Everolimus versus mycophenolate mofetil in heart transplantation: a randomized, multicenter trial.

In an open-label, 24-month trial, 721 de novo heart transplant recipients were randomized to everolimus 1.5 mg or 3.0 mg with reduced-dose cyclosporine, or mycophenolate mofetil (MMF) 3 g/day with standard-dose cyclosporine (plus corticosteroids ± induction). Primary efficacy endpoint was the 12-month composite incidence of biopsy-proven acute rejection, acute rejection associated with hemodynamic compromise, graft loss/retransplant, death or loss to follow-up. Everolimus 1.5 mg was noninferior to MMF for this endpoint at month 12 (35.1% vs. 33.6%; difference 1.5% [97.5% CI: -7.5%, 10.6%]) and month 24. Mortality to month 3 was higher with everolimus 1.5 mg versus MMF in patients receiving rabbit antithymocyte globulin (rATG) induction, mainly due to infection, but 24-month mortality was similar (everolimus 1.5 mg 10.6% [30/282], MMF 9.2% [25/271]). Everolimus 3.0 mg was terminated prematurely due to higher mortality. The mean (SD) 12-month increase in maximal intimal thickness was 0.03 (0.05) mm with everolimus 1.5 mg versus 0.07 (0.11) mm with MMF (p < 0.001). Everolimus 1.5 mg was inferior to MMF for renal function but comparable in patients achieving predefined reduced cyclosporine trough concentrations. Nonfatal serious adverse events were more frequent with everolimus 1.5 mg versus MMF. Everolimus 1.5 mg with reduced-dose cyclosporine offers similar efficacy to MMF with standard-dose cyclosporine and reduces intimal proliferation at 12 months in de novo heart transplant recipients.

Intercellular transfer of the virally derived precursor form of acid alpha-glucosidase corrects the enzyme deficiency in inherited cardioskeletal myopathy Pompe disease.

Pompe disease is a lethal cardioskeletal myopathy in infants and results from genetic deficiency of the lysosomal enzyme acid alpha-glucosidase (GAA). Genetic replacement of the cDNA for human GAA (hGAA) is one potential therapeutic approach. Three months after a single intramuscular injection of 10(8) plaque-forming units (PFU) of E1-deleted adenovirus encoding human GAA (Ad-hGAA), the activity in whole muscle lysates of immunodeficient mice is increased to 20 times the native level. Direct transduction of a target muscle, however, may not correct all deficient cells. Therefore, the amount of enzyme that can be transferred to deficient cells from virally transduced cells was studied. Fibroblasts from an affected patient were transduced with AdhGAA, washed, and plated on transwell culture dishes to serve as donors of recombinant enzyme. Deficient fibroblasts were plated as acceptor cells, and were separated from the donor monolayer by a 22-microm pore size filter. Enzymatic and Western analyses demonstrate secretion of the 110-kDa precursor form of hGAA from the donor cells into the culture medium. This recombinant, 110-kDa species reaches the acceptor cells, where it can be taken up by mannose 6-phosphate receptor-mediated endocytosis. It then trafficks to lysosomes, where Western analysis shows proteolytic processing to the 76- and 70-kDa lysosomal forms of the enzyme. Patient fibroblasts receiving recombinant hGAA by this transfer mechanism reach levels of enzyme activity that are comparable to normal human fibroblasts. Skeletal muscle cell cultures from an affected patient were also transduced with Ad-hGAA. Recombinant hGAA is identified in a lysosomal location in these muscle cells by immunocytochemistry, and enzyme activity is transferred to deficient skeletal muscle cells grown in coculture. Transfer of the precursor protein between muscle cells again occurs via mannose 6-phosphate receptors, as evidenced by competitive inhibition with 5 mM mannose 6-phosphate. In vivo studies in GAA-knockout mice demonstrate that hepatic transduction with adenovirus encoding either murine or human GAA can provide a depot of recombinant enzyme that is available to heart and skeletal muscle through this mechanism. Taken together, these data show that the mannose 6-phosphate receptor pathway provides a useful strategy for cell-to-cell distribution of virally derived recombinant GAA.

Mitochondrial adenosine triphosphatase in the oxyphil cells of a renal oncocytoma.

Oxyphil cells are characterized by cytoplasm packed with large numbers of mitochondria. Study of these unusual cells may provide information about the regulation of mitochondrial biogenesis. Although it has been suggested that this is a compensatory proliferation due to a mitochondrial dysfunction, no such dysfunction has been well documented. In this study we considered the possibility of dysfunction in the mitochondrial enzyme F1/Fo-adenosine triphosphatase(ATPase) as a stimulating factor involved in the mitochondrial proliferation of oxyphil cells. Mitochondria isolated from frozen tissue of a renal oncocytoma showing structural integrity and purity by electron microscopy were studied. Submitochondrial particles formed by sonic disruption showed the presence of the F1 component of mitochondrial ATPase with electron microscopy which was functionally active. The oligomycinsensitive ATPase activity from the renal oncocytoma was 0.133 mumol/min.mg submitochondrial particle protein which was higher than the readings obtained from normal kidney tissue (0.091 mumol/min.mg SMP protein) obtained from hamsters. Normal human renal tissue obtained at autopsy contained only nonfunctional mitochondria and therefore could not be used as control tissue. Mitochondrial ATPase dysfunction does not appear to be the inciting factor in the proliferation of mitochondria seen in oxyphil cell metaplasia and future studies should consider other possibilities. Preliminary functional studies of this nature can be performed with properly prepared frozen surgical tissue.

Selenium distribution in mammary epithelial cells reveals its possible mechanism of inhibition of cell growth.

The subcellular and macromolecular distribution of 75Se-selenite was determined in murine mammary epithelial cell lines which demonstrated marked differences in their growth response to 5 microM selenite. MOD cells responded sooner to the inhibitory effects of selenite than COMMA-D cells. The MOD cells also incorporated a slightly higher percentage of 75Se-selenite into proteins and attained a higher ratio of selenoprotein to selenonucleic acids than did COMMA-D cells. Most selenium and selenoproteins were located in the cytoplasm as revealed by autoradiography and subcellular fractionations. These data suggest that a cytoplasmic selenoprotein may be an intermediate for selenite's nontoxic growth inhibitory effects.

Mitochondrial inclusions and mitochondrial respiratory function in selenite-treated mammary epithelial cell lines.

The effect of selenite on mitochondrial morphology, selenoprotein synthesis, membrane potential, phosphorylating respiration, P/O ratio and respiratory control index were evaluated relative to selenite inhibition of DNA synthesis in murine mammary epithelial cell lines. No inhibition of mitochondrial function was noted. Mitochondrial inclusions and most mitochondrial specific selenoproteins were not observed until after DNA synthesis was inhibited. Pyruvate, methionine, hydroxybutyrate, dexamethasone or carnitine had no effect on the inclusions. The results provide evidence for the hypothesis emphasizing the importance of cytosolic selenoproteins modulating the growth inhibitory effects of selenite.

D-Ribose as a supplement for cardiac energy metabolism.

Metabolic support for the heart has been an attractive concept since the pioneering work of Sodi-Pallares et al. four decades ago.* Recently, interest has increased in the use of over-the-counter supplements and naturally occurring nutriceuticals for enhancement of cardiac and skeletal muscle performance. These include amino acids such as creatine, L-carnitine, and L-arginine, as well as vitamins and cofactors such as alpha-tocopherol and coenzyme Q. Like these other molecules, D-ribose is a naturally occurring compound. It is the sugar moiety of ATP and has also received interest as a metabolic supplement for the heart. The general hypothesis is that under certain pathologic cardiac conditions, nucleotides (particularly ATP, ADP, and AMP) are degraded and lost from the heart. The heart's ability to resynthesize ATP is then limited by the supply of D-ribose, which is a necessary component of the adenine nucleotide structure. In support of this hypothesis, recent reports have used D-ribose to increase tolerance to myocardial ischemia. Its use in patients with stable coronary artery disease improves time to exercise-induced angina and electrocardiographic changes. In conjunction with thallium imaging or dobutamine stress echocardiography, D-ribose supplementation has been used to enhance detection of hibernating myocardium. In this article, we review the biochemical basis for using supplemental D-ribose as metabolic support for the heart and discuss the experimental evidence for its benefit.

Reduced left ventricular dimension and normalized atrial natriuretic hormone level after repair of aortic coarctation in an adult.

Although unusual in the older patient, coarctation of the aorta can be an occult cause of cardiomyopathy. This report describes a 53-year-old man with new-onset heart failure symptoms, global left ventricular (LV) dysfunction, and underlying aortic coarctation. Surgical correction resulted in reduced LV size, resolution of symptoms, and normalization of atrial natriuretic hormone levels.

The benefits of ribose in cardiovascular disease.

Cardiovascular disease still ranks as the leading cause of death in men and women. Adults have tried to lower their risk of cardiovascular disease by improving their diet, quitting smoking, controlling blood pressure and exercising regularly. Additionally, many adults have turned to nutriceutical or natural products. Myocardial ischemia, produces a depression in myocardial tissue levels of high energy compounds, along with a compromise in myocardial function. Ribose, a naturally occurring sugar, has been extensively investigated, both in animal and clinical studies, as an agent to enhance the recovery of these depressed energy compounds. Results of these studies have been promising in enhancing the recovery of these energy molecules along with an improvement in myocardial function. Therefore, ribose should be considered as a potential agent in the treatment of ischemic cardiovascular disease.

Influence of phenotype and pharmacokinetics on beta-blocker drug target pharmacogenetics.

Two common polymorphisms in the beta1-adrenergic receptor gene, Ser49Gly and Arg389Gly, are associated with variable antihypertensive response to metoprolol. We sought to determine whether similar pharmacogenetic associations were present with the negative chronotropic response phenotype to metoprolol. Metoprolol was titrated in 54 untreated hypertensive patients to achieve blood pressure control. We found no association between either resting or exercise heart rate at baseline (untreated) or in response to metoprolol by codon 389 genotype. In contrast, when compared by codon 49 genotype, Ser49 homozygotes had significantly higher resting heart rates at baseline (untreated) than Gly49 carriers (82+/-10 versus 74+/-11 bpm, respectively, P=0.016). When corrected for plasma concentration, we found no difference in reduction in exercise heart rate in response to metoprolol between Ser49 homozygotes and Gly49 carriers (0.75+/-0.11 versus 0.57+/-0.17%/ng/ml, respectively, P=0.37). However, if one fails to account for plasma concentration, trends toward a significant difference in heart rate reduction are seen between Ser49 homozygotes and Gly49 carriers (31% reduction versus 25% reduction, P=0.05). Our data suggest that neither the beta1-adrenergic receptor Arg389Gly, nor the Ser49Gly polymorphisms are associated with variable negative chronotropic response to metoprolol. In addition, our data highlight the importance of measuring metoprolol concentration in order to account for variable pharmacokinetics and avoid misinterpretation of the data.

Noninvasive discrimination of rejection in cardiac allograft recipients using gene expression profiling.

Rejection diagnosis by endomyocardial biopsy (EMB) is invasive, expensive and variable. We investigated gene expression profiling of peripheral blood mononuclear cells (PBMC) to discriminate ISHLT grade 0 rejection (quiescence) from moderate/severe rejection (ISHLT > or = 3A). Patients were followed prospectively with blood sampling at post-transplant visits. Biopsies were graded by ISHLT criteria locally and by three independent pathologists blinded to clinical data. Known alloimmune pathways and leukocyte microarrays identified 252 candidate genes for which real-time PCR assays were developed. An 11 gene real-time PCR test was derived from a training set (n = 145 samples, 107 patients) using linear discriminant analysis (LDA), converted into a score (0-40), and validated prospectively in an independent set (n = 63 samples, 63 patients). The test distinguished biopsy-defined moderate/severe rejection from quiescence (p = 0.0018) in the validation set, and had agreement of 84% (95% CI 66% C94%) with grade ISHLT > or = 3A rejection. Patients >1 year post-transplant with scores below 30 (approximately 68% of the study population) are very unlikely to have grade > or = 3A rejection (NPV = 99.6%). Gene expression testing can detect absence of moderate/severe rejection, thus avoiding biopsy in certain clinical settings. Additional clinical experience is needed to establish the role of molecular testing for clinical event prediction and immunosuppression management.

Importance of acyl-CoA availability in interpretation of carnitine palmitoyltransferase I kinetics.

Bovine serum albumin is generally employed as a substrate depot for the delivery of acyl units to lipid metabolizing enzymes in vitro. Here we test the possibility that albumin alters the availability of substrate to mitochondrial carnitine palmitoyltransferase I and thereby alters its apparent kinetics. Binding competition with palmitoyl-CoA indicates that albumin has 5-6 high affinity sites which avidly bind the substrate, while isolated mitochondria compete favorably for substrate only as the albumin sites become saturated. In contrast to albumin, artificial phospholipid vesicles bind palmitoyl-CoA uniformly. Palmitoyl-CoA distribution between vesicles and mitochondrial membranes appears simply to be a function of the relative size of the two lipid compartments. Both albumin and artificial vesicles reduce the effective concentration of substrate available to the enzyme and in this way reduce apparent affinity. Direct measurement of mitochondrially bound substrate removes this effect and brings the results into agreement with an affinity constant of 6-7 nmol/mg. Changes in gross mitochondrial structure, as indicated by decreased optical density and increased nonpelleting protein, do not begin occurring until levels of mitochondrially bound palmitoyl-CoA are 15 times greater than this. The highly sigmoidal activity profile of carnitine palmitoyltransferase with respect to palmitoyl-CoA (apparent Hill coefficient = 3.0 +/- 0.3) is lost when vesicles are substituted for albumin, suggesting that albumin binding sites contribute to the sigmoidal kinetics in the range of palmitoyl-CoA studied.

Control of mitochondrial respiration in muscle.

Control of mitochondrial respiration depends on ADP availability to the F1-ATPase. An electrochemical gradient of ADP and ATP across the mitochondrial inner membrane is maintained by the adenine nucleotide translocase which provides ADP to the matrix for ATP synthesis and ATP for energy-dependent processes in the cytosol. Mitochondrial respiration is responsive to the cytosolic phosphorylation potential, ATP/ADP.Pi which is in apparent equilibrium with the first two sites in the electron transport chain. Conventional measures of free adenine nucleotides is a confounding issue in determining cytosolic and mitochondrial phosphorylation potentials. The advent of phosphorus-31 nuclear magnetic resonance (P-31 NMR) allows the determination of intracellular free concentrations of ATP, creatine-P and Pi in perfused muscle in situ. In the glucose-perfused heart, there is an absence of correlation between the cytosolic phosphorylation potential as determined by P-31 NMR and cardiac oxygen consumption over a range of work loads. These data suggest that contractile work leads to increased generation of mitochondrial NADH so that ATP production keeps pace with myosin ATPase activity. The mechanism of increased ATP synthesis is referred to as 'stimulus-response-metabolism' coupling. In muscle, increased contractility is a result of interventions which increase cytosolic free Ca2+ concentrations. The Ca2+ signal thus generated increases glycogen breakdown and myosin ATPase in the cytosol. This signal is concomitantly transmitted to the mitochondria which respond to small increases in matrix Ca2+ by activation of Ca2+-sensitive dehydrogenases. The Ca2+-activated dehydrogenase activities are key rate-controlling enzymes in tricarboxylic acid cycle flux, and their activation by Ca2+ leads to increased pyridine nucleotide reduction and oxidative phosphorylation.(ABSTRACT TRUNCATED AT 250 WORDS)

Carnitine palmitoyltransferase in cardiac ischemia. A potential site for altered fatty acid metabolism.

The sensitivity of carnitine palmitoyl coenzyme A (CoA) transferase I to inhibition of its activity by malonyl-CoA is progressively reduced in mitochondria isolated from ischemic cardiac cells as blood flow decreases to 30% or less of the preocclusion flow. The activity of carnitine palmitoyl-CoA transferase I in mitochondria isolated from nonischemic cardiac cells demonstrates incomplete inhibition, even at high concentrations of malonyl-CoA. Kinetic analyses of these data gave results most consistent with the expression of two overt enzyme activities: one activity that is sensitive to inhibition by malonyl-CoA and one activity that demonstrates little or no sensitivity to such inhibition. The decrease in malonyl-CoA-sensitive activity associated with ischemia results from a 13% decrease in the activity of the sensitive component and a corresponding 13% increase in the activity of the insensitive component. Decreased sensitivity of ischemic carnitine palmitoyl-CoA transferase I to inhibition by malonyl-CoA, together with potential fluctuations in the content of malonyl-CoA in tissue, would increase the synthesis of palmitoylcarnitine during ischemia and facilitate return to the use of fatty acid as a preferred metabolic fuel on reperfusion. This apparent conversion occurs concomitantly with a decrease in the free protein thiol content of the mitochondrial membranes isolated from ischemic cardiac cells. Treatment of the mitochondria from ischemic cardiac cells with dithiothreitol in vitro partially reverses the loss in sensitivity to malonyl-CoA, suggesting the possible role of thiol oxidation in the altered metabolism of ischemic mitochondria. Western blot analysis of these mitochondria using an antibody against carnitine palmitoyltransferase II purified from beef heart demonstrates a 68-kDa protein, which under ischemic conditions apparently is decreased by 2 kDa. These results are more indicative of a modification in protein folding of carnitine palmitoyltransferase than proteolytic changes during ischemia.

Carnitine-acylcarnitine translocase in ischemia: evidence for sulfhydryl modification.

After coronary occlusion and reflow, carbohydrate catabolism is enhanced, whereas fatty acid utilization is delayed. To test the hypothesis that "stunning" of fatty acid use by ischemic heart reflects reduced fatty acid transport into the mitochondria, two activities involved in the transport were examined: carnitine-acylcarnitine translocase and carnitine palmitoyltransferase II (CPT II). The maximal velocity for carnitine exchange of the translocase is reduced 55% in mitochondria isolated from ischemic canine heart (60-min left circumflex occlusion). Mitochondria from ischemic heart show 50% depletion in total matrix glutathione, a 200% increase in glutathione disulfide (GSSG), and an 80% decrease in the ratio of reduced glutathione (GSH) to GSSG, suggesting that the loss of translocase activity may be a consequence of protein sulfhydryl modifications. In support of this, treatment of these mitochondria with the sulfhydryl-reducing agents, GSH or dithiothreitol, restores carnitine exchange to control. Partial return of mitochondrial GSH and a decrease in GSSG are observed with a 20-min reperfusion of the ischemic myocardium. Continued depression in carnitine exchange with reperfusion suggests that other mechanisms may prevent restoration of activity. Import of palmitoylcarnitine on the translocase is coupled to palmitoyl-CoA production by CPT II. Mitochondria from ischemic heart with decreased coupling activity also have the lowest palmitoylcarnitine-supported respiratory rates, suggesting that in severely ischemic tissue the translocation-transesterification sequence may become rate limiting to fatty acid oxidation.

Chymotrypsin activates cardiac mitochondrial carnitine-acylcarnitine translocase.

The carnitine-acylcarnitine translocase facilitates carnitine and acylcarnitine transport into the mitochondrial matrix during beta-oxidation. Our results demonstrate that chymotrypsin can activate the maximal velocity of N-ethylmaleimide (NEM)-sensitive carnitine or palmitoylcarnitine exchange 7-fold, while doubling the affinity of the translocase for carnitine. Chymotrypsin activation is strictly dependent on the presence of free or short-chain acylcarnitine in the proteolysis medium, the extent of activation decreasing as the acylcarnitine chain length in the proteolysis medium increases. Chymotrypsin treatment decreases the apparent I50 value (inhibitor concentration required to give half-maximal inhibition) of the translocase for inhibition by NEM only under conditions which produce translocase activation. Modification of submitochondrial particle membranes by chymotrypsin does not result in gross ultrastructural changes or in an increase in the passive permeability of these membranes to carnitine. The data suggest that carnitine binding produces a change in translocase conformation which allows chymotrypsin modification to occur. This modification alters the kinetic and inhibitor-binding properties of the translocase.

Pyrenedodecanoylcarnitine and pyrenedodecanoyl coenzyme A: kinetics and thermodynamics of their intermembrane transfer.

The intermembrane transfer kinetics and transition-state thermodynamics of pyrenedodecanoylcarnitine (PDC), pyrenedodecanoyl coenzyme A (PDCoA), and pyrenedodecanoic acid (PDA) were measured by observing the time-dependent decay in pyrene excimer fluorescence. Probe molecules transferred more slowly with an increase in vesicle size. Rates of PDC and PDA transfer were increased from a liquid lipid phase when compared to a gel phase, while a saturated lipid phase had variable effects on the transfer kinetics when compared to an unsaturated lipid vesicle. Increasing vesicle surface charge by the introduction of phosphatidylserine (PS) into the vesicle matrix had two distinct effects: (i) a decrease in PDC transfer rates as the PS concentration increased and (ii) an initial increase in transfer rates of the amphiphilic anions PDA and PDCoA, followed by a decrease as the PS content increased. Transfer from natural membranes (cardiac and hepatic reticular and mitochondrial membranes) was markedly decreased (up to 35-fold) when compared to large phospholipid vesicles. These decreases in rates were accompanied by significant increases in the transition-state free energies. Finally, the pyrenedodecanoate esters had critical micelle concentrations similar to the natural long-chain esters, i.e., palmitate. In the presence of acceptor vesicles all probes showed only slight accessibility to quenching by the aqueous quencher nicotinamide.

Complete correction of acid alpha-glucosidase deficiency in Pompe disease fibroblasts in vitro, and lysosomally targeted expression in neonatal rat cardiac and skeletal muscle.

The enzyme acid alpha-glucosidase catalyzes the breakdown of lysosomal glycogen. Absence of this enzyme results in infantile Pompe disease, characterized by hypertrophic cardiomyopathy, skeletal muscle weakness and fatal heart failure by 2 years of age. We have examined the possibility of gene replacement therapy for this disease, by constructing an E1-deleted recombinant adenovirus encoding human acid alpha-glucosidase (Ad-GAA). The dose-response in fibroblasts from patients with Pompe disease transduced with this vector is linear over the range tested (one to 2000 plaque forming units (p.f.u.) of Ad-GAA per cell), and acid alpha-glucosidase activity comparable to that of normal fibroblasts is achieved at 100 p.f.u. per cell. Targeting of the recombinant protein to the lysosomal compartment was confirmed by immunocytochemistry. In vivo expression was examined by injecting Ad-GAA into newborn rats; intracardiac administration produced 10 times the normal level of acid alpha-glucosidase activity in whole heart lysates, while a hind-limb i.m. injection increased activity in that muscle to six times the normal level. Western blotting of these tissues defected species at 76 kDa consistent with the size of processed lysosomal enzyme, and levels of expression as high as 1.0 mg recombinant protein per gram of tissue wet weight were produced. These data demonstrate high-level, lysosomal expression of recombinant acid alpha-glucosidase in treated target tissues and support the feasibility of gene replacement strategies for Pompe disease.

Protection by verapamil of mitochondrial glutathione equilibrium and phospholipid changes during reperfusion of ischemic canine myocardium.

Pretreatment of the ischemic myocardium with verapamil protects against mitochondrial respiratory depression observed during ischemic arrest as well as during reperfusion. Since ischemic mitochondrial function appears not to be altered further by reperfusion, the purpose of this study is to identify a biochemical event affecting mitochondria that is specifically associated with reperfusion injury. It has been proposed that increased cellular Ca2+ influx and oxygen toxicity may result from reintroduction of coronary flow. Increased cytosolic Ca2+ is transmitted to the mitochondria with subsequent activation of Ca2+-dependent events, including phospholipase A2. Net production of lysophospholipids (and loss of total diacylphospholipids from the mitochondria) will proceed when reacylation mechanisms are inhibited. Since acyl-CoA:lysophospholipid acyltransferase is a sulfhydryl-sensitive enzyme and since increased activity of glutathione peroxidase shifts the levels of the mitochondrial sulfhydryl buffer, glutathione, towards oxidation, levels of glutathione and its oxidation state were measured during reperfusion in the absence or presence of verapamil pretreatment. Ischemia lowers total glutathione and reduces the redox ratio (reduced glutathione: oxidized glutathione) by 85%. Reperfusion partially returns the redox ratio to control by causing oxidized glutathione to disappear from the matrix. Verapamil maintains both the concentration and the redox potential of glutathione at control levels. Concomitant with alterations in reduced glutathione:oxidized glutathione is a decrease in ischemic mitochondrial phospholipid content. During reperfusion, phosphatidylethanolamine and its major constituent fatty acids (C 18:0 and C 20:4) are specifically lost from the mitochondrial membrane. Accompanying the significant loss of arachidonic acid during reperfusion is the decreased content of 11-OH, 12-OH, and 15-OH arachidonate. These lipid peroxidation products are not increased in ischemia. It is proposed that oxidation of matrix glutathione to glutathione disulfide during ischemia results in formation of glutathione-protein mixed disulfides and inhibition of sulfhydryl-sensitive proteins, including acyl-CoA lysophosphatide acyltransferase. Thus, metabolic events occurring within the ischemic period set the stage for prolonged dysfunction during reperfusion.