beta-Adrenergic modulation of the inwardly rectifying potassium channel in isolated human ventricular myocytes. Alteration in channel response to beta-adrenergic stimulation in failing human hearts.

The beta-adrenergic modulation of the inwardly-rectifying K+ channel (IK1) was examined in isolated human ventricular myocytes using patch-clamp techniques. Isoproterenol (ISO) reversibly depolarized the resting membrane potential and prolonged the action potential duration. Under the whole-cell C1- -free condition, ISO applied via the bath solution reversibly inhibited macroscopic IdK1. The reversal potential of the ISO-sensitive current was shifted by approximately 60 mV per 10-fold change in the external K+ concentration and was sensitive to Ba2+. The ISO-induced inhibition of IK1 was mimicked by forskolin and dibutyrl cAMP, and was prevented by including a cAMP-dependent protein kinase (PKA) inhibitor (PKI) in the pipette solution. In single-channel recordings from cell-attached patches, bath applied ISO could suppress IK1 channels by decreasing open state probability. Bath application of the purified catalytic sub-unit of PKA to inside-out patches also inhibited IK1 and the inhibition could be antagonized by alkaline phosphatase. When beta-adrenergic modulation of IK1 was compared between ventricular myocytes isolated from the failing and the nonfailing heart, channel response to ISO and PKA was significantly reduced in myocytes from the failing heart. Although ISO inhibited IK1 in a concentration-dependent fashion in both groups, a half-maximal concentration was greater in failing (0.12 microM) than in nonfailing hearts (0.023 microM). These results suggest that IK1 in human ventricular myocytes can be inhibited by a PKA-mediated phosphorylation and the modulation is significantly reduced in ventricular myocytes from the failing heart compared to the nonfailing heart.

Left ventricular dynamic geometry and diastolic mechanics in a model of chronic cyanosis and right ventricular pressure overload.

Left ventricular (LV) mechanics and dynamic geometry were studied in eight dogs 1 to 151 days after creation of a model of cyanosis and increased right ventricular (RV) pressure. In each dog, an 8 mm conduit was interposed between the main pulmonary artery and left atrium; the pulmonary artery was then banded distal to this shunt. Ultrasonic dimension transducers were subsequently implanted for the measurement of LV equatorial minor axis and wall thickness. Catheter-tipped micromanometers were used to measure LV and pleural pressures; RV pressure was measured with a fluid-filled catheter and an external transducer. Eight control animals were similarly instrumented. At the time of study, the cyanotic dogs had significantly decreased arterial oxygen saturations (66% +/- 7% versus controls: 96% +/- 5%), significantly elevated peak RV pressures, (55 +/- 7 mm Hg versus controls: 30 +/- 5 mm Hg) and significantly elevated ratios of RV to LV mass (0.52 +/- 0.05 versus controls: 0.36 +/- 0.05). Diastolic pressure-dimension curves were generated and time constant for LV relaxation were calculated for each animal. The diastolic curves obtained from the cyanotic dogs were not significantly different from those of the control animals, and LV relaxation was not prolonged in the cyanotic dogs. In the three dogs that were cyanotic for 4 months or longer, there was a profound abnormality in the geometric pattern of LV contraction, manifested by asynchronous shortening of the anteroposterior equatorial minor axis. In two of these three dogs, inotropic reserves were assessed by means of postextrasystolic potentiation and were found to be normal. The results of this study indicate that short-term mild cyanosis and RV pressure overload do not alter diastolic compliance nor prolong relaxation of the LV. LV dynamic geometry may become abnormal after 4 months, with preservation of global LV inotropic reserves.

Modulation of alloreactivity in transplant recipients by phenotypic manipulation of donor endothelium.

Phenotypic manipulation of allograft endothelium to reduce immunogenicity would have a significant impact on transplantation. In this study we have demonstrated that random seeding of a heart allograft with endothelium, of host origin, not only promotes long-term survival, but reduces the requirement for pharmacologic immunosuppression. We propose that this simple technology could easily be extrapolated to the clinical arena where hypothermia and preservation solutions have allowed allografts to remain ex vivo for extended periods.

Right lower lobectomy for pulmonary infarction before orthotopic heart transplantation.

A 39-year-old potential heart transplant recipient had a right lower lobe infiltrate and on pulmonary angiography was found to have an embolous to the common basilar artery. This was successfully managed by a right lower lobectomy, after aggressive medical management failed. The patient was treated postoperatively with antibiotics and subsequently underwent orthotopic heart transplantation. At 1 year after transplant the patient has no evidence of cardiac or pulmonary insufficiency.

Primary cutaneous aspergillosis in a heart transplant recipient treated with surgical excision and oral itraconazole.

A 24-year-old man underwent orthotopic heart transplantation for treatment of end-stage complex congenital heart disease. Six weeks postoperatively, five erythematous skin lesions developed on the patient's right forearm. Punch biopsy revealed Aspergillus. Despite extensive testing, no other potential primary site was located. Because of concern of dissemination, the patient was treated with a combination of local debridement and systemic antifungal therapy with itraconazole. He is presently without signs or symptoms of recurrent disease.

Intraoperative procurement of autologous fibrin glue.

A method of intraoperative procurement of autologous fibrin glue is described. The relative efficacy of our autologous preparation is compared with that of fibrin glue made with homologous cryoprecipitate. Experimentally, the fibrinogen content and the strength are less than those found in cryoprecipitate and appear related to the fibrinogen content of the autologous plasma used as substrate in the fibrin glue reaction. Clinically, no significant differences are noted in the performance of autologous fibrin glue. We believe the absence of the risk of blood-borne infection with the autologous product is a major advantage.

A frequency domain analysis of spatial organization of epicardial maps.

Mapping of organized rhythms like sinus rhythm uses activation times from individual electrograms, and often assumes that the map for a single activation is similar to maps for subsequent activations. However, during fibrillation, activation times and electrograms are not easy to define, and maps change from activation to activation. Volume and complexity of data make analysis of more than a few seconds of fibrillation difficult. Magnitude Squared Coherence (MSC), a frequency domain measure of the phase consistency between two signals, can be used to help interpret longer data segments without defining activation times or electrograms. Sinus rhythm, flutter, and fibrillation in humans and swine were mapped with an array of unipolar electrodes (2.5 mm apart) at 240 sites on the atrial or ventricular epicardium. Four-second data segments were analyzed. One site near the center of the array was chosen ad hoc as a reference. MSC maps were made by measuring mean MSC from 0-50 Hz between every point in the array relative to the reference. Isocoherence contours were drawn. The effects of bias in the coherence estimate due to misalignment were investigated. Average MSC versus distance from the reference was measured for all rhythms. Results indicate that in a 4-s segment of fibrillation, there can exist some phase consistency between one site and the reference and little or none between a second site and the reference even when both sites are equidistant from the reference. In fibrillation, isocoherence contours are elongated and irregularly shaped, reflecting long-term, but nonuniform, spatial organization. That is, activation during fibrillation cannot be considered as random over a 4-s interval. Bias in the coherence estimate due to misalignment is significant for sinus rhythm and flutter, but can be corrected by manual realignment. Average MSC drops with distance for all rhythms, being most pronounced for fibrillation, MSC maps may provide insights into long-term spatial organization of rhythms that would otherwise be cumbersome and difficult to interpret with standard time domain analysis.

Hepatic and vena cava resection using cardiopulmonary bypass with hypothermic circulatory arrest.

When large hepatic or retroperitoneal tumors encroach upon hepatic veins or vena cava and make conventional resection hazardous, the most commonly used method of hepatic resection or vena cava reconstruction includes hepatic vascular exclusion, at times with venovenous bypass or aortic occlusion. These techniques result in warm liver ischemia, and may be accompanied by significant systemic hypotension, despite aggressive central venous preloading. Hepatic lobe (two patients) and retroperitoneal sarcoma (one patient) resections were done in a cold, bloodless field without significant complications. Standard cardiopulmonary bypass techniques with heparin and cardioplegia were used. Systemic circulatory arrest was done at 15 degrees C with isolated retrograde perfusion of the brain through the jugular veins. Hepatic vein and vena cava reconstructions were performed with arrest times of between 30 and 78 minutes. Blood loss was gradual and easily controlled, occurring during the rewarming phase when clot formation was inhibited by cold and heparin.

The relationship between hospital charges and a modified Parsonnet risk score.

Health care now consumes approximately 14 percent of the U.S. Gross National Product (GNP). The amount of money spent on health care in America per capita and as a percentage of GNP far exceeds that of any other industrialized country. Currently, the financial burden of health care is being shouldered by government and business. The expenditure of billions of dollars of corporate profits on health care progressively undermines the global competitiveness of American business. These economic realities have emerged as the dominant driving force in health care reform. Cost control efforts to date have focused on strategies to limit inpatient hospital expenditures. The DRG prospective payment system is designed to reimburse a fixed sum based on the diagnostic category of the patient. The DRG payment is essentially independent of underlying patient characteristics that can potentially drive up expenditures. The work reported in this article was done to develop a descriptive formula that could be used to predict resource consumption in the care of patients. The financial viability of a hospital depends on its ability to predict expenditures, allocate resources, and choose its service areas correctly. Errors in financial forecasting in the era of prospective payment will result in financial failures of entire institutions.

Characterization of inwardly rectifying K+ channel in human cardiac myocytes. Alterations in channel behavior in myocytes isolated from patients with idiopathic dilated cardiomyopathy.

BACKGROUND: Little is known about the characteristics of the inwardly rectifying K+ channel (IK1) and the influence of preexisting heart disease on the channel properties in the human heart. METHODS AND RESULTS: We studied the characteristics of cardiac IK1 in freshly isolated adult human atrial and ventricular myocytes by using the patch-clamp technique. Specimens were obtained from the atria and ventricles of 48 patients undergoing cardiac surgery or transplantation and from four explanted donor hearts. The action potential in ventricular myocytes exhibited a longer duration (391.4 +/- 30.2 milliseconds at 90% repolarization, n = 10) than in atrium (289.4 +/- 23.0 milliseconds, n = 18, P < .001) and had a fast late repolarization phase (phase 3). The final phase of repolarization in ventricle was frequency independent. Whole-cell IK1 in ventricle exhibited greater slope conductance (84.0 +/- 7.9 nS at the reversal potential, EK; n = 27) than in atrium (9.7 +/- 1.2 nS at EK; n = 8, P < .001). The steady-state current-voltage (I-V) relation in ventricular IK1 demonstrated inward rectification with a region of negative slope. This negative slope region was not prominent in atrial IK1. The macroscopic currents were blocked by Ba2+ and Cs+. The channel characteristics in ventricular myocytes from patients with congestive heart failure after idiopathic dilated cardiomyopathy (DCM) exhibited distinct properties compared with those from patients with ischemic cardiomyopathy (ICM). The action potential in ventricular myocytes from patients with DCM had a longer duration (490.8 +/- 24.5 milliseconds, n = 11) compared with that for ICM (420.6 +/- 29.6 milliseconds, n = 11, P < .01) and had a slow repolarization phase (phase 3) with a low resting membrane potential. The whole-cell current slope conductance for DCM was smaller (41.2 +/- 9.0 nS at EK, n = 7) than that for ICM (80.7 +/- 17.0 nS, n = 6, P < .05). In single-channel recordings from cell-attached patches, ventricular IK1 channels had characteristics similar to those of atrial IK1; channel openings occurred in long-lasting bursts with similar conductance and gating kinetics. In contrast, the percent of patches in which IK1 channels were found was 34.7% (25 of 72) of patches in atrium and 88.6% (31 of 35) of patches in ventricle. Single IK1 channel activity for DCM exhibited frequent long-lasting bursts separated by brief interburst intervals at every holding voltage with the open probability displaying little voltage sensitivity (approximately 0.6). Channel activity was observed in 56.2% (18 of 32) of patches for DCM and 77.4% (24 of 31) of patches for ICM. Similar results were obtained from atrial IK1 channels for DCM. In addition, channel characteristics were not significantly different between ICM and explanted donor hearts (donors). IK1 channels in cat and guinea pig had characteristics virtually similar to those of humans, with the exception of lower open probability than that in humans. CONCLUSIONS: These results suggest that the electrophysiological characteristics of human atrial and ventricular IK1 channels were similar to those of other mammalian hearts, with the possible exception that the channel open probability in humans may be higher, that the whole-cell IK1 density is higher in human ventricle than in atrium, and that IK1 channels in patients with DCM exhibited electrophysiological properties distinct from IK1 channels found in patients with ICM and in donors.

Alterations in muscarinic K+ channel response to acetylcholine and to G protein-mediated activation in atrial myocytes isolated from failing human hearts.

BACKGROUND: A variety of previous studies have demonstrated reduced diastolic potential and electrical activity in atrial specimens from patients with heart disease. Although K+ channels play a major role in determining resting membrane potential and repolarization of the action potential, little is known about the effects of preexisting heart disease on human atrial K+ channel activity. METHODS AND RESULTS: We characterized the inwardly rectifying K+ channel (IKI) and the muscarinic K+ channel [IK(ACh)] in atrial myocytes isolated from patients with heart failure (HF) and compared electrophysiological characteristics with those from donors (control) by the patch-clamp technique. Resting membrane potentials of isolated atrial myocytes from HF were more depolarized (-51.1 +/- 9.7 mV, mean +/- SD, n = 30 patients) than those from donors (-73.0 +/- 7.2 mV, n = 4 patients, P < .001). The action potential duration in HF was longer than that in donors. Although acetylcholine (ACh) shortened the action potential, reduced the overshoot, and hyperpolarized the atrial cell membrane in HF, these effects were attenuated compared with those observed in donors. The whole-cell membrane current slope conductance in HF was small, the reversal potential was more positive, and the sensitivity to ACh was less compared with donors. In single-channel recordings from cell-attached patches, IK1 channel conductance and gating characteristics were the same in HF and donor atria. When ACh was included in the pipette solution, IK(ACh) was activated in both groups. Single-channel slope conductance of IK(ACh) averaged 42 +/- 3 pS (n = 28) in HF and 44 +/- 2 pS (n = 4) in donors, and mean open lifetime was 1.3 +/- 0.3 milliseconds (n = 24) in HF and 1.5 +/- 0.4 milliseconds (n = 4) in donors. These values were virtually identical in the two groups (not significantly different, NS), although both single IK1 and IK(ACh) channel densities were less in HF. Channel open probability of IK(ACh) was also less in HF (4.0 +/- 1.2%, n = 24) than in donors (6.8 +/- 1.1%, n = 3, P < .01). The concentration of ACh at half-maximal activation was 0.11 mumol/L in HF and 0.03 mumol/L in donors. In excised inside-out patches, IK(ACh) from HF required higher concentrations of GTP and GTP gamma S to activate the channel compared with donors. These results suggest a reduced IK(ACh) channel sensitivity to M2 cholinergic receptor-linked G protein (Gi) in HF compared with donors. CONCLUSIONS: Atrial myocytes isolated from failing human hearts exhibited a lower resting membrane potential and reduced sensitivity to ACh compared with donor atria. Whole-cell and single-channel measurements suggest that these alterations are caused by reduced IK1 and IK(ACh) channel density and reduced IK(ACh) channel sensitivity to Gi-mediated channel activation in HF.

Improved immunosuppression for heart transplantation.

Since 1981, at the University of Minnesota, and more recently at Washington University in St. Louis, cyclosporine has been used as the main immunosuppressive agent for heart transplantation. It was initially combined with prednisone and given in a manner similar to that described at Stanford. In late 1983, concern regarding the nephrotoxic side effects of cyclosporine were heightened due to the fact that a potential recipient had chronic renal insufficiency secondary to renal damage suffered during previous heart surgery. In this patient it was decided to use lower doses of cyclosporine and to add azathioprine to maintain adequate immunosuppression. Initially, the same prednisone therapy was employed. This patient had an uncomplicated course following heart transplantation and was discharged with a normal renal function. This experience was the origin of a trial consisting of using cyclosporine, azathioprine, and prednisone as immunotherapy for heart transplantation. This report describes the results of this therapy in 17 patients.

Acetylcholine-sensitive potassium channels in human atrial myocytes.

Single channel recording techniques were used to study acetylcholine (ACh)-sensitive K+ channel activity in human atrial myocytes isolated from specimens obtained during corrective cardiac surgery. Under conditions of cell-attached patch, the presence of ACh in the patch pipette activated K+ channels. Single channel activity occurred in periodic bursts. The channels exhibited a slope conductance of 46 +/- 2 pS inwardly (means +/- SD, n = 4). During a burst, both open and closed time histograms were fitted by a single exponential curve, suggesting the existence of one open and one closed state during a burst. Open probability increased directly with ACh concentration without affecting open time. The channel could be activated by GTP and guanosine 5'-O-(3-thiotriphosphate) (GTP gamma S) (in the presence and absence of ACh in the pipette, respectively). Slope conductance, the response to GTP and GTP gamma S, and the independence of activation from Ca2+ were similar to those for other species. In contrast, sensitivity to ACh appeared diminished compared with frog atrial myocytes.

Abnormalities in myocardial perfusion during tachycardia in dogs with left ventricular hypertrophy: metabolic evidence for myocardial ischemia.

This study tested the hypothesis that in the chronically hypertrophied left ventricle pacing stress may cause abnormalities of perfusion that result in myocardial ischemia. Left ventricular hypertrophy (LVH) was produced by banding the ascending aorta of 10 dogs at 6 weeks of age, and studies were carried out after the animals had reached adulthood and when mean left ventricular/body weight ratio was 74% greater than in eight control dogs. Myocardial blood flow was measured with microspheres during pacing at 100, 200, and 250 beats/min, while aortic and coronary sinus blood samples were obtained for determination of concentrations of lactate and the adenosine metabolites inosine and hypoxanthine. In the control dogs, increasing heart rates were associated with an increase in mean myocardial blood flow while subendocardial flow was maintained at a level equal to or greater than subepicardial flow. Myocardial lactate uptake ranged from +60% to -5%, and adenosine metabolites were not detected in coronary sinus blood (less than 0.5 microM/l). In four dogs that underwent aortic banding no production of lactate or adenosine metabolites was observed at any heart rate; in these animals subendocardial flow was maintained at a level equal to or greater than subepicardial flow at all pacing rates. The remaining six dogs with LVH demonstrated net lactate production significantly greater than control during pacing at 250 beats/min; five of these six animals also produced adenosine metabolites.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhanced atrioventricular conduction in patients without preexcitation syndrome: relation to heart rate in paroxysmal reciprocating tachycardia.

We studied the electrophysiologic characteristics of atrioventricular (AV) nodal conduction in patients with reciprocating tachycardia (RT) without ventricular preexcitation, and the relation of these characteristics to RT cycle length (CL). Thirty-five symptomatic patients who had a normal PR interval (0.13-0.20 second) during sinus rhythm underwent detailed intracardiac electrophysiologic study during which ventricular preexcitation was excluded, and the RT mechanism was determined. RT was due to reentry using an accessory AV pathway capable of conduction only in the retrograde direction (concealed AP) in 13 patients (37%) and to reentry within the AV node in 22 (63%). Dynamic properties of AV conduction (assessed by degree of AH prolongation during progressive increase in atrial pacing rate) were normally distributed (p less then 0.005); 12 patients (34%) fulfilled the criteria for enhanced AV conduction (EAVC). The patients with EAVC had a shorter RT CL than did patients without EAVC (294 +/- 43.3 msec vs 360 +/- 68.1 msec, p less than 0.01). However, CL differences were primarily due to the influence of EAVC in the subgroup of patients with RT using a concealed AP (EAVC CL, 274 +/- 35.1 msec; without EAVC, 326 +/- 15.7 msec, p less than 0.005). The RT CL in patients with reentry within AV node was not measureable influenced by concomitant EAVC (EAVC, 314 +/- 43.8 msec; without EAVC, 376 +/- 76.8 msec) (NS). This study suggests that despite the presence of a normal PR interval during sinus rhythm, dynamic AV conduction responses can vary widely in patients with RT. In patients with RT using a concealed AP, but not in those with reentry within the AV node, coexisting diminished physiologic AV conduction slowing may be associated with more rapid tachycardia rates.

The diastolic mechanical properties of the intact left ventricle.

Recent studies have improved our understanding of the diastolic mechnical properties of intact myocardium. In order to obtain meaningful data, pressures external to the heart should be measured, forces and dimensions should be properly normalized, and measurements should be obtained over a wide range of ventricular volumes. Diastolic filling appears to be a passive phenomenon and is not affected significantly by systolic relaxation or mural inertia. Thus, the relationship between diastolic myocardial force and length is determined primarily by the elastic properties of the muscle and by viscous properties during dynamic filling. In the absence of ischemia, the diastolic mechanics of intact myocardium are not altered significantly by acute physiological interventions. Chronic changes in diastolic properties do occur, however, and are fundamentally important to the regulation of cardiac function. Myocardial creep induced by chronically elevated diastolic presssure produces ventricular dilatation, thereby altering chamber geometry, systolic loading, and overall global function. Thus, a detailed analysis of diastolic mechanical properties is essential to the assessment of the performance characteristics of the intact heart.

Characterization of the sodium current in single human atrial myocytes.

Patch-clamp recording techniques have permitted measurement of the fast Na+ current (INa) in isolated cardiac cells from a number of species in recent years. However, there is still only very little information concerning human cardiac INa. The purpose of this study was to describe the kinetics of INa in normal-appearing, Ca(2+)-tolerant, enzymatically isolated human atrial myocytes using whole-cell voltage-clamp techniques. Atrial specimens were obtained from 46 patients undergoing open heart surgery. Cs+ was substituted for K+ in both pipette and external solutions and F- was added to the former. The reversal potential of the rapid inward current varied approximately 57 mV at 17 +/- 1 degrees C with a 10-fold change in [Na+]o, and the current was completely blocked by 100 microM tetrodotoxin, findings typical of the fast cardiac Na+ current. The tetrodotoxin dose-response curve was best fitted by an equation describing binding to high- and low-affinity sites. INa was activated at a voltage threshold of -70 to -60 mV, and peak inward current was obtained at approximately -30 mV (holding potential, -140 mV). The inactivation time course was voltage dependent and was fitted best by the sum of two exponentials. The relation between voltage and steady-state availability (h infinity) was sigmoidal with the half-inactivation at -95.8 +/- 0.9 mV and a slope factor of 5.3 +/- 0.1 mV (n = 46), and we did not observe a significant difference with disease and age. The overlap of the h infinity and activation curves suggested the presence of a Na+ "window" current. Recovery from inactivation also was voltage dependent and best fitted by a model describing the sum of two exponentials. Recovery occurred after an initial delay at potentials positive to -140 mV, suggesting that inactivation of human atrial INa is a multistate process. We conclude that INa of normal-appearing, Ca(2+)-tolerant human atrial myocytes is similar to that of other mammalian cardiac cells with the possible exception of having two tetrodotoxin binding sites.