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Harris NR, Bálint L, Dy DM, Nielsen NR, Méndez HG, Aghajanian A, Caron KM. The ebb and flow of cardiac lymphatics: a tidal wave of new discoveries. Physiol Rev 2023; 103:391-432. [PMID: 35953269 PMCID: PMC9576179 DOI: 10.1152/physrev.00052.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 06/16/2022] [Accepted: 07/18/2022] [Indexed: 12/16/2022] Open
Abstract
The heart is imbued with a vast lymphatic network that is responsible for fluid homeostasis and immune cell trafficking. Disturbances in the forces that regulate microvascular fluid movement can result in myocardial edema, which has profibrotic and proinflammatory consequences and contributes to cardiovascular dysfunction. This review explores the complex relationship between cardiac lymphatics, myocardial edema, and cardiac disease. It covers the revised paradigm of microvascular forces and fluid movement around the capillary as well as the arsenal of preclinical tools and animal models used to model myocardial edema and cardiac disease. Clinical studies of myocardial edema and their prognostic significance are examined in parallel to the recent elegant animal studies discerning the pathophysiological role and therapeutic potential of cardiac lymphatics in different cardiovascular disease models. This review highlights the outstanding questions of interest to both basic scientists and clinicians regarding the roles of cardiac lymphatics in health and disease.
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Affiliation(s)
- Natalie R Harris
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - László Bálint
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Danielle M Dy
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Natalie R Nielsen
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hernán G Méndez
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Amir Aghajanian
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kathleen M Caron
- Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Al-Kofahi M, Omura S, Tsunoda I, Sato F, Becker F, Gavins FNE, Woolard MD, Pattillo C, Zawieja D, Muthuchamy M, Gashev A, Shihab I, Ghoweba M, Von der Weid PY, Wang Y, Alexander JS. IL-1β reduces cardiac lymphatic muscle contraction via COX-2 and PGE 2 induction: Potential role in myocarditis. Biomed Pharmacother 2018; 107:1591-1600. [PMID: 30257377 DOI: 10.1016/j.biopha.2018.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 02/05/2023] Open
Abstract
The role of lymphatic vessels in myocarditis is largely unknown, while it has been shown to play a key role in other inflammatory diseases. We aimed to investigate the role of lymphatic vessels in myocarditis using in vivo model induced with Theiler's murine encephalomyelitis virus (TMEV) and in vitro model with rat cardiac lymphatic muscle cells (RCLMC). In the TMEV model, we found that upregulation of a set of inflammatory mediator genes, including interleukin (IL)-1β, tumor necrosis factor (TNF)-αand COX-2 were associated with disease activity. Thus, using in vitro collagen gel contraction assays, we decided to clarify the role(s) of these mediators by testing contractility of RCLMC in response to IL-1β and TNF-α individually and in combination, in the presence or absence of: IL-1 receptor antagonist (Anakinra); cyclooxygenase (COX) inhibitors inhibitors (TFAP, diclofenac and DuP-697). IL-1β impaired RCLMC contractility dose-dependently, while co-incubation with both IL-1β and TNF-α exhibited synergistic effects in decreasing RCLMC contractility with increased COX-2 expression. Anakinra maintained RCLMC contractility; Anakinra blocked the mobilization of COX-2 induced by IL-1β with or without TNF-α. COX-2 inhibition blocked the IL-1β-mediated decrease in RCLMC contractility. Mechanistically, we found that IL-1β increased prostaglandin (PG) E2 release dose-dependently, while Anakinra blocked IL-1β mediated PGE2 release. Using prostaglandin E receptor 4 (EP4) receptor antagonist, we demonstrated that EP4 receptor blockade maintained RCLMC contractility following IL-1β exposure. Our results indicate that IL-1β reduces RCLMC contractility via COX-2/PGE2 signaling with synergistic cooperation by TNF-α. These pathways may help provoke inflammatory mediator accumulation within the heart, driving progression from acute myocarditis into dilated cardiomyopathy.
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Affiliation(s)
- Mahmoud Al-Kofahi
- Department of Molecular & Cellular Physiology, United States; Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN, United States
| | - Seiichi Omura
- Department of Microbiology and Immunology, United States; Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Ikuo Tsunoda
- Department of Microbiology and Immunology, United States; Department of Neurology, Louisiana State University Health Sciences Center-Shreveport, LA, United States; Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Fumitaka Sato
- Department of Microbiology and Immunology, United States; Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Felix Becker
- Department of Molecular & Cellular Physiology, United States; Department of General, Visceral and Transplant Surgery, University Hospital Muenster, Muenster, Germany
| | - Felicity N E Gavins
- Department of Molecular & Cellular Physiology, United States; Department of Neurology, Louisiana State University Health Sciences Center-Shreveport, LA, United States
| | | | | | - David Zawieja
- Texas A&M University, College Station, TX, United States
| | | | | | - Israa Shihab
- Department of Molecular & Cellular Physiology, United States
| | - Mohamed Ghoweba
- Department of Molecular & Cellular Physiology, United States
| | | | - Yuping Wang
- Department of Molecular & Cellular Physiology, United States; Department of Obstetrics and Gynecology, United States
| | - J Steven Alexander
- Department of Molecular & Cellular Physiology, United States; Department of Neurology, Louisiana State University Health Sciences Center-Shreveport, LA, United States.
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Al-Kofahi M, Yun JW, Minagar A, Alexander JS. Anatomy and roles of lymphatics in inflammatory diseases. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/cen3.12400] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Mahmoud Al-Kofahi
- Department of Experimental and Clinical Pharmacology; College of Pharmacy; University of Minnesota; Minneapolis MN USA
| | - J. Winny Yun
- Department of Molecular and Cellular Physiology; Louisiana State University Health Sciences Center Shreveport; Shreveport LA USA
| | - Alireza Minagar
- Department of Neurology; Louisiana State University Health Sciences Center Shreveport; Shreveport LA USA
| | - J. Steven Alexander
- Department of Molecular and Cellular Physiology; Louisiana State University Health Sciences Center Shreveport; Shreveport LA USA
- Department of Neurology; Louisiana State University Health Sciences Center Shreveport; Shreveport LA USA
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Liu S, Liu Z, Li L, Liu P, Liu H. Keeping the heart empty and beating: an alternative technique to preserve hypertrophied hearts during valvular surgery. J Cardiothorac Surg 2015; 10:71. [PMID: 25968233 PMCID: PMC4434573 DOI: 10.1186/s13019-015-0273-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 05/01/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION To determine whether keeping the heart empty and beating is an effective technique to preserve hypertrophied pig hearts, and to investigate the underlying mechanism. METHODS Ten Bama Miniature pigs with hypertrophied hearts were divided into 2 groups (n = 5 in each group). One group underwent normothermic normokalemic simultaneous perfusion (NNSP). The other group was subjected to normothermic hypermokalemic simultaneous perfusion (NHSP) and used as controls. Cardiac contractive function, myocardial energy metabolism and myocardial perfusion were assessed using magnetic resonance imaging. Western blot analysis was carried out to determine the expression of Troponin I (cTnI), Troponin T (cTnT), SM-MHC, Casapase-3 and PARP4. TUNEL assay was used to detect apoptotic cardiomyocytes. RESULTS Keeping the heart empty and beating with NNSP improved the preservation of contractile function in comparison with cardioplegic arrest using NHSP. No significant differences existed in the effects of NNSP and NHSP in maintaining myocardial energy metabolism. 13 % perfusion defects areas were found in one heart in the NHSP group, whereas none was found in all other hearts in both groups. The expressions of cTnI, cTnT, Casapase-3 and PARP4 in NHSP group were abundantly increased compared to NNSP group as measured by Western blotting. Conversely, the expression of SM-MHC in NHSP group was reduced compared with NNSP group. The number of TUNEL positive nuclei per mm(2) area was significantly increased in NHSP group compared with NNSP group. CONCLUSIONS Keeping the heart beating with NNSP is an alternative technique to preserve hypertrophied hearts during valvular surgery.
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Affiliation(s)
- Shangdian Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Road, Harbin, Heilongjiang, 150001, China.
| | - Zonghong Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Road, Harbin, Heilongjiang, 150001, China.
| | - Lulu Li
- Department of Magnetic Resonance Imaging (MRI), the First Affiliated Hospital of Harbin Medical University, Harbin, China.
| | - Pengfei Liu
- Department of Magnetic Resonance Imaging (MRI), the First Affiliated Hospital of Harbin Medical University, Harbin, China.
| | - Hongyu Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Road, Harbin, Heilongjiang, 150001, China.
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Salhiyyah K, Raja SG, Akeela H, Pepper J, Amrani M. Beating heart continuous coronary perfusion for valve surgery: what next for clinical trials? Future Cardiol 2010; 6:845-58. [DOI: 10.2217/fca.10.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Prior to the introduction of cardioplegia, beating heart continuous coronary perfusion (BHCCP) was the only available method of myocardial protection. Currently, cardiac surgery on cardiopulmonary bypass with cardioplegic arrest is the gold standard strategy. Cardioplegic arrest provides an easier and safer way to operate on a still heart. It enables the performance of a broader range of cardiac procedures, and avoids the potential difficulties of continuous perfusion on a beating heart. Despite the overall effectiveness and safety of cardioplegia, some adverse effects remain, mainly due to the insult of ischemia, which results in ischemic reperfusion injury. As a result BHCCP has seen a revival as an alternative to cardioplegia for performing complex valvular surgery. Increasing experience reporting safety and efficacy of BHCCP is being published. However, despite the reported advantages, current available evidence validating safety and efficacy of BHCCP is controversial. This article provides an overview of BHCCP highlighting the current best available evidence supporting this strategy, concerns, controversies and potential areas for further research.
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Affiliation(s)
| | - Shahzad G Raja
- Department of Cardiothoracic Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Hill End Road, Harefield, London, UB9 6JH, UK
| | - Hiba Akeela
- Department of Cardiothoracic Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Hill End Road, Harefield, London, UB9 6JH, UK
| | - John Pepper
- Department of Cardiothoracic Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Hill End Road, Harefield, London, UB9 6JH, UK
| | - Mohamed Amrani
- Department of Cardiothoracic Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Hill End Road, Harefield, London, UB9 6JH, UK
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Salerno TA, Panos AL, Tian G, Deslauriers R, Calcaterra D, Ricci M. Surgery for cardiac valves and aortic root without cardioplegic arrest ("beating heart"): experience with a new method of myocardial perfusion. J Card Surg 2008; 22:459-64. [PMID: 18039204 DOI: 10.1111/j.1540-8191.2007.00448.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Simultaneous antegrade/retrograde warm blood perfusion with a beating heart has not been previously reported as a mean of protecting hypertrophied hearts in cardiac valve and aortic root surgeries. Similarly, beating heart mitral valve surgery via the trans-septal approach with the aorta unclamped, is a novel technique. We, herein, report a series of 346 patients with a variety of cardiac pathologies who were operated upon utilizing a new modality of myocardial perfusion. Among this group of patients, there were 55 patients who were diagnosed with endocarditis of one or more valves. These patients were excluded from this series of patients. Mean age was 59 +/- 12, and there were 196 (67.3%) males and 95 (32.7%) females. There were six aortic root procedures, 90 mitral valve replacements (MVR), 46 mitral valve repairs, 20 MVR+ coronary artery bypass grafting (CABG), 28 tricuspid valve repairs, 106 aortic valve replacements (AVR), 17 AVR+CABG, and 8 AVR/MVR. Crude mortality for the group was 20 of 291 (6.8%). Intra-aortic balloon pump utilization at time of weaning from cardiopulmonary bypass was 6/291 (2.06%), and re-operation for bleeding was needed in 12 of 291 (4.1%) patients. Postoperative stroke occurred in 4 of 291 (1.3%) patients. In these patients, the clinical diagnosis of stroke was made prior to surgery. This initial experience with this new method of myocardial perfusion indicates that results are at least comparable, if not superior, to conventional techniques utilizing intermittent cold blood cardioplegia.
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Affiliation(s)
- Tomas A Salerno
- Division of Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida, USA.
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Wang J, Liu H, Xiang B, Li G, Gruwel M, Jackson M, Tomanek B, Salerno TA, Deslauriers R, Tian G. Keeping the heart empty and beating improves preservation of hypertrophied hearts for valve surgery. J Thorac Cardiovasc Surg 2006; 132:1314-20. [PMID: 17140949 DOI: 10.1016/j.jtcvs.2006.07.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Revised: 07/06/2006] [Accepted: 07/13/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study was designed to determine whether keeping the heart empty and beating improved myocardial fluid homeostasis and energy metabolism of hypertrophied pig hearts in comparison with cardioplegic arrest. METHODS Twenty piglets underwent a 8-weeks (corrected) ascending aortic banding to induce left ventricular hypertrophy. Isolated hypertrophied hearts were divided into 4 groups (n = 5 in each group). Two groups underwent normothermic normokalemic simultaneous perfusion. The other 2 groups were subjected to normothermic hyperkalemic simultaneous perfusion and used as controls. Intramyocardial hydrostatic pressure was monitored with a microtip pressure transducer. Volumes of intracellular and extracellular compartments and myocardial energy metabolism were monitored by using phosphorus 31 magnetic resonance spectroscopy. RESULTS Normothermic normokalemic simultaneous perfusion (NNSP) maintained intramyocardial hydrostatic pressure at a significantly lower level (13.0 +/- 0.6 mm Hg) compared with normothermic hyperkalemic simultaneous perfusion (NHSP) (23.3 +/- 1.2 mm Hg) during a 90-minute preservation. NNSP maintained the normal volume of the intracellular compartment throughout the preservation period, whereas NHSP caused significant enlargement (to 123% +/- 6% of its normal volume) of the intracellular compartment. Expansion of the extracellular compartment during preservation was significantly less in the NNSP group (124% +/- 6%) than in the NHSP group (152% +/- 7%). NNSP maintained normal levels of phosphocreatine and adenosine triphosphate until coronary perfusion flow was reduced to 50% of the initial control level. No decrease in energy metabolites was observed in the NHSP group even when coronary perfusion flow was reduced to 10% of the initial control level. CONCLUSIONS Keeping the heart empty and beating improves myocardial fluid homeostasis for hypertrophied hearts relative to cardioplegic arrest. Its ability to maintain energy metabolism depends on the degree of coronary stenosis. This technique may be a promising protective strategy for hypertrophied hearts.
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Affiliation(s)
- Jian Wang
- Institute for Biodiagnostics, National Research Council, Winnipeg, Manitoba, Canada
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Abstract
Fluid accumulation in the cardiac interstitium or myocardial edema is a common manifestation of many clinical states. Specifically, cardiac surgery includes various interventions and pathophysiological conditions that cause or worsen myocardial edema including cardiopulmonary bypass and cardioplegic arrest. Myocardial edema should be a concern for clinicians as it has been demonstrated to produce cardiac dysfunction. This article will briefly discuss the factors governing myocardial fluid balance and review the evidence of myocardial edema in various pathological conditions. In particular, myocardial microvascular, interstitial, and lymphatic interactions relevant to the field of cardiac surgery will be emphasized.
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Affiliation(s)
- U Mehlhorn
- Clinic for Cardiothoracic Surgery, University of Cologne, Cologne, Germany.
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Allen SJ, Geissler HJ, Davis KL, Gogola GR, Warters RD, de Vivie ER, Mehlhorn U. Augmenting cardiac contractility hastens myocardial edema resolution after cardiopulmonary bypass and cardioplegic arrest. Anesth Analg 1997; 85:987-92. [PMID: 9356088 DOI: 10.1097/00000539-199711000-00006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED Although myocardial edema is associated with cardiopulmonary bypass (CPB) and cardioplegic arrest (CPA), interventions to expedite edema removal have not been investigated. The primary mechanism for the removal of excess interstitial fluid in the heart is myocardial lymphatic drainage, but lymphatic function can be impaired by decreased contractility because of edema. The purpose of this study was to determine whether enhancing cardiac contractility would increase myocardial lymphatic function and hasten edema resolution after CPB. Sixteen dogs were subjected to CPB and 1 h of hypothermic CPA. After weaning from CPB, 10 dogs received an intravenous dobutamine infusion and 6 dogs received no inotropic support. We determined myocardial lymph driving pressure from the major cardiac lymphatic, myocardial water content by using microgravimetry, and the peak rate of left ventricular pressure increase (dP/dmax) by using micromanometry. Measurements were taken at baseline, during CPA, and 60 min after CPB. Compared with controls, dobutamine-treated dogs had an increased dP/dmax (P < 0.05), which was associated with higher lymph driving pressures (P < 0.05), resulting in lower myocardial water gain 1 h after CPB (P < 0.05). We conclude that the resolution of myocardial edema after CPB was hastened by dobutamine. Organized ventricular contraction and myocardial contractility seem to be important determinants of myocardial lymphatic function and myocardial edema removal. These findings suggest that the administration of inotropic drugs after CPB may hasten cardiac recovery. IMPLICATIONS Myocardial edema, which develops during cardiopulmonary bypass and cardioplegic arrest, contributes to cardiac dysfunction after heart surgery. This study demonstrated that enhancement of cardiac contractility by the administration of dobutamine after cardiopulmonary bypass and cardioplegic arrest was associated with increased myocardial lymphatic function and hastened edema resolution in dogs.
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Affiliation(s)
- S J Allen
- Department of Anesthesiology, University of Texas-Houston Medical School, 77030, USA.
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Allen SJ, Geissler HJ, Davis KL, Gogola GR, Warters RD, de Vivie ER, Mehlhorn U. Augmenting Cardiac Contractility Hastens Myocardial Edema Resolution After Cardiopulmonary Bypass and Cardioplegic Arrest. Anesth Analg 1997. [DOI: 10.1213/00000539-199711000-00006] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Taira A, Yamashita M, Arikawa K, Hamada Y, Toyohira H, Akita H. Cardia lymph in electrical ventricular fibrillation: an experimental study. Ann Thorac Surg 1979; 27:144-7. [PMID: 453972 DOI: 10.1016/s0003-4975(10)63256-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The flow velocity of cardiac lymph during electrical ventricular fibrillation under normothermic cardiopulmonary bypass was studied experimentally in dogs. The time needed for the cardiac lymph node to become stained after injection of dye into the apex myocardium of the left ventricle was measured as an indicator in determining flow velocity of cardiac lymph. The flow velocity was markedly decelerated immediately after the commencement of electrical ventricular fibrillation. It was accelerated, however, after 2 hours of continuous electrical ventricular fibrillation. The difference between the two values was significant (p less than 0.01). Absent contractility of the heart influenced the deceleration of flow velocity of cardiac lymph immediately after the commencement of electrical ventricular fibrillation. Acceleration after 2 hours involved stasis of cardiac lymph as a result of absent contractility and increment of lymph production due to the nonphysiological condition of the myocardium.
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Fjeld NB, Kluge TH, Stokke KT, Skrede S. The effect of generalized hypoxia upon flow and composition of cardiac lymph in the dog. Eur J Clin Invest 1976; 6:255-9. [PMID: 939247 DOI: 10.1111/j.1365-2362.1976.tb00518.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Generalized hypoxia lasting 60 seconds more than doubled the cardiac lymph flow in dogs. The number of erythrocytes per mm3 of cardiac lymph increased by about 300%. However, there was no change in total protein or in the concentrations of different lipids following hypoxia. Thus, the transfer of erythrocytes across the myocardial interstitium increased by a factor of ten, and proteins and lipids by 150%. An increase of the capillary surface area probably explained the increased lymph flow. Permeability for macromolecules through the endothelial cells was not increased, since the selectivity for different lipids did not change. The increased transfer of erythrocytes may be explained by an increased permeability through intercellular junctions. The triglyceride content of thoracic duct lymph decreased by about 60% in the corresponding period, but no changes in flow or permeability were observed.
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