Ketamine attenuates post-operative cognitive dysfunction after cardiac surgery.

BACKGROUND: Post-operative cognitive dysfunction (POCD) commonly occurs after cardiac surgery. Ketamine exerts neuroprotective effects after cerebral ischemia by anti-excitotoxic and anti-inflammatory mechanisms. We hypothesized that ketamine attenuates POCD in patients undergoing cardiac surgery concomitant with an anti-inflammatory effect. METHODS: Patients randomly received placebo (0.9% saline; n=26) or an i.v. bolus of ketamine (0.5 mg/kg; n=26) during anesthetic induction. Anesthesia was maintained with isoflurane and fentanyl. A nonsurgical group (n=26) was also included as control. Recent verbal and nonverbal memory and executive functions were assessed before and 1 week after surgery or a 1-week waiting period for the nonsurgical controls. Serum C-reactive protein (CRP) concentrations were determined before surgery and on the first post-operative day. RESULTS: Baseline neurocognitive and depression scores were similar in the placebo, ketamine, and nonsurgical control groups. Cognitive performance after surgery decreased by at least 2 SDs (z-score of 1.96) in 21 patients in the placebo group and only in seven patients in the ketamine group compared with the nonsurgical controls (P<0.001, Fisher's exact test). Cognitive performance was also significantly different between the placebo- and the ketamine-treated groups based on all z-scores (P<0.001, Mann-Whitney U-test). Pre-operative CRP concentrations were similar (P<0.33, Mann-Whitney U-test) in the placebo- and ketamine-treated groups. The post-operative CRP concentration was significantly (P<0.01, Mann-Whitney U-test) lower in the ketamine-treated than in the placebo-treated group. CONCLUSIONS: Ketamine attenuates POCD 1 week after cardiac surgery and this effect may be related to the anti-inflammatory action of the drug.

Ischemia-induced coronary collateral growth is dependent on vascular endothelial growth factor and nitric oxide.

BACKGROUND: We hypothesized that ischemia-induced expression of vascular endothelial growth factor (VEGF) and the production of NO stimulate coronary collateral growth. METHODS AND RESULTS: To test this hypothesis, we measured coronary collateral blood flow and VEGF expression in myocardial interstitial fluid in a canine model of repetitive myocardial ischemia under control conditions and during antagonism of NO synthase. Collateralization was induced by multiple (1/h; 8/d), brief (2 minutes) occlusions of the left anterior descending coronary artery for 21 days. In controls, collateral blood flow (microspheres) progressively increased to 89+/-9 mL. min(-1). 100 g(-1) on day 21, which was equivalent to perfusion in the normal zone. Reactive hyperemic responses (a measure of the severity of ischemia) decreased as collateral blood flow increased. In N(G)-nitro-L-arginine methyl ester (L-NAME)- and L-NAME+nifedipine-treated dogs, to block the production of NO and control hypertension, respectively, collateral blood flow did not increase and reactive hyperemia was robust throughout the occlusion protocol (P<0.01 versus control). VEGF expression (Western analyses of VEGF(164) in myocardial interstitial fluid) in controls peaked at day 3 of the repetitive occlusions but waned thereafter. In sham-operated dogs (instrumentation but no occlusions), expression of VEGF was low during the entire protocol. In contrast, VEGF expression was elevated throughout the 21 days of repetitive occlusions after L-NAME. Reverse transcriptase-polymerase chain reaction analyses revealed that the predominant splice variant expressed was VEGF(164). CONCLUSIONS: NO is an important regulator of coronary collateral growth, and the expression of VEGF is induced by ischemia. Furthermore, the induction of coronary collateralization by VEGF appears to require the production of NO.

Zatebradine, a specific bradycardic agent, enhances the positive inotropic actions of dobutamine in ischemic myocardium.

OBJECTIVES: This investigation determined whether attenuation of the tachycardia produced by dobutamine administration would improve perfusion and function distal to a severe coronary artery stenosis. BACKGROUND: Tachycardia adversely affects perfusion and function distal to a coronary artery stenosis. It is not known whether a specific bradycardic agent can improve blood flow and function in an ischemic zone during administration of dobutamine. METHODS: The effects of dobutamine (2, 5 and 10 micrograms/kg body weight per min) alone and in combination with zatebradine (0.5 mg/kg), a specific bradycardic agent, on hemodynamic status, segment shortening (ultrasound length transducers) and myocardial perfusion (microspheres) were studied in anesthetized dogs with severe left circumflex coronary artery stenosis. RESULTS: A 50% reduction in left circumflex coronary artery blood flow (58 +/- 4 to 29 +/- 2 ml/min [mean value +/- SEM]) produced a decrease in systolic shortening in the ischemic zone. Only a dose of dobutamine that did not elevate heart rate (2 micrograms/kg per min) produced an increase in segment shortening in the ischemic zone. High doses of dobutamine (10 micrograms/kg per min) caused an increase in heart rate without improvement in function and a reduction in the subendocardial/subepicardial flow ratio (0.74 +/- 0.06 to 0.48 +/- 0.05). Zatebradine administered in the presence of dobutamine caused a decrease in heart rate, an increase in subendocardial/subepicardial blood flow ratio (0.48 +/- 0.05 to 0.78 +/- 0.09) and allowed an increase in ischemic zone segment shortening. When normalized for changes in heart rate, ischemic zone subendocardial flow increased by 123 +/- 41% (0.39 +/- 0.09 to 0.71 +/- 0.12 ml/100 g per beat). Atrial pacing abolished the effects of zatebradine. CONCLUSIONS: The present data suggest that the perfusion-contraction matching that accompanies a decrease in heart rate results in enhancement of inotropic stimulation of an ischemic zone. The actions of zatebradine are related to an increase in subendocardial blood flow per beat that allows improvement of regional contractile function.

Intracoronary amiloride prevents contractile dysfunction of postischemic "stunned" myocardium: role of hemodynamic alterations and inhibition of Na+/H+ exchange and L-type Ca2+ channels.

OBJECTIVES: This study sought to establish the effect of amiloride on stunned myocardium and to determine the role of hemodynamic alterations and inhibition of sodium/proton (Na+/H+) exchange and L-type cytosolic calcium (Ca2+) channels. BACKGROUND: Amiloride is a nonspecific agent that may reduce reperfusion injury, but its effect on reversible dysfunction or stunned myocardium is unclear. METHODS: Ninety-seven open chest dogs undergoing 15 min of left anterior descending coronary artery occlusion and 3 h of reperfusion with monitoring of hemodynamic variables, systolic shortening and myocardial blood flow were randomized to seven intracoronary infusions: control dogs (5% dextrose, n = 16); low dose amiloride (1 mg/min, n = 14); high dose amiloride (5 mg/min) with (n = 12) and without (n = 16) atrial pacing; sodium nitroprusside (20 micrograms/min, n = 16); hexamethylene amiloride (a specific inhibitor of Na+/H+ exchange, 60 micrograms/min, n = 14); and nifedipine (a specific inhibitor of L-type Ca2+ channels, 5 micrograms/min, n = 9). Drug infusions were started 40 min before occlusion and stopped at 30 min after reperfusion. RESULTS: Forty-three dogs were excluded because of ventricular fibrillation or high collateral flow. The incidence of ventricular fibrillation was similar in all groups to that in control dogs. Systolic shortening completely recovered (p = NS vs. baseline; p < 0.01 vs. control group) by 2 h after reperfusion in the low dose amiloride group and 30 min in the high dose group (p < 0.01 vs. low dose). High dose amiloride increased myocardial blood flow and had positive inotropic and negative chronotropic effects (p < 0.05 vs. control group). Atrial pacing did not attenuate recovery. The only effect of low dose amiloride was increased myocardial blood flow after reperfusion. Systolic shortening did not deteriorate after washout of drug effects. Sodium nitroprusside and nifedipine similarly increased myocardial blood flow, but systolic shortening never recovered. Hexamethylene amiloride had no hemodynamic effects, and systolic shortening never recovered. CONCLUSIONS: Amiloride prevented the contractile dysfunction of myocardial stunning but did not prevent arrhythmias. Hemodynamic alterations, increased myocardial blood flow and inhibition of Na+/H+ exchange or L-type Ca2+ channels alone did not account for the improved function. Inhibition of Na+/Ca2+ exchange may be the mechanism of improved postischemic function.

Intracoronary versus intravenous nitroglycerin on the transmural distribution of coronary blood flow.

The effect of intracoronary versus intravenous administration of nitroglycerin (GTN) on the transmural distribution of coronary blood flow (epi/endo) was studied in an isolated canine heart preparation and intact dogs. The distribution of blood flow between epicardium and endocardium of the left ventricle was determined by use of radioactive microspheres (15 micrometer diameter). Intracoronary infusion of GTN in the isolated heart significantly increased epi/endo during a constant coronary blood flow, whereas no change in epi/endo was observed during a constant coronary perfusion pressure. When maximal coronary vasodilatation was produced by chromonar, the epi/endo increased significantly, however intracoronary GTN produced no further vasodilatation and did not improve epi/endo. In contrast, intravenous infusion of GTN in intact hearts significantly decreased epi/endo. These results suggest that intracoronary GTN does not enhance endocardial perfusion and may even produce a coronary steal, whereas intravenous GTN may improve endocardial perfusion via indirect haemodynamic actions.

Changes in regional myocardial perfusion by muscarinic receptor subtypes in dogs.

To determine the muscarinic receptor subtype (M1 or M2 or both) responsible for cholinergic coronary vasodilatation and alterations in the transmural distribution (endocardial to epicardial blood flow ratio) of coronary blood flow, systemic and coronary haemodynamic indices and regional myocardial blood flow (radioactive microspheres) were measured in anaesthetised dogs. Submaximal vasodilative doses of the mixed muscarinic agonist acetylcholine were given by intracoronary infusion to avoid peripheral haemodynamic effects. Acetylcholine produced significant increases in myocardial perfusion and selectively redistributed flow to the subendocardium (increased endocardial to epicardial blood flow ratio). Pirenzepine (160 nmol X kg-1 iv), a selective M1 antagonist, produced no change in endocardial to epicardial blood flow ratio or myocardial blood flow but blocked the increase in endocardial to epicardial blood flow ratio and attenuated the transmural increase in myocardial perfusion during acetylcholine infusion. 4-Diphenylacetoxy-N-methylpiperidine methyl bromide (4-DAMP) (17 nmol X kg-1 iv), a selective M2 antagonist, also attenuated the transmural increase in myocardial blood flow but had little effect on the increase in endocardial to epicardial blood flow ratio produced by acetylcholine. These results support the hypothesis that M1 muscarinic coronary receptors are responsible for the redistribution of blood flow to the subendocardium (increased endocardial to epicardial blood flow ratio) during cholinergic coronary vasodilatation, whereas both M1 and M2 receptors are involved in increasing myocardial perfusion.

Differential roles of myocardial Ca2+ channels and Na+/Ca2+ exchange in myocardial reperfusion injury in open chest dogs: relative roles during ischemia and reperfusion.

OBJECTIVE: Compare the roles of Ca2+ channels and Na+/Ca2+ exchange in reperfusion injury (reperfusion ventricular fibrillation and myocardial stunning). METHODS: Open chest dogs undergoing 15 minutes of left anterior descending coronary artery occlusion and 3 hours of reperfusion were randomized to controls or intracoronary infusions of the respective antagonists, nifedipine (50 micrograms/min) or amiloride (5 mg/min), according to five protocols: (A) 40 minutes before occlusion to 30 minutes after reperfusion; (B) 2 minutes before to 5 minutes after reperfusion; (C) 10 minutes before to 10 minutes after reperfusion (two step infusion for nifedipine only 5 micrograms/min during occlusion and 50 micrograms/min after reperfusion); and (D) 0 to 30 minutes after reperfusion. The role of Ca2+ channels was further investigated by infusing the agonist, Bay K 8644 (50 micrograms/min), alone or simultaneously with any protocol B, C, or D infusions altering both reperfusion ventricular fibrillation and myocardial stunning. RESULTS: Effects of the agents on injury did not result from hemodynamic effects or alterations in blood flow. Amiloride had no effect on ventricular fibrillation. Only protocol A infusion of amiloride prevented myocardial stunning. In contrast, protocol A and B infusions of nifedipine prevented both myocardial stunning (p = ns vs. baseline, p < 0.01 vs. control) and ventricular fibrillation (0%, p < 0.01). Protocol C prevented reperfusion ventricular fibrillation, but not stunning (p = ns vs. control). Protocol D did not alter injury. Bay K 8644 co-treatment reversed the effects of Protocol B infusion of nifedipine. Ventricular fibrillation was common and postischemic function worst in dogs treated with Bay K 8644 alone (protocol B). CONCLUSION: Myocardial Ca2+ channels contribute to both reperfusion ventricular fibrillation and stunning, whereas Na+/Ca2+ exchange contributes only to stunning. Inhibitors of myocardial Ca2+ channels are protective when infused in high doses just before reperfusion, whereas the efficacy of Na+/Ca2+ exchange inhibitors is dependent on pretreatment.

Differential sensitivity of proximal and distal coronary arteries to a nitric oxide donor following reperfusion injury or inhibition of nitric oxide synthesis.

OBJECTIVE: The effect of the nitric oxide donor, SIN-1, in proximal and distal coronary arteries with normal endothelium was characterised before and after inhibition of NO synthesis with L-nitroarginine methyl ester (L-NAME). The effect of reperfusion injury in vivo in similar vessels on the response to SIN-1 was also assessed. METHODS: In vitro reactivity of preconstricted coronary arterial rings was studied in control dogs (group 1), and dogs in which the left circumflex coronary artery was subjected in vivo to four acute occlusions of 5 min duration, with three intervening reperfusion periods of 5 min and a final reperfusion period of 60 min (group 2). The effects of acetylcholine and SIN-1 on the tone of left circumflex and left anterior descending coronary vascular rings were examined before and after treatment with L-NAME. RESULTS: Proximal [1851 (SEM 82) microns] and distal [477(19) microns] vessels were studied. In control dogs (group 1) acetylcholine caused relaxation in proximal and distal coronary arteries (p > 0.05). No difference in responsiveness of left circumflex or left anterior descending coronary arteries was observed in the control group. In group 2 the response to acetylcholine was significantly (p < 0.05) attenuated in left circumflex coronary arteries exposed to ischaemia and reperfusion compared with left anterior descending control rings from the same heart. Proximal vessels in group 1 and group 2 showed greater sensitivity to the vasodilator effects of SIN-1 than distal vessels. Proximal left circumflex vessels exposed to ischaemia and reperfusion showed enhanced sensitivity to the relaxant effects of SIN-1 compared to control proximal vessels obtained from the same hearts. Reperfusion was not associated with any alteration in sensitivity of distal vessels to SIN-1. Similarly, inhibition of the synthesis of endothelium derived relaxing factor (EDRF) by L-NAME resulted in an enhanced response to SIN-1 in proximal vessels only. CONCLUSIONS: Endothelium dependent vasodilatation is attenuated by ischaemia and reperfusion in both proximal and distal coronary arteries of the size studied. The response to direct nitric oxide donation (bypassing vascular endothelial synthesis of EDRF) is inhibited by a basal endothelial process present in proximal coronary arteries only. This inhibition is abolished following reperfusion injury or inhibition of NO synthesis.

Recovery of contractile function in post-ischaemic reperfused myocardium of conscious dogs: influence of nicorandil, a new antianginal agent.

The effects of intravenous administration of nicorandil, a new antianginal agent, on the recovery of regional myocardial contractile function after a 10 minute coronary artery occlusion were studied in chronically instrumented conscious dogs. Compared with the control group nicorandil administration resulted in an increase in heart rate and a decrease in blood pressure with an overall increase in the double product during the preocclusion period, no significant difference in double product during ischaemia, and a significant decrease in double product during reperfusion. After reperfusion the return of regional contractile function was appreciably enhanced in the nicorandil treated group. These effects were seen immediately after coronary reflow and persisted throughout the reperfusion period. These data suggest that nicorandil protects ischaemic cardiac tissue, and that the beneficial actions may be mediated through a reduction in left ventricular afterload.

Temporal dependence of coronary collateral development.

OBJECTIVE: Previous evidence suggests that episodes of myocardial ischemia of sufficient duration and intensity are required to produce coronary collateral development during repetitive coronary occlusion. This investigation tested the hypothesis that coronary collateral development is also temporal-dependent. METHODS: Chronically instrumented dogs (n = 16) were subjected to brief (2 min) left anterior descending coronary artery (LAD) occlusions, once every hour, 8 h a day, for 3 weeks or once every hour, 24 h a day for 1 week. Collateral perfusion (radioactive microspheres), LAD contractile function (ultrasonic crystals), and post-occlusive flow debt repayment (LAD flow probe) were measured during occlusions 1, 55, 105, and 155. RESULTS: Increases (P < 0.05 in subendocardial collateral blood flow to ischemic myocardium, progressive normalization of contractile function during LAD occlusion, and successive reduction in flow debt repayment were observed in dogs receiving occlusions over 3 weeks. In contrast, dogs receiving the same number of coronary occlusions over 1 week demonstrated minimal increases in collateral blood flow, persistent regional contractile dysfunction, and sustained flow debt repayment. CONCLUSIONS: The results demonstrate that LAD collateral development in response to repetitive coronary occlusion requires sufficient time for growth adaptation of the collateral circulation to occur.

Transmural triglycerides in acute myocardial ischaemia.

The effect of coronary artery occlusion on endogenous triglycerides of left ventricular subepicardium and subendocardium was studied in the open-chest anaesthetised dog. Under control conditions, the subepicardium was found to have a greater concentration of triglycerides than the subendocardium. Thirty minutes after acute coronary artery occlusion there was a decrease followed by a steady increase at 60, 120, and 240 min in subepicardial triglycerides of the ischaemic region. No change in triglycerides in the subendocardium of normal or ischaemic regions was observed. The initial decrease of subepicardial triglycerides in the ischaemic region was blocked by administration of propranolol or bevantolol (CI-775; a specific beta 1 antagonist) given 30 min before occlusion. It is concluded that the effect of coronary artery ligation on transmural endogenous triglycerides is biphasic with an initial period of increased mobilisation followed by a period of increased deposition.

Multifactorial basis for coronary collateralization: a complex adaptive response to ischemia.

Angiogenesis and vasculogenesis are adaptive responses of the coronary collateral circulation to myocardial ischemia. This review focuses on the concerted action of growth factors, growth factor receptors, extracellular matrix, and inflammatory cellular responses to regulate angiogenesis and vasculogenesis in response to myocardial ischemia and alterations in shear stress. Therapeutic angiogenesis represents a novel approach to increase myocardial perfusion in patients with coronary artery disease and provides an opportunity to further clarify the mechanisms that regulate collateral development. Impairment of angiogenic adaptive responses to ischemia during disease states is an important subject for future investigation.

Myocardial distribution of coronary blood flow in the isolated supported heart preparation.

The regional distribution of myocardial blood flow was studied by use of radioactive microspheres (15 micro-meters [mum]) under control conditions and during an intracoronary infusion of norepinephrine (2mug/min). In control experiments endocardial blood flow was generally greater than epicardial flow; during administration of norepinephrine the endocardium received significantly less blood flow. It is proposed that normally the endocardium is well perfused, but under conditions of stress, eg, norepinephrine infusion in the presence of a constant coronary blood flow, decreased endocardial blood flow results.

Injury to the Ca2+ ATPase of the sarcoplasmic reticulum in anesthetized dogs contributes to myocardial reperfusion injury.

OBJECTIVE: Sarcoplasmic reticulum dysfunction may contribute to calcium (Ca2+) overload during myocardial reperfusion. The aim of this study was to investigate its role in reperfusion injury. METHODS: Open chest dogs undergoing 15 min of left anterior descending coronary artery occlusion and 3 h of reperfusion were randomized to intracoronary infusions of 0.9% saline, vehicle, or the Ca2+ channel antagonist, nifedipine (50 micrograms/min from 2 minutes before to 5 minutes after reperfusion). After each experiment, transmural myocardial biopsies were removed from ischemic/reperfused and nonischemic myocardium in the beating state and analyzed for (i) sarcoplasmic reticulum protein content (Ca2+ ATPase, phospholamban, and calsequestrin) by immunoblotting and (ii) Ca2+ uptake by sarcoplasmic reticulum vesicles with and without 300 micromolar ryanodine or the Ca2+ ATPase activator, antiphospholamban (2D12) antibody. RESULTS: Contractile function did not recover in controls and vehicle-treated dogs after ischemia and reperfusion (mean systolic shortening, -2 +/- 2%), but completely recovered in nifedipine-treated dogs (17 +/- 2%, p = NS vs. baseline, p < 0.01 vs. control). Ventricular fibrillation occurred in 50% of controls and vehicle dogs and 0% of nifedipine-treated dogs (p < 0.01). Ca2+ uptake by the sarcoplasmic reticulum vesicles was severely reduced in ischemic/reperfused myocardium of controls and vehicle dogs (p < 0.01 vs. nonischemic). Ryanodine and the 2D12 antibody improved, but did not reverse the low Ca2+ uptake. Protein content was similar in ischemic/reperfused and nonischemic myocardium. In contrast, Ca2+ uptake and the responses to ryanodine and 2D12 antibody were normal in ischemic/reperfused myocardium from nifedipine-treated dogs. CONCLUSION: Dysfunction of the sarcoplasmic reticulum Ca2+ ATPase pump correlates with reperfusion injury. Reactivation of Ca2+ channels at reperfusion contributed to Ca2+ pump dysfunction. Ca2+ pump injury may be a critical event in myocardial reperfusion injury.

Quantitative ultrasonic assessment of normal and ischaemic myocardium with an acoustic microscope: relationship to integrated backscatter.

PURPOSE OF INVESTIGATION: The aim was to study ultrasonic propagation properties of normal and ischaemic myocardium with a scanning laser acoustic microscope and to correlate these changes with ultrasonic backscatter. DESIGN: Myocardial ischaemia was produced by total occlusion of left anterior descending coronary artery in anaesthetised open chest dogs. Myocardium supplied by left circumflex coronary artery served as normal control. IBR5, an optimum weighted frequency average (4-6.8 MHz) of the squared envelope of diffraction corrected backscatter, was measured in vivo. Ultrasonic attenuation coefficient, an index of loss per unit distance, the propagation speed and heterogeneity index were measured from normal and ischaemic regions with a scanning laser acoustic microscope which operates at 100MHz in vitro. Myocardial water content of normal and ischaemic myocardium was also estimated. SUBJECTS: Were five anaesthetised mongrel dogs. RESULTS: Attenuation coefficient of 33.8(SD4.2) dB.mm-1 in the ischaemic tissue was lower than 63.8(17.2) dB.mm-1 in the normal tissue (p less than 0.01). Ultrasonic speed was lower in ischaemic than normal myocardium at 1584(25) v 1612(35) m.s-1 (p less than 0.05). Heterogeneity index of 11(7) m.s-1 in the ischaemic region was lower than 14(8) m.s-1 in the normal region (27% reduction, p less than 0.05). IBR5 and myocardial water content were higher in the ischaemic than the normal myocardium: -37.2(SEM1.8) dB v -46.6(0.6) dB, (p less than 0.01) and 80.9(0.0)% v 78(0.2)%, (p less than 0.05) respectively. CONCLUSION: Ultrasonic properties of the myocardium are significantly altered during acute ischaemia.

Cloning and expression of canine glycoprotein Ibalpha.

The interaction of the glycoprotein (GP) Ib-IX-V complex with von Willebrand factor (vWF) is critical in initiation of haemostasis and thrombosis through platelet adhesion to damaged endothelium. The binding site for vWF resides within the GPIbalpha subunit of the complex. To further define the physiological function of platelet GPIbalpha we cloned and expressed the canine GPIbalpha cDNA. A canine platelet cDNA library was constructed and screened with a randomly primed 32P-labeled 1041-base-pair restriction fragment of the human GPIbalpha cDNA. Analysis of 23 clones demonstrated that the canine GPIbalpha cDNA is 2530 nucleotides in length and includes a short 5' untranslated segment of 42 nucleotides followed by a signal peptide of 16 amino acids, a mature peptide of 645 amino acids and a 3' noncoding region of 455 nucleotides. A single intron of 142 nucleotides, 6 nucleotides upstream from the ATG translation initiation codon was identified in the canine gene in a similar location to that present in the human gene. Chinese hamster ovary cells that stably express human GPIbbeta and GPIX were transfected with the canine GPIbalpha cDNA. Canine GPIbalpha was expressed on the surface of these cells and bound vWF in the presence of botrocetin. The binding of vWF was inhibited by an anti-vWF human monoclonal antibody known to inhibit vWF binding to GPIbalpha. The results of this investigation will allow the development of reagents to study the physiological function of GPIbalpha in an animal model.

Coronary steal-induced increase in myocardial infarct size after pharmacologic coronary vasodilation.

This study was performed to determine if maximal coronary arterial vasodilation of nonischemic areas would produce an increase in myocardial infarct size through a "steal" of collateral flow from an ischemic region. Myocardial infarction was produced by a 2 hour occlusion and reperfusion of the distal left anterior descending coronary artery in anesthetized dogs. Five minutes after occlusion, 7 dogs were given saline solution, and in 12 dogs the coronary vasodilator chromonar (8 mg/kg, intravenously) was administered. Chromonar produced a significant increase (p less than 0.05) in blood flow to nonischemic regions and a concomitant decrease in flow to ischemic areas. Associated with these changes in flow was an elevation in total release and peak plasma creatine kinase compared with values in saline-treated control dogs. Myocardial infarct size determined with nitroblue tetrazolium stanining was significantly increased (p less than 0.05). These demonstarte that maximal coronary vasodilation of nonischemic areas can result in an extension of myocardial infarction by a steal of collateral flow away from the ischemic region.

Redistribution of myocardial blood flow distal to a dynamic coronary arterial stenosis by sympathomimetic amines: comparison of dopamine, dobutamine and isoproterenol.

The effects of dopamine, dobutamine and isoproterenol on coronary hemodynamics, severity of stenosis, distal bed resistance and transmural myocardial perfusion gradients with radioactive microspheres were studied in dogs with a mild obstruction of the left circumflex coronary artery anesthetized with morphine-chloralose. Changes in transmural blood flow were related to the ratio of the diastolic aortic pressure-time index to tension-time index (DPTI/TTI) and the ratio of the distal diastolic coronary pressure-time index to tension-time index (DDPTI/TTI). At doses of 5 microgram/kg per min, dopamine had no significant effect on DPTI/TTI, DDPTI/TTI or endocardial/epicardial flow ratio; however, dobutamine produced a slight decrease in this flow ratio and in DDPTI/TTI. At doses of 10 microgram/kg per min, both drugs produced a significant (p less than 0.05) reduction in diastolic coronary pressure distal to the stenosis. DDPTI/TTI and endocardial/epicardial flow ratio without change in DPTI/TTI. In comparison, isoproterenol (0.01 and 0.05 microgram/kg per min) produced dose-related decreases in endocardial/epicardial flow ratio, DDPTI/TTI and DPTI/TTI. During infusion of each sympathomimetic agent, there was a corresponding reduction in distal bed vascular resistance but a concomitant increase in stenosis resistance. The results also show that dopamine and dobutamine, as well as isoproterenol, area capable of producing a maldistribution of coronary blood flow distal to a mild coronary arterial stenosis and that such a redistribution of glow is dependent on dose, reduction of the distal diastolic coronary pressure-time index and decrease in DDPTI/TTI. It is further concluded that hemodynamic changes distal to a coronary arterial stenosis seriously jeopardize the usefulness of DPTI/TTI; however, DDPTI/TTI can be used to predict drug effects on the endocardial/epicardial flow ratio in an ischemic area. This study demonstrates that "fixed" stenoses can undergo dynamic processes and sympathomimetic amines increase the resistance to flow through a stenotic coronary artery in the nonfailing heart.

Effect of omega-3 fatty acids on the vascular response to angiotensin in normotensive men.

There is a widespread interest in fish oil as a dietary supplement and possible nonpharmacologic adjunct in the treatment of hypertension. The effect of dietary fish oil on blood pressure is controversial and the effect on systemic hemodynamics and regional vascular reactivity in humans is unknown. To address these questions, a double-blind, placebo-controlled, crossover study on the effect of dietary fish oil substitution was performed during a carefully controlled diet in 8 normotensive men. Systemic hemodynamics and the forearm vascular response to intrabrachial artery infusions of norepinephrine, phentolamine and angiotensin II were obtained. Compared with a safflower oil placebo, dietary fish oil had no effect on cardiac output (6.42 +/- 0.38 vs 6.87 +/- 0.28 liters/min, p = not significant) or 24-hour blood pressure (122/68 +/- 3/3 vs 122/68 +/- 3/2 mm Hg, p = not significant). The vascular response to norepinephrine and phentolamine was unchanged. Fish oil, however, significantly (p < 0.05) reduced forearm vascular resistance responses to angiotensin II. These changes were associated with a reduction in plasma triglycerides (64 +/- 9 vs 39 +/- 4 mg/dl, p = 0.02) and an increase in plasma eicosapentaenoic acid levels (0.51 +/- 0.25 vs 1.72 +/- 0.35 microM, p < 0.05). Substitution of a moderate dose of fish oil for fat in a "Western diet" selectively attenuates the vascular response to angiotensin independently of changes in alpha-adrenergic vasoconstriction or systemic hemodynamics.

Influence of levosimendan, pimobendan, and milrinone on the regional distribution of cardiac output in anaesthetized dogs.

1. The distribution of cardiac output during administration of levosimendan, a new myofilament calcium sensitizer, is unknown. We examined and compared the effects of levosimendan, pimobendan, and milrinone on regional tissue perfusion by use of the radioactive microsphere technique in barbiturate-anaesthetized dogs. 2. Haemodynamics and regional blood flow were determined before and during infusions of levosimendan (0.75, 1.5, and 3.0 micrograms kg-1 min-1), pimobendan (10, 20, and 40 micrograms kg-1 min-1), or milrinone (1.0, 2.0, and 4.0 micrograms kg-1 min-1). 3. All three drugs caused similar increases in heart rate, cardiac output, and left ventricular +dP/dt and decreases in end-diastolic pressure and systemic vascular resistance. No changes in subendocardial, midmyocardial, and subepicardial blood flow occurred during administration of levosimendan. However, a redistribution of blood flow from subendocardium to subepicardium was observed. Pimobendan increased midmyocardial and subepicardial blood flow and reduced the endo/epi ratio to a greater degree than levosimendan. Milrinone did not affect myocardial perfusion. 4. Levosimendan increased blood flow to the renal medulla and decreased renal medullary and cortical vascular resistance. Levosimendan increased blood flow to the small intestine and liver and reduced vascular resistance in these organs. Pimobendan increased hepatic blood flow to a greater degree than levosimendan but did not alter small intestinal perfusion. All three drugs decreased splenic blood flow to similar degrees. Levosimendan and pimobendan reduced cerebral vascular resistance. Levosimendan and milrinone reduced skeletal muscle vascular resistance. 5. The results indicate that levosimendan, pimobendan, and milrinone cause subtlety different alterations in regional tissue perfusion while producing similar haemodynamic effects.