function seen in chronic MR returned to normal after correction of the chronic volume overload by MVR.

Myocardial contractility and ventricular myosin isoenzymes as influenced by cardiac hypertrophy and its regression

Changes in myocardial contractility and ventricular myosin isoenzymes were examined during pressure-overloaded cardiac hypertrophy in rats. Effects of regression of cardiac hypertrophy were also examined. Cardiac hypertrophy was induced by abdominal aortic constriction in 7-week-old male Wistar rats. Regression of cardiac hypertrophy was obtained by opening the aortic band. Myocardial contractility was estimated by measuring isometrically developed tension and maximum rate of tension rise (+dT/dtmax) in isolated left-ventricular papillary muscles perfused with Tyrode solution (32 degrees C, pH 7.4, bubbled with 95% O2.5% CO2, stimulation frequency: 0.2 Hz). Left-ventricular myosin isoenzymes were separated by pyrophosphate gel electrophoresis and the isoenzyme pattern was determined by densitometry. Isometrically developed tension (T) in hypertrophic myocardium remained unchanged, but +/-dT/dtmax decreased as compared with hearts of normal rats. Decreased +/-dT/dtmax recovered near to the level in normal rats by regression of cardiac hypertrophy. Left-ventricular myosin isoenzyme pattern shifted towards VM-3 in hypertrophied myocardium and shifted again toward VM-1 by regression of cardiac hypertrophy. In conclusion, myocardial contractility and ventricular myosin isoenzymes were changed in pressure-overloaded hypertrophy in rats and these changes were reversible to a normal level by regression of cardiac hypertrophy.

Regional changes in hemodynamics and cardiac myocyte size in rats with aortocaval fistulas. 1. Developing and established hypertrophy

The effects of a large arteriovenous fistula on left and right ventricular hemodynamics and cardiac myocyte size were examined in adult rats at 1 week and 1 month after surgery. Cardiac output, left ventricular function, and right ventricular function were evaluated before obtaining isolated myocytes for cell size measurements. Average heart weight increased 35% at 1 week and 86% at 1 month in rats with fistulas. In general, myocyte hypertrophy was due to a proportional increase in length and width (length/width ratio remained constant). This change was more evident in the large hearts from rats with 1-month fistulas. At both the 1-week and 1-month intervals, the hypertrophic response of right ventricular myocytes was slightly greater than that observed in the left ventricle or interventricular septum. Left ventricular systolic pressure and dP/dtmax were significantly reduced at 1 week but returned to normal after 1 month of overloading. Left ventricular end-diastolic pressure was increased approximately fivefold and twofold at 1 week and 1 month, respectively. Right ventricular systolic pressure and dP/dtmax were increased at both intervals examined. We conclude that severe volume overloading from a large aortocaval fistula in the rat is characterized by 1) depressed left ventricular function at 1 week followed by a large compensatory hypertrophy and near normal function at 1 month, 2) right ventricular pressure overload, and 3) changes in myocyte shape that resemble normal physiological growth.

Muscle fiber orientation in the development and regression of right ventricular hypertrophy in pigs

The development and regression of right ventricular hypertrophy was investigated in 12 pigs with special reference to changes in ventricular function and myocardial fiber orientation. Nine ventricles were pressure-loaded by banding the pulmonary artery for 28-81 days, and four of them were then released from the load by removing the band. Right ventricular systolic pressure (RVSP), end-diastolic pressure (RVEDP) and end-systolic volume index (ESVI) increased significantly during banding and decreased after debanding. End-diastolic volume index (EDVI) and stroke volume index (SVI) showed no significant change during banding and after debanding. The weight of the right ventricle relative to both ventricles (RV/TV) and the thickness of muscle fibers were increased significantly in the loaded ventricles, and reduced again to the control level in ventricles released from the load. The intramyocardial distribution of angles (theta) of inclination of muscle fibers from the transverse plane of the outflow tract was estimated histometrically. There was a significantly larger proporation of circularly oriented fibers (magnitue of theta less than or equal to 30 degrees) in the pressure-loaded ventricles than in the control, whereas these fibers decreased again to the control level after removal of the pressure load. The present findings indicates that 1) the right ventricular hypertrophy induced by pressure loading is characterized not only by an increase in ventricular weight and muscle fiber thickness, but also by a change in intramyocardial fiber orientation, and 2) the hypertrophic right ventricle can regress both functionally and morphologically to a normal state after removal of the pressure load.

Impact of Fontan operation on left ventricular size and contractility in tricuspid atresia

Left ventricular dimensions and contractility were determined by echocardiography in 33 patients with tricuspid atresia in 1985 and again in 1988. Eight patients remained palliated throughout the 3-year period; neither the left ventricular end-diastolic diameter (153 +/- 15% of normal vs. 157 +/- 19%, p = NS) nor a load-independent index of contractility (rate-corrected velocity of shortening [VCFc]/end-systolic meridional stress [ESSM]) changed. Eleven patients underwent a Fontan operation during the study and were reevaluated at least 6 months after surgery; left ventricular dimension decreased (130 +/- 15% vs. 114 +/- 19%, p less than 0.001), and the contractility index VCFc/ESSM improved (p less than 0.05). Fourteen patients had undergone a Fontan operation 0.9-9.5 years (mean, 4.2 years) before initial examination in 1985. Over the 3-year period, left ventricular dimensions did not change (121 +/- 17% vs. 118 +/- 11%, p = NS), but the contractility index showed significant improvement (p less than 0.01). Eight additional patients were studied just before and after a Fontan operation to examine the early effects of surgery. Left ventricular dimensions decreased from 130 +/- 14% to 100 +/- 13% by 10 days p less than 0.001) with no further change at 2 months. An inappropriate degree of ventricular hypertrophy was observed in only the early postoperative period. Successful Fontan repair results in rapid reduction of left ventricular size, followed by regression of hypertrophy to a normal mass-to-volume ratio. Operating at more favorable dimensions and loading conditions results in an early increase in left ventricular contractility, which further improves in the medium term follow-up.

New perspectives on left ventricular hypertrophy: anatomy, physiology, and significance

The advent of echocardiography has added an important and sensitive tool for assessment of left ventricular hypertrophy (increased left ventricular mass). Recent echocardiographic studies in large population-based samples suggest an epidemic of left ventricular hypertrophy. Preliminary data suggesting important prognostic importance for such left ventricular hypertrophy (independent of standard risk factors) has fueled interest in the development, determinants, and other features of the hypertrophy. Hemodynamic and neurohumoral factors are the most prominent stimuli to adaptive (physiologic) myocardial hypertrophy, which can progress to maladaptive (pathologic) hypertrophy. The overall blood pressure experience, overweight, the cardiovascular response to recurrent psychosocial stress and physical activity level are four important correlates and potential determinants of left ventricular mass in various urban-suburban populations. Determination of the relative contributions and interrelations of these and other factors (such as heredity) to various forms of left ventricular hypertrophy found in various demographic groups warrants intensive investigation.

Complete reversibility of physiological coronary vascular abnormalities in hypertrophied hearts produced by pressure overload in the rat

Using an experimental model of ascending aortic banding in the rat, we examined whether coronary circulation abnormalities in hypertrophied hearts are reversible after debanding. 4-wk banding produced significant increases in in vivo left ventricular (LV) pressure (194 +/- 13 vs. 114 +/- 9 mmHg in shamoperated controls) and LV dry wt/body wt (48 +/- 5% above controls). In isolated hearts perfused with Krebs-Henseleit buffer, coronary flow rate (CFR) was estimated under nonworking conditions. During maximal vasodilation after 1 min-ischemia, CFR at a coronary perfusion pressure (CPP) of 100 mmHg and CFR/myocardidial mass at CPPs of 100 and 150 mmHg decreased significantly (72 +/- 5%; 53 +/- 4 and 61 +/- 4% of controls). 1 or 4 wk after debanding, LV systolic pressures were similar to control values, and the degree of myocardial hypertrophy decreased to levels 23 +/- 6 (P less than 0.01) and 11 +/- 6% (P less than 0.01) above their control values, respectively. At 1 wk there was no significant increase in CFR/myocardial mass, compared to values in the banded group (67 +/- 8 vs. 53 +/- 4% of controls at 100 mmHg and 67 +/- 9 vs. 61 +/- 4% at 150 mmHg of CPP). At 4 wk, CFR and the ratio had increased toward normal. Thus, decreased coronary perfusion in hypertrophied hearts is completely reversible.

Myocardial characteristics of thyroxine stimulated hypertrophy. A structural and functional study

The effects of thyroxine-stimulated hypertrophy (TSH) were studied in the porcine left ventricular myocardium. Hypertrophy was produced in six adult pigs by administration of triiodothyronine (1 mg/kg; i.v.) for eight days. Six pigs served as controls. The degree of hypertrophy, determined by left ventricular-to-body weight ratio, was 47%. With hypertrophy there was a significant increase in heart rate, blood pressure and myocardial blood flows. Minimal coronary resistance measured during adenosine infusion was lower in the TSH group compared with the control group. Anatomic studies revealed a balanced proliferative response of mitochondria, myofibrils and the t-tubular system during TSH. Analysis of the microvasculature indicated that the capillary and arteriolar beds both experienced growth which paralleled myocyte growth during TSH. These results suggest that thyroxine administration promotes angiogenesis in the microvascular bed which provides a partial anatomic rationale for the lowered minimal coronary resistance.

The relationship between hypertrophy and dilatation in the postmortem heart

Confusion may exist at the time of postmortem examination as to whether the diseased heart is dilated, hypertrophied, or both. Ventricular dilatation and ventricular hypertrophy were therefore evaluated by cardiac partition techniques in 441 subjects at autopsy to determine their relationship. Specific weight and surface area of each ventricle were obtained and patients were divided into categories of disease. Wall thickness measurements, a parameter routinely used in the ordinary autopsy, were found to be unreliable in defining hypertrophy. Ventricular surface area (an index of dilatation) was highly correlated with ventricular weight in most disease categories. Exceptions were cardiomyopathy and aortic stenosis, in which hypertrophy predominated. We conclude from these data that dilatation and hypertrophy occur proportionately in the postmortem heart in most disease categories except in cardiomyopathy and aortic stenosis. These findings clarify the relationship of dilatation and hypertrophy at the time of autopsy in most cases. Therefore, uncertainty as to whether cardiac dilatation or hypertrophy is present or which predominates is usually related to the inability to assess these states critically at the time of autopsy when the ordinary pathological methods are used.

Fontan hemodynamics

Right atrial-pulmonary artery connection places the pulmonary circulation in series with the systemic circulation rather than the single ventricular "parallel" circulatory arrangement that usually is present prior to repair. The accompanying central cardiac shunt and volume overload physiology are eliminated. Favorable changes in ventricular dimension, ventricular wall stress, cardiovascular efficiency, relative systemic perfusion, and arterial oxygen saturation should result. The ongoing myocardial injury associated with the single-ventricle volume overload is presumably arrested and repair is initiated to a variable degree. Some candidates for right atrial-pulmonary artery connection may not benefit from repair because of irreversible ventricular injury. More accurate indices of systolic and diastolic ventricular function should be applied to this difficult group of borderline patients to further define potential for myocardial recovery and, therefore, candidacy for Fontan repair.

Control of myocardial tissue components and cardiocyte organelles in pressure-overload hypertrophy of the cat right ventricle

Previous studies have demonstrated that there is a disproportionate increase in connective tissue in right ventricular myocardium subjected to pressure-overload hypertrophy associated with depressed cardiac contractility. While the myocardium is primarily responsive to load, the aim of the present study was to determine whether catecholamines also modulate the response of myocardial tissue components and cardiocyte organelles in pressure-overload-induced cardiac hypertrophy. Four experimental groups of cats were examined: a sham-operated control group, a group which had their pulmonary arteries banded in order to induce a pressure overload, a group which had been subjected to the same pressure overload, but in addition had beta-adrenoceptor blockade produced prior to and during the pressure overloading, and a group which had been subjected to the same pressure overload, but in addition had alpha-adrenoceptor blockade produced prior to and maintained during the pressure overloading. As in our previous study, there was a significant and equivalent degree of right ventricular hypertrophy in all experimental groups with pressure overload when assessed either as the ratio of right ventricular weight to body weight or as cardiocyte cross-sectional area. At the light microscopic level, the disproportionate increase in the volume density of myocardial connective tissue seen in banded animals was completely prevented by either alpha- or beta-adrenoceptor blockade. At the electron microscopic level, there was a reduction in the mitochondrial and myofibrillar volume fractions following beta-adrenoceptor blockade. The results of this study provide evidence for a modulatory role of catecholamines in the control of myocardial connective-tissue proliferation in pressure-overload-induced cardiac hypertrophy. There is also evidence to support the role of the adrenergic nervous system in regulating cardiocyte subcellular organelles, independent of the regulation of cardiocyte size.

Quantitative structural analysis of the myocardium during physiologic growth and induced cardiac hypertrophy: a review

The quantitative structural properties of the ventricular myocardium during postnatal physiologic growth are compared with those accompanying an increased load in the adult rat heart to determine whether induced cardiac hypertrophy is a pathologic condition or simply a form of well compensated accelerated growth. The expansion of the ventricular myocardium during maturation shows a remarkable degree of well balanced compensatory response, because the capillary microvasculature, parenchymal cells and subcellular components of myocytes all grow in proportion to the increase in cardiac mass. In contrast, the increases in myocyte diameter and length caused by pressure hypertrophy, volume hypertrophy and infarction-induced hypertrophy are consistent with concentric, eccentric and a combination of concentric and eccentric hypertrophic growth of the whole ventricle, respectively. These cellular shape changes may represent a compensatory response of the myocardium at the cellular level of organization that tends to minimize the effects of an increased pressure or volume load, or both, on the heart. Cardiac hypertrophy, however, may also show alterations affecting capillary luminal volume and surface and the mitochondrial to myofibril volume ratio, which indicate an inadequate growth adaptation of the component structures responsible for tissue oxygenation and energy production. Thus, hypertrophy of the adult heart differs from that during physiologic growth, and the hypertrophied myocardium may exhibit structural abnormalities that can be expected to increase its vulnerability to ischemia.

Ultrastructural morphometric analysis of myocardium from dogs, rats, hamsters, mice, and from human hearts

Volume densities of mitochondria, myofibrils, and unspecified cytoplasm were measured by ultrastructural morphometry in myocardium from dogs, rats, hamsters, mice, and in biopsied tissue from human hearts. Human myocardium was composed of 23% mitochondria, 59% myofibrils, and 18% cytoplasm. Volume densities for mitochondria were 22% for dogs, 28% for rats and hamsters, and 32% for mice. Myofibrillar volume densities were highest in dogs with 63%, 57% for rats and hamsters, and 49% for mice. Differences were significant between all except man and dog, and rat and hamster. In an extensive analysis of canine myocardium, it could be shown that the quantitative composition of tissue from the left ventricular free wall (anterior, lateral, posterior) and the papillary muscles was identical. There were also no differences between subepi- and subendocardium as well as the midmyocardium. Volume densities from longitudinal sections were identical to those from transversal sections. Fixation with glutaraldehyde by perfusion or immersion provided identical results. There were no differences between volume densities in samples from the left ventricular free wall (anterior, lateral, and posterior) in rats, hamsters, and mice. It is concluded that each mammalian species is characterized by a very typical quantitative composition of the myocardium. The increase in mitochondrial volume correlated well with the increase in heart rate and oxygen consumption in smaller animals. These quantitative data are regarded as the morphological correlate of the differing functional capacity of hearts from different species.

Development and regression of left ventricular hypertrophy

Left ventricular hypertrophy is an important adaptive response to chronic pressure or volume overload of the left ventricle. The different types and the pathophysiologic mechanisms of the development of left ventricular hypertrophy in various disease states are reviewed. Detection of left ventricular hypertrophy may be accomplished by electrocardiography and cardiac angiography. Echocardiography, however, is the most accurate noninvasive method to detect the presence and estimate the severity of increased left ventricular mass. The clinical significance of left ventricular hypertrophy and its prognostic implications in several cardiac diseases associated with hypertrophy are discussed. The critical transition stage from adaptive, compensatory and reversible left ventricular hypertrophy to "pathologic" hypertrophy with impaired left ventricular contractility and irreversible myocardial damage is yet unknown. Recent data are presented that provide evidence of regression of left ventricular hypertrophy after medical treatment of patients with hypertension and after aortic valve replacement in patients with aortic valve disease. The clinical importance of regression of hypertrophy and its effects on long-term prognosis remain to be determined.

Complete reversibility of cat right ventricular chronic progressive pressure overload

Chronic, progressive pressure overload of the cat right ventricle produces persistent, ongoing abnormalities of contractile, energetic, and biochemical function in vitro at a time when in vivo pump function is still normal. The present study tested the reversibility of the in vitro changes in this clinically relevant hypertrophy model. Fourteen sham-operated and 14 reversal cats were studied. After banding the animals as 1-kg kittens, right ventricular pressures were normal. Before band removal (25.2 +/- 0.5 weeks later for the control group and 25.5 +/- 0.3 weeks later for the hypertrophy reversal group), systolic right ventricular pressures were 24 +/- 1 mm Hg for controls and 71 +/- 5 mm Hg for the hypertrophy reversal group (P less than 0.05). At study, 19.5 +/- 1.1 weeks after a second sham operation for controls or 18.7 +/- 0.7 weeks after band removal for the hypertrophy reversal group, these pressures were 24 +/- 1 mm Hg for controls and 23 +/- 1 mm Hg for the hypertrophy reversal group (P = NS); cardiac output was 0.18 +/- 0.01 liters/kg per min for controls and 0.19 +/- 0.01 liters/kg per min for the hypertrophy reversal group (P = NS). The ratio of right ventricle to body weight was normal in both groups, as was the right ventricular papillary muscle myocyte cross-sectional area and the myocardial collagen concentration. A right ventricular papillary muscle from each cat was studied at 29 degrees C in a polarographic myograph. Preloaded shortening velocity was 0.79 +/- 0.04 muscle lengths/sec for controls and 0.86 +/- 0.03 muscle lengths/sec for the hypertrophy reversal group (P = NS); extent of shortening was 0.15 +/- 0.01 muscle lengths for controls and 0.16 +/- 0.01 muscle lengths for the hypertrophy reversal group (P = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

Selected enzyme activities in mouse cardiac muscle during training and terminated training

We studied the effects of running-training, heavy exercise and termination of training on the heart weight, the ratio heart to body weight and the cardiac muscle activities of actomyosin ATPase, citrate synthase, succinate dehydrogenase, cytochrome c oxidase, malate dehydrogenase, adenylate kinase and beta-glucuronidase with adult male NMRI-mice. Stable hypertrophy (6-7%), estimated by the ratio heart or ventricle weight to body weight, was achieved by 28 exercises and it was dependent on the running speed (20 vs. 25 m X min-1). The withdrawal of training for 5-61 days did not permanently decrease the heart weight or the heart to body weight ratio to the level of sedentary controls. The activity of enzymes of energy metabolism or actomyosin ATPase were not affected by training, heavy exercise or terminated training. beta-glucuronidase activity slightly (20-25%) increased in the trained animals and remained at a higher level during the period of terminated training. The results suggest that the capacity for aerobic metabolism of normal mice heart is sufficient to meet the enhanced demand for ATP imposed by running-training and that the heart enlargement occurs in equal proportions with the enzymatic potential of the cardiac tissue.

Effects of the cessation of training on left ventricular function in the racing greyhound. Serial studies in a model of cardiac hypertrophy

Exercise-induced cardiac hypertrophy has been associated with normal resting left ventricular function and, after cessation of training, variable degrees of regression. The racing greyhound is an animal with cardiac hypertrophy said to be part congenital and part exercise-induced. Racing greyhounds underwent serial cardiac catheterization three times during an 8-month period after cessation of racing/training to determine the functional consequences of the cessation of training. At the end of 8 months of inactivity the animals' hearts were excised and weighed in order to compare heart weight/body weight (HW/BW) ratios with those obtained in a group of racing greyhounds killed within one month, 19 +/- 16 days (mean +/- SD), of the cessation of training. Comparison of HW/BW ratios failed to reveal a significant difference between the serially studied group, 12.1 +/- 1.9 g/kg (mean +/- SD), and the more recently exercising group, 12.7 +/- 1.4 g/kg (mean +/- SD) of dogs. After 2 months of inactivity, 9 of 12 greyhounds in the serially studied group showed increases in max dP/dt and dP/dt normalized to a pressure of 50 mmHg. Modified pre-ejection period and peak negative dP/dt also increased significantly (p less than .004) during this same period. No further changes in these variables were found at the final 8-month study. Our failure to demonstrate a difference in HW/BW ratios between these two groups of dogs suggests that the exercise-induced component of cardiac hypertrophy in the trained racing greyhound is probably very small and, if it exists, regresses very early (less than 1 month). Changes in contractility indices that were observed occurred after this time period (between 1 and 2 months) and are therefore probably not due to regression of cardiac hypertrophy.

Echocardiographic changes after successful renal transplantation in young nondiabetic patients

Eighteen young nondiabetic patients with chronic renal failure were studied by M-mode echocardiography before and three to 67 weeks after a successful renal transplant. Left ventricular mass (LVM), cardiac output (CO), and stroke work, which were increased before the operation, decreased afterward, in some cases to normal values. Both regression of the LVM and normalization of CO were detected as early as three weeks postoperatively and probably resulted from changes in the end-diastolic volume, mean systemic blood pressure, and hematocrit as a consequence of normal renal function. Because all the patients had normal left ventricular function and only moderate dilatation of the left ventricle, it is not known whether these striking beneficial changes after SRT also will occur in patients with significant dilatation or dysfunction of the left ventricle.

Postoperative thallium-201 myocardial images. Evidence of regression of right ventricular hypertrophy in man

Thallium-201 myocardial scintigraphic studies were performed on 24 patients with chronic right ventricular overload before and after surgical correction of haemodynamic overload. The ages of the patients ranged from 20 to 65 years (mean 39 years) at operation. The degree of right ventricular visualisation remained essentially unchanged in an early postoperative study (four to 60 days), though a decrease in right ventricular cavity size was noted in patients with right ventricular volume overload. On later follow-up (18 to 36 months), thallium uptake in the right ventricle was definitely less than before operation in all 13 patients studied at this time. Because thallium-201 radioactivity reflects myocardial blood flow and mass, our study indicates that right ventricular hypertrophy is largely reversible. Thus, thallium-201 myocardial scintigraphy can be used to assess non-invasively regression of right ventricular hypertrophy in patients with right ventricular overload.

Mitral valve replacement in children. Comparative study of pre- and postoperative haemodynamics and left ventricular function

Haemodynamic variables and left ventricular function were studied before and after mitral valve replacement in 44 children age 3 to 17 years (mean 11.9 years). Thirty-nine Starr-Edwards prostheses and five Hancock prostheses were used; postoperative study took place two to six months (mean 3.9 months) after operation. Pulmonary hypertension was present preoperatively in most patients, with mean pulmonary artery pressures of 18 to 75 (mean 46.5 mmHg). Postoperatively there was a pronounced drop in pressure to a mean value of 25.6 mmHg, partially explained by a decrease in pulmonary capillary wedge pressure. Pulmonary arteriolar resistance, however, also decreased conspicuously from an average of 590 dynes s cm-5 m-2 preoperatively to 282 dynes s cm-5 m-2 postoperatively. A return to normal resistance was seen in every case when preoperative resistance did not exceed 650 dynes s cm-5 m-2; above this threshold some degree of pulmonary hypertension often persisted. The residual gradient across the prosthetic valve was slightly higher for the Hancock than for the Starr-Edwards prosthesis (mean 8.7 mmHg, vs mean 6.9 mmHg). The left ventricular end-diastolic volume was much increased before surgery, with a mean value of 190 ml/m2; it decreased conspicuously after operation to 103 ml/m2. The left ventricular ejection fraction ranged from 40% to 76% (mean 57%) before operation; there was no significant change after operation, with values ranging from 40% to 73%. This left ventricular dysfunction is probably the result of myocardial injury caused by a chronic volume overload and the sequelae of rheumatic carditis.

Cardiac response to exercise in patients with chronic aortic regurgitation

Rest and exercise measurements of left ventricular (LV) ejection fraction (EF) and volumes were obtained by radionuclide angiocardiography (RNV) in 30 patients with severe aortic regurgitation (AR). The ratio of peak systolic pressure to end-systolic volume was used as an index of contractility. Volumetric cardiac output (CO) averaged 11.7 +/- 3.8 L/min at rest and 18.4 +/- 5.6 L/min during exercise. Much individual variation occurred in LVEF and end-diastolic volume (EDV) responses to exercise, and there was no consistent change in these measurements. Resting hemodynamic parameters and clinical history correlated poorly with changes observed during exercise. An increase in heart rate was one mechanism used by all 30 patients to increase CO during exercise. An inverse relationship was defined between the change in myocardial contractility and the change in EDV during exercise. Patients with the greatest increase in contractility during exercise showed the greatest decrease in EDV. Less use of an exercise increase in contractility was associated with an exercise increase in EDV to meet the demand for greater CO. Therefore, exercise measurements of LV function provide unique information regarding the degree of impairment of the LV myocardium in these patients with chronic AR.

Current status of radionuclide imaging in valvular heart disease

In valvular heart disease, there is a different radionuclide angiographic pattern in each of three left-sided valve abnormalities: pressure overload (aortic stenosis), volume overload (aortic or mitral regurgitation) and inflow obstruction (mitral stenosis). In pressure overload, the left ventricle is usually normal in size or minimally dilated. The ejection fraction may be normal, increased or decreased. In volume overload, there is left ventricular dilatation with a normal or reduced ejection fraction at rest. Scans may be performed during exercise to unmask abnormalities of ventricular function not evident at rest. In inflow obstruction, left ventricular function is usually normal but may be depressed. Right ventricular function may be abnormal secondary to pulmonary hypertension. Radionuclide angiography in valvular heart disease evaluates the impact of the valve abnormality on cardiac chamber size and function, which is useful in managing the patient, in determining the prognosis and in evaluating the success of valve surgery. Thallium-2-1 imaging evaluates regional myocardial blood flow and cell integrity and can be used to assess associated coronary artery disease.

Early ultrastructural changes in the myocardium following thyroxine-induced hypertrophy

The model of myocardial hypertrophy induced by thyroxine was studied with particular regard to the early ultrastructural changes in fractional volume of the mitochondria and myofibrils, and capillary distribution. Following injections of L-thyroxine (25 mg/kg IP) for 9 consecutive days, rats were sacrificed by vascular perfusion and cardiac tissue samples from the mid-wall zone of the left ventricle were processed routinely for electron microscopy. Heart weight/body weight ratios of thyroxine treated (T) rats showed a significant increase (P less than 0.001) over the ratios in control (C) rats. Likewise, the fractional volume of mitochondria (42%) was significantly increased (P less than 0.001) in the myocardium of T rats when compared with C rats (31%). However, the fractional volume of myofibrils was significantly decreased in the myocardium of T rats (P less than 0.001) and there was no significant difference between the hearts of T and C rats with respect to capillary luminal area/myocyte area. The mitochondria/myofibril ratio was increased in the hearts of T rats (0.82) over that found in control hearts (0.52). These results suggest that in the early stages of thyroxine-induced myocardial hypertrophy there is not an immediate increase in capillary area which may account for the ischemia and significant increase in mitochondrial volume which characterized myocardial hypertrophy in this model.

Dicrotic pulse after open heart surgery

Pre- and postoperative echophonocardiograms (EPCGs) and preoperative hemodynamic data of 108 patients who underwent valve replacement were reviewed to establish the frequency and significance of a dicrotic pulse (DP) postoperatively. DP occurred almost exclusively in patients who underwent valve replacement for regurgitant lesions (20 of 28 with aortic regurgitation, nine of 25 with mitral regurgitation, and four of six with both aortic and mitral regurgitation). These patients were divided into dicrotic and nondicrotic groups. Preoperatively, the dicrotic group had significantly larger end-diastolic volumes (p < 0.01) and end-systolic volumes (p < 0.01) and significantly lower ejection fractions (p < 0.01). Echocardiographically, the dicrotic group had larger left ventricular dimensions, both systolic (p < 0.01) and diastolic (p < 0.05), reduced percentage fractional shortening of the left ventricular cavity (p < 0.01) and poor thickening properties of the left ventricular posterior wall (% delta Th-LVPW) (p < 0.01). Postoperatively the dicrotic group had a slightly larger end-diastolic dimension (p = NS) and markedly depressed % delta Th-LVPW (p < 0.001) compared with the nondicrotic group. On follow-up EPCG the persistence of a DP correlated with continued left ventricular dysfunction by echocardiographic and hemodynamic studies and an extremely poor clinical course. DP after valve replacement is therefore an important prognostic sign.

Haemodynamics of hypertension in pregnancy assessed by M-mode echocardiography

1. Echocardiographic haemodynamic and left ventricular parameters were determined in twenty-one normontensives and thirty-six hypertensives during the last trimester of pregnancy. 2. Equivalent blood pressure control was obtained in hypertensives with bet rest only, oxprenolol or methyldopa, but remained above normotensive levels. 3. Cardiac output was elevated in the last trimester of pregnancy in normotensivves and hypertensives. 4. Left ventricular mass was increased in normal pregnancy, but displayed an exaggerated increase in hypertensives. 5. Total peripheral resistance was inappropriately elevated in hypertensive pregnancy, but was normalized in the oxprenolol-treated group. 6. There was no reduction in heart rate or cardiac output in the beta-adrenoreceptor blocker-treated group. This feature, in combination with lowered peripheral resistance, may contribute to the improvement in foetal outcome observed in maternal hypertension of pregnancy treated with oxprenolol.