Takotsubo (apical ballooning) syndrome in the recovery period following dobutamine stress echocardiography: a first report.

We report a case of Takotsubo syndrome occurring in the recovery phase after a dobutamine stress echocardiogram. Takotsubo syndrome is a widely acknowledged cause of reversible left ventricular systolic dysfunction. It has garnered much attention from the cardiological community since its presentation frequently mimics that of ST-segment elevation myocardial infarction. The exact aetiology remains incompletely defined, although stress is recognized frequently as a precipitating factor. In recent years it has emerged that stress testing, as part of a patient's investigative assessment, can also induce Takotsubo's syndrome. All prior reports of dobutamine-induced Takotsubo's syndrome have described apical ballooning at peak stress. We describe the case of an 85-year-old lady who developed apical ballooning in the recovery period after a dobutamine stress echocardiogram, despite having normal left ventricular wall motion at rest and at peak stress. We believe this to be the first such case reported in the literature. Dobutamine stress testing can precipitate Takotsubo's syndrome not just at peak stress but also during the recovery period. All those performing dobutamine stress tests should be aware of this rare but potentially important complication.

The peripheral immune response in hyperglycemic stroke.

OBJECTIVES: Hyperglycemia is common in acute ischemic stroke patients and is associated with poor clinical outcome. However, aggressive reduction of post-stroke hyperglycemia did not improve clinical outcome, suggesting that other mechanisms are playing a detrimental role in hyperglycemic stroke. We hypothesize that the acute post-stroke immune response is altered in the hyperglycemic state leading to higher mortality and morbidity. The objective of this study was to characterize temporal changes in circulating immune cells after stroke and their association with clinical outcomes in hyperglycemic compared to euglycemic patients. PATIENTS AND METHODS: This retrospective study included 97 (58 % euglycemic, 42 % hyperglycemic) patients presenting within 12 h of symptom onset of stroke. Blood neutrophil, monocyte and lymphocyte concentrations were measured sequentially for 96 h post stroke. Primary clinical outcome was the difference in the NIH stroke scale at admission compared to discharge. Secondary outcome measures included discharge disposition and the modified Rankin Scale (mRS) at 90 days. RESULTS: Circulating neutrophils were significantly higher in hyperglycemic than in euglycemic patients within the first 48 h post stroke, while lymphocyte counts trended to be lower. Hyperglycemic patients had higher mortality rates, less favorable discharge disposition and worse neurological function at 90 days. In both groups, the neutrophil to lymphocytes ratio ((NLR) remained strongly associated with neurological function at discharge within the first 24 h (p < 0.001), and remained significant in hyperglycemic patients up to 48 h (p < 0.001). Multivariate regression analysis showed no confounding by other factors and a significant correlation with differences in NIHSS score (CI; - 9.287 to -1.46, p = 0.0077**) and NLR (CL; 0.6058-6.901, p = 0.0203*) in hyperglycemic patients. CONCLUSIONS: Our data suggests that circulating immune cells play an important role in mediating poor clinical outcome in hyperglycemic patients following stroke. The NLR is a strong predictor of neurological outcomes in hyperglycemic patients. Thus, the modulation of immune cells may be a viable therapeutic approach to improve outcomes for this high risk group.

Insulin receptor phosphorylation may not be a prerequisite for acute insulin action.

An antiserum to the insulin receptor mimicked insulin's acute actions on glucose transport, phosphorylation of integral membrane proteins, and internalization of the insulin receptor in isolated rat adipose cells. These insulinomimetic actions of the antiserum occurred without the equivalent increase in phosphorylation of the beta subunit of the insulin receptor observed with insulin. Thus, a role of receptor phosphorylation in acute insulin action is now questioned.

Divergent mechanisms for the insulin resistant and hyperresponsive glucose transport in adipose cells from fasted and refed rats. Alterations in both glucose transporter number and intrinsic activity.

The effects of fasting and refeeding on the glucose transport response to insulin in isolated rat adipose cells have been examined using 3-O-methylglucose transport in intact cells and cytochalasin B binding and Western blotting in subcellular membrane fractions. After a 72-h fast, basal glucose transport activity decreases slightly and insulin-stimulated activity decreases greater than 85%. Following 48 h of fasting, insulin-stimulated glucose transport activity is diminished from 3.9 +/- 0.5 to 1.3 +/- 0.3 fmol/cell per min (mean +/- SEM). Similarly, the concentrations of glucose transporters are reduced with fasting in both the plasma membranes from insulin-stimulated cells from 38 +/- 5 to 18 +/- 3 pmol/mg of membrane protein and the low density microsomes from basal cells from 68 +/- 8 to 34 +/- 9 pmol/mg of membrane protein. Ad lib. refeeding for 6 d after a 48-h fast results in up to twofold greater maximally insulin-stimulated glucose transport activity compared with the control level (7.1 +/- 0.4 vs. 4.5 +/- 0.2 fmol/cell per min), before returning to baseline at 10 d. However, the corresponding concentration of glucose transporters in the plasma membranes is restored only to the control level (45 +/- 5 vs. 50 +/- 5 pmol/mg of membrane protein). Although the concentration of glucose transporters in the low density microsomes of basal cells remains decreased, the total number is restored to the control level due to an increase in low density microsomal protein. Thus, the insulin-resistant glucose transport in adipose cells from fasted rats can be explained by a decreased translocation of glucose transporters to the plasma membrane due to a depleted intracellular pool. In contrast, the insulin hyperresponsive glucose transport observed with refeeding appears to result from (a) a restored translocation of glucose transporters to the plasma membrane from a repleted intracellular pool and (b) enhanced plasma membrane glucose transporter intrinsic activity.

A possible mechanism of insulin resistance in the rat adipose cell in streptozotocin-induced diabetes mellitus. Depletion of intracellular glucose transport systems.

The effects of insulin-dependent diabetes mellitus on glucose transport activity and on the concentrations of glucose transport systems in the plasma and low density microsomal membranes in adipose cells isolated from streptozotocin-induced diabetic rats have been examined. Glucose transport activity was assessed by measuring 3-O-methylglucose transport and the concentration of glucose transport systems estimated by measuring specific D-glucose-inhibitable cytochalasin B-binding. Basal glucose transport activity decreases from 0.19 to 0.12 fmol/cell per min with the induction of diabetes, but remains constant per unit cellular surface area and is accompanied by a constant 6 pmol of glucose transport systems/mg of membrane protein in the plasma membrane fraction. Maximally insulin-stimulated glucose transport activity decreases from 3.16 to 1.05 fmol/cell per min and from 0.26 to 0.12 amol/micrometers 2 per min, and is accompanied by a decrease from 25 to 15 pmol of glucose transport systems/mg of plasma membrane protein. These diminished effects of insulin on glucose transport activity and the concentration of glucose transport systems in the plasma membrane fraction are paralleled by a 45% decrease in the basal number of glucose transport systems per milligram of membrane protein in the low density microsomal membrane fraction, the source of those glucose transport systems appearing in the plasma membrane in response to insulin. Thus, the "insulin resistant" glucose transport of the adipose cell in the streptozotocin-induced diabetic rat appears to be the consequence of a depletion of glucose transport systems in the intracellular pool.

The midcycle increase in ovarian glucose uptake is associated with enhanced expression of glucose transporter 3. Possible role for interleukin-1, a putative intermediary in the ovulatory process.

This study characterizes the rat ovary as a site of hormonally dependent glucose transporter (Glut) expression, and explores the potential role of interleukin (IL)-1, a putative intermediary in the ovulatory process, in this regard. Molecular probing throughout a simulated estrous cycle revealed a significant surge in ovarian Glut3 (but not Glut1) expression at the time of ovulation. Treatment of cultured whole ovarian dispersates from immature rats with IL-1beta resulted in upregulation of the relative abundance of the Glut1 (4.5-fold) and Glut3 (3.5-fold) proteins as determined by Western blot analysis. Other members of the Glut family (i.e., Gluts 2, 4, and 5) remained undetectable. The ability of IL-1 to upregulate Glut1 and Glut3 transcripts proved time-, dose-, nitric oxide-, and protein biosynthesis-dependent but glucose independent. Other ovarian agonists (i.e., TNF alpha, IGF-I, interferon-gamma, and insulin) were without effect. Taken together, our findings establish the mammalian ovary as a site of cyclically determined Glut1 and Glut3 expression, and disclose the ability of IL-1 to induce the ovarian expression as well as translation of Glut1 and Glut3 (but not of Gluts 2, 4, or 5). Our observations also establish IL-1 as the first known regulator of Glut3, the most efficient Glut known to date. In so doing, IL-1, a putative component of the ovulatory process, may be acting to meet the increased metabolic demands imposed on the growing follicle and the ovulated cumulus-enclosed oocyte.

Mechanism of insulin-resistant glucose transport activity in the enlarged adipose cell of the aged, obese rat.

The effects of increasing cell size on glucose transport activity and metabolism and on the concentrations of glucose transport systems in both the plasma and low density microsomal membranes in isolated adipose cells from the aging rat model of obesity have been examined. Glucose transport activity was assessed by measuring l-arabinose transport and the concentration of glucose transport systems estimated by measuring specific d-glucose-inhibitable cytochalasin B-binding. Basal glucose transport activity increases from 0.3 to 1.4 fmol/cell/min with a 10-fold increase in cell size, but remains constant per unit cellular surface area and is accompanied by a constant 5 pmol of glucose transport systems/mg of membrane protein in the plasma membrane fraction. Maximally insulin-stimulated glucose transport activity, on the other hand, remains constant at 2.3 fmol/cell per min with increasing cell size, but markedly decreases per unit cellular surface area and is accompanied by a decrease from 30 pmol of glucose transport systems/mg of plasma membrane protein to the basal level. These diminished effects of insulin on glucose transport activity and the number of glucose transport systems in the plasma membrane fraction in enlarged cells are paralleled by an 80% decrease in the basal number of glucose transport systems/mg of membrane protein in the low density microsomal membrane fraction, the source of those glucose transport systems appearing in the plasma membrane in response to insulin. The effects of cell size on the metabolism of a low concentration of [1-(14)C]glucose (0.56 mM) directly parallel those on glucose transport activity and the concentration of glucose transport systems in the plasma membrane fraction, and are not associated with significant alterations in the cell's sensitivity to insulin. Thus, adipose cellular enlargement is accompanied by the development of a marked "insulin resistance" at the glucose transport level, which may be the consequence of a relative depletion of glucose transport systems in the intracellular pool.

Internalization of insulin and its receptor in the isolated rat adipose cell. Time-course and insulin concentration dependency.

The time-course and insulin concentration dependency of internalization of insulin and its receptor have been examined in isolated rat adipose cells at 37 degrees C. The internalization of insulin was assessed by examining the subcellular distribution of cell-associated [125I]insulin among plasma membrane, and high-density (endoplasmic reticulum-enriched) and low-density (Golgi-enriched) microsomal membrane fractions prepared by differential ultracentrifugation. The distribution of receptors was measured by the steady-state exchange binding of fresh [125I]insulin to these same membrane fractions. At 37 degrees C, insulin binding to intact cells is accompanied initially by the rapid appearance of intact insulin in the plasma membrane fraction, and subsequently, by its rapid appearance in both the high-density and low-density microsomal membrane fractions. An apparent steady-state distribution of insulin per mg of membrane protein among these subcellular fractions is achieved within 30 min in a ratio of 1:1.54:0.80, respectively. Concomitantly, insulin binding to intact cells is associated with the rapid disappearance of approx. 30% of the insulin receptors initially present in the plasma membrane fraction and appearance of 20-30% of those lost in the low-density microsomal membrane fraction. However, the number of receptors in the high-density microsomal membrane fraction does not change. This redistribution of receptors also appears to reach a steady-state within 30 min. Both processes are insulin concentration-dependent, correlating with receptor occupancy in the intact cell, and are partially inhibited at 16 degrees C. While the steady-state subcellular distributions of insulin and its receptor do not correlate with that of acid phosphatase, chloroquine markedly increases the levels of insulin associated with all three membrane fractions in apparent proportion to the distribution of this lysosomal marker enzyme activity, without more than marginally potentiating insulin's effects on the distribution of receptors. These results demonstrate that insulin, initially bound to the plasma membrane of the isolated rat adipose cell, is rapidly translocated by a receptor-mediated process into at least two intracellular compartments associated with the cell's high- and low-density microsomes. Furthermore, insulin simultaneously induces the translocation of its own receptor from the plasma membrane into the latter compartment. These translocations appear to represent the internalization and partial dissociation of the insulin-receptor complex through insulin-induced receptor cycling.

Insulin-stimulated translocation of glucose transporters in the isolated rat adipose cells: characterization of subcellular fractions.

Insulin stimulates glucose transport in rat adipose cells through the translocation of glucose transporters from an intracellular pool to the plasma membrane. A detailed characterization of the morphology, protein composition and marker enzyme content of subcellular fractions of these cells, prepared by differential ultracentrifugation, and of the distribution of glucose transporters among these fractions is now described. Glucose transporters were measured using specific D-glucose-inhibitable [3H]cytochalasin B binding. In the basal state, roughly 90% of the cells' glucose transporters are associated with a low-density microsomal, Golgi marker enzyme-enriched membrane fraction. However, the distributions of glucose transporters and Golgi marker enzyme activities over all fractions are clearly distinct. Incubation of intact cells with insulin increases the number of glucose transporters in the plasma membrane fraction 4-5 fold and correspondingly decreases the intracellular pool, without influencing any other characteristics of the subcellular fractions examined or the estimated total number of glucose transporters (3.7 X 10(6)/cell). Insulin does not influence the Kd of the glucose transporters in the plasma membrane fraction for cytochalasin B binding (98 nM), but lowers that in the intracellular pool (from 141 to 93 nM). The calculated turnover numbers of the glucose transporters in the plasma membrane vesicles from basal and insulin-stimulated cells are similar (15 X 10(3) mol of glucose/min per mol of transporters at 37 degrees C), whereas insulin appears to increase the turnover number in the plasma membrane of intact cells roughly 4-fold. These results suggest that (1) the intracellular pool of glucose transporters may comprise a specialized membrane species, (2) intracellular glucose transporters may undergo conformational changes during their cycling to the plasma membrane in response to insulin, and (3) the translocation of glucose transporters may represent only one component in the mechanism through which insulin regulates glucose transport in the intact cell.

Insulin-induced internalization of the insulin receptor in the isolated rat adipose cell. Detection of both major receptor subunits following their biosynthetic labeling in culture.

A protocol has been developed for maintaining isolated rat adipose cells in primary tissue culture. Using this protocol, cells remain fully viable and responsive to insulin for at least 24 h, as assessed by measuring 3-0-methylglucose transport, lipogenesis from [U-14C]glucose, and the incorporation of [35S]methionine into total membrane protein. The acute insulin-induced internalization of its own receptor was then examined by biosynthetically labeling cells in culture with either [35S]methionine or [3H]glucosamine, maximally inducing receptor internalization with a 30-min incubation in the presence of saturating insulin, and preparing plasma and low-density microsomal membrane fractions by differential ultracentrifugation. Receptors were immunoprecipitated with anti-receptor antiserum, and the receptor subunits separated by NaDodSO4-PAGE under reducing conditions and analyzed by autoradiography. When cells not acutely treated with insulin are examined, both the 135K alpha- and 95K beta-receptor subunits are prominently labeled in the plasma membrane fraction, but only faintly labeled in the low-density microsomal membrane fraction. Following the induction of maximal acute receptor internalization, both subunits are decreased by 20-30% in the plasma membrane fraction and concomitantly increased in the low-density microsomal membrane fraction. However, the relative molecular weights and labeling intensities of the two subunits remain constant and correspond to those observed in the biosynthetically labeled human lymphocyte receptor. A minor band of Mr congruent to 190K is also labeled, but its labeling intensity is similar in the two membrane fractions from basal cells and does not change in response to insulin.(ABSTRACT TRUNCATED AT 250 WORDS)

A possible mechanism of insulin resistance in the rat adipose cell with high-fat/low-carbohydrate feeding. Depletion of intracellular glucose transport systems.

The effects of high-fat/low-carbohydrate feeding on glucose transport activity and on the concentrations of glucose transport systems in the plasma and low-density microsomal membranes in isolated rat adipose cells have been examined. Glucose transport activity was assessed by measuring 3-O-methylglucose transport and the concentration of glucose transport systems estimated by measuring specific D-glucose-inhibitable cytochalasin B-binding. Basal glucose transport activity is not significantly influenced by high-fat/low-carbohydrate relative to low-fat/high-carbohydrate feeding and is accompanied by a constant 10 pmol of glucose transport systems/mg of membrane protein in the plasma membrane fraction. In contrast, maximally insulin-stimulated glucose transport activity decreases from 4.72 to 2.29 fmol/cell/min and is accompanied by a decrease from 44 to 26 pmol of glucose transport systems/mg of plasma membrane protein. These diminished effects of insulin on glucose transport activity and the concentration of glucose transport systems in the plasma membrane fraction are paralleled by a 48% decrease in the basal number of glucose transport systems/mg of membrane protein in the low-density microsomal membrane fraction, the source of those glucose transport systems appearing in the plasma membrane in response to insulin. Thus, the "insulin-resistant" glucose transport of the adipose cell with high-fat/low-carbohydrate feeding may be the consequence of a depletion of glucose transport systems in the intracellular pool.

Current status of flow convergence for clinical applications: is it a leaning tower of "PISA"?

Spatial appreciation of flow velocities using Doppler color flow mapping has led to quantitative evaluation of the zone of flow convergence proximal to a regurgitant orifice. Based on the theory of conservation of mass, geometric analysis, assuming a series of hemispheric shells of increasing velocity as flow converges on the orifice--the so-called proximal isovelocity surface area (PISA) effect--has yielded methods promising noninvasive measurement of regurgitant flow rate. When combined with conventional Doppler ultrasound to measure orifice velocity, regurgitant orifice area, the major predictor of regurgitation severity, can also be estimated. The high temporal resolution of color M-mode can be used to evaluate dynamic changes in orifice area, as seen in many pathologic conditions, which enhances our appreciation of the pathophysiology of regurgitation. The PISA methodology is potentially applicable to any restrictive orifice and has gained some credibility in the quantitative evaluation of other valve pathology, particularly mitral and tricuspid regurgitation, and in congenital heart disease. Although the current limitations of PISA estimates of regurgitation have tempered its introduction as a valuable clinical tool, considerable efforts in in vitro and clinical research have improved our understanding of the problems and limitations of the PISA methodology and provided a firm platform for continuing research into the accurate quantitative assessment of valve regurgitation and the expanding clinical role of quantitative Doppler color flow mapping.

Doppler color flow mapping of simulated in vitro regurgitant jets: evaluation of the effects of orifice size and hemodynamic variables.

The spatial distribution of simulated regurgitant jets imaged by Doppler color flow mapping was evaluated under constant flow and pulsatile flow conditions. Jets were simulated through latex tubings of 3.2, 4.8, 6.35 and 7.9 mm by varying flow rates from 137 to 1,260 cc/min. Color jet area was linearly related to flow rate at each orifice (r = 0.96, SEE = 3.4; r = 0.99, SEE = 1.6; r = 0.97, SEE = 2.3; r = 0.97, SEE = 3.2, respectively), but significantly higher flow rates were required to maintain the same maximal spatial distribution of the jet at the larger regurgitant orifices. Constant flow jets were also simulated through needle orifices of 0.2, 0.5 and 1 mm, with a known total volume (5 cc) injected at varying flow rates and with differing absolute volumes injected at the same flow rate (0.2, 1.0 and 2.0 cc/s, respectively). Again, maximal color jet area was linearly related to flow rate at each orifice (r = 0.97, SEE = 2.3; r = 0.97, SEE = 2.4; r = 0.92, SEE = 3.9, respectively), but was not related to the absolute volume of regurgitation. Color encoding of regurgitant jets on Doppler color flow maps was demonstrated to be highly dependent on velocity and, hence, driving pressure, such that color encoding was obtained from a constant flow jet injected at a velocity of 4 m/s through an orifice of 0.04 mm diameter with flow rates as low as 0.008 cc/s. Mitral regurgitant jets were also simulated in a physiologic in vitro pulsatile flow model through three prosthetic valves with known regurgitant orifice sizes (0.2, 0.6 and 2.0 mm2). For each regurgitant orifice size, color jet area at each was linearly related to a regurgitant pressure drop (r = 0.98, SEE = 0.15; r = 0.97, SEE = 0.20; r = 0.97, SEE = 0.23, respectively), regurgitant stroke volume (r = 0.77, SEE = 0.55; r = 0.94, SEE = 0.30; r = 0.91, SEE = 0.41, respectively) and peak regurgitant flow rate (r = 0.98, SEE = 0.16; r = 0.97, SEE = 0.21; r = 0.93, SEE = 0.37, respectively), but the spatial distribution of the regurgitant jets was most highly dependent on the regurgitant pressure drop. Jet kinetic energy calculated from the summation of the individual pixel intensities integrated over the jet area was closely related to driving pressure (r = 0.84), but integration of the power mode area times pixel intensities provided the best estimation of regurgitant stroke volume (r = 0.80).(ABSTRACT TRUNCATED AT 400 WORDS)

Spatial velocity distribution and acceleration in serial subvalve tunnel and valvular obstructions: an in vitro study using Doppler color flow mapping.

To evaluate the spatial distribution of flow velocities, turbulence and spatial acceleration in serial tunnel-valve obstruction, Doppler color flow mapping was performed in a pulsatile flow model with a tunnel obstruction (1.0 or 1.5 cm2) inserted at 2, 20 and 40 mm proximal to a mildly stenotic bioprosthetic valve studied at flow rates of 1, 2.7 and 4.9 liters/min. Measured pressure gradients were consistently higher across the tunnel (mean +/- SD 32.7 +/- 26.5 mm Hg) than across the tunnel plus valve (28.8 +/- 26.9 mm Hg, p less than 0.01). Doppler color flow map images were analyzed using a Sony RGB video-digitizing computer, providing numerical velocity assignments for the blue, red and green (variance) pixel components to allow the flow maps to be constructed into digital velocity maps and pseudo three-dimensional velocity maps. The maximal velocity stream extended distal to the tunnel (2 to 19 mm), and the length of this extension correlated well with the pressure gradient measured across the tunnel (r = 0.89), with a rapidly decelerating and turbulent spray area seen immediately distal to the valve. Pressure gradient calculated from the maximal velocity derived from the color flow map, which could only be estimated from the velocity maps for the 1.5 cm2 tunnel, correlated well with the gradient measured across the tunnel (18.0 +/- 14.1 versus 19.2 +/- 14.5 mm Hg, respectively, r = 0.98). Acceleration was seen proximal to both tunnels.(ABSTRACT TRUNCATED AT 250 WORDS)

Subcellular distribution and phosphorylation state of insulin receptors from insulin- and isoproterenol-treated rat adipose cells.

Rat adipose cells treated with insulin followed by isoproterenol exhibit a change in glucose transporter intrinsic activity (lowered maximal activity) and a decrease in insulin sensitivity (rightward shift of the concentration-response curve) when assayed for 3-O-methylglucose transport. To investigate the latter phenomenon, the distribution and phosphorylation state of insulin receptors was examined. Isoproterenol augmented the effect of insulin to reduce cell surface receptors by 20-30%. These receptors were recovered in microsomal fractions. Isoproterenol also markedly reduced insulin-stimulated [32P]phosphate incorporation into the plasma membrane receptor beta-subunit. These effects may account for the effect of isoproterenol to decrease the sensitivity of the glucose transport response to insulin.

Cholera and pertussis toxins modify regulation of glucose transport activity in rat adipose cells: evidence for mediation of a cAMP-independent process by G-proteins.

Adenylyl cyclase in rat adipose cells is stimulated by ligands for Rs receptors (e.g. isoproterenol) and inhibited by ligands for Ri receptors (e.g. adenosine). In contrast, Rs receptors mediate inhibition and Ri receptors mediate augmentation of insulin-stimulated glucose transport activity by a process independent of changes in cellular cAMP-dependent protein kinase activity [Kuroda M., Honnor R. C., Cushman S. W., Londos C. and Simpson I. A. (1987) J. biol. Chem. 262, 245-253]. The present study examines the possible role of G-proteins in the regulation of insulin-stimulated glucose transport activity by Rs and Ri receptors. First, conditions were established that permit intoxication of isolated rat adipocytes by cholera and pertussis toxins without compromising cell integrity. Effectiveness of toxin treatment was monitored by examining adenylyl cyclase activity in isolated plasma membranes. Secondly, neither toxin interfered with the ability of a maximal concentration insulin to initiate the glucose transport response. Thirdly, pertussis toxin eliminated the augmenting effects of adenosine on insulin-stimulated glucose transport activity, but enhanced the inhibitory effects of isoproterenol. Findings with ligands for other Ri receptors (nicotinic acid and prostaglandin E2) mirrored those with adenosine. Finally, cholera toxin elicited a modest depression of transport activity, and only in the absence of an Ri ligand (e.g. adenosine). Furthermore, in contrast to the enhanced stimulation of adenylyl cyclase by isoproterenol and GTP, cholera toxin eliminated the inhibitory effect of isoproterenol on transport activity. The augmentative effects of adenosine on transport activity were unchanged. Measurements of (-/+cAMP) cAMP-dependent protein kinase activity ratios reinforce the notion that modulation of glucose transport activity is independent of changes in cAMP. We conclude that regulation of glucose transport activity by Rs and Ri receptors is mediated by the G-proteins, Gs and Gi (or other toxin substrates), respectively. Inasmuch as such regulation occurs at the plasma membrane and appears to be cAMP-independent, it is suggested that glucose transporters may be direct targets for receptor: G-protein interactions.

Assessment of coronary artery bypass graft flow by intraoperative Doppler ultrasound technique.

A high frequency (10 MHz) Doppler ultrasound pencil probe was used to estimate flow in coronary artery bypass grafts in vitro and during cardiac surgery. In vitro, increasing the angle of the Doppler transducer in relation to flow caused underestimation of the Doppler derived flow, and using the external rather than internal vessel diameter to calculate cross sectional area caused significant overestimation. This overestimation was considerably greater for the internal mammary artery. Accurate flow estimation was obtained in vitro by the Doppler technique, but considerable variation occurred in patients studied during coronary artery bypass surgery. In conclusion, intraoperative Doppler ultrasound provides a qualitative assessment of phasic flow in coronary artery bypass grafts but is less accurate in quantifying absolute flow in these patients.

Comparison of Doppler ultrasound velocity measurements with pressure differences across bioprosthetic valves in a pulsatile flow model.

Continuous wave Doppler ultrasound was used in vitro to assess the pressure differences across four different cardiac bioprosthetic valves in a pulsatile flow test apparatus. Valves were tested under four different flow conditions. Pressure differences were calculated from the maximum flow velocity measured by Doppler ultrasound and correlated well with the pressure differences measured directly in the flow model (r = 0.98). Thus Doppler ultrasound can accurately measure pressure differences across bioprosthetic valves in vitro.

Left ventricular energetics: heat production by the human heart.

OBJECTIVE: The aim was to examine the effect of coronary artery disease on human left ventricular energetics by a comparison of left ventricular oxygen consumption and heat production. The usefulness of measurement of left ventricular heat production for the detection of the expected change in left ventricular energetics produced by atrial pacing to a faster heart rate was also assessed. METHODS: Forty six patients (mean age 57 years; 31 men) undergoing cardiac catheterisation and coronary arteriography for the investigation of chest pain were studied. Normal left ventricular function and normal coronary arteries were present in eight and 38 had atheromatous coronary artery disease. Left ventricular heat production was calculated from coronary blood flow, the coronary arteriovenous (aorta-coronary sinus) temperature difference, and the areas under thermodilution curves recorded in the aorta and coronary sinus after injection of cold saline into the pulmonary artery. Mean external left ventricular power was calculated from mean arterial blood pressure and cardiac output. Left ventricular mechanical efficiency was derived from heat production and the energy value of myocardial oxygen use, assuming aerobic metabolism. In 27 patients studies were repeated during atrial pacing from the coronary sinus. RESULTS: At rest under basal conditions left ventricular heat production was 2.4(SD 1.0) W in patients with normal hearts and 3.1(1.4) W in patients with coronary disease (NS). Mechanical efficiency was 44.2(9.7)% in the normal patients and 30.7(10.9)% in those with coronary disease (p = 0.003). During atrial pacing to a faster heart rate left ventricular energy supply increased from 4.6(2.7) W to 5.9(3.3) W (p < 0.0005), and heat production increased from 3.0(1.6) W to 4.6(2.4) W (p < 0.0005), but mean external power was not altered. As the extra energy used during pacing was "wasted" as heat, there was a significant fall in left ventricular mechanical efficiency with pacing from 33.9(13.5)% to 18.9(15.2)% (p < 0.0005). CONCLUSIONS: These results show the effect of coronary artery disease on the energetics of left ventricular function. They also show that the method and equipment can detect the expected alteration in left ventricular energetics produced by atrial pacing. The measurement of left ventricular heat production and oxygen consumption allows assessment of the total left ventricular energy flux, and may be useful for the evaluation of drug treatment with such as inotropes and vasodilators, and for the investigation of the functional consequences of left ventricular disease.