Frequent occurrence of occult pulmonary embolism from venous sheaths during endomyocardial biopsy.

To determine the frequency of occult right heart thromboembolism during endomyocardial biopsy, 51 cardiac transplant recipients undergoing routine endomyocardial biopsy were studied echocardiographically. Patients were randomized to two groups. In Group 1, the venous sheath was flushed between each biopsy attempt; in Group 2, it was flushed only at the time of initial placement. Right heart thromboemboli were identified in 18 (35%) of 51 patients. Seventeen (94%) of these 18 patients were in Group 2. Patients requiring more than six biopsy attempts had a significantly higher incidence of embolism. Other variables such as antiplatelet therapy, operator experience and total time of the procedure did not correlate with occurrence of thrombus. All right heart emboli were asymptomatic. These data demonstrate a high incidence of occult pulmonary embolism during uncomplicated routine endomyocardial biopsy. Meticulous flushing of the introducer sheath significantly reduces the incidence of thrombus formation in intravenous sheaths.

Rapid lysis of life-threatening pulmonary thromboembolism following recent abdominal surgery using a modified systemic infusion of rt-PA.

A case of pulmonary thromboembolism in a young woman three days status post-abdominal surgery is treated successfully with a low-dose infusion rate of tissue plasminogen activator (10 mg/hr over 10 h). Clinical improvement is rapid and there are no bleeding complications.

Regulation of the oxidative phosphorylation rate in the intact cell.

The mechanisms that underlie the balance between the consumption and oxidative generation of ATP in the intact cell are not well-defined. Cytosolic inorganic phosphate (Pi) and ADP levels, the cytosolic ATP/ADP ratio, and the cytosolic phosphorylation potential (PP) have all been proposed as major regulatory variables, the latter as a component of a "near-equilibrium" thermodynamic regulatory scheme. Therefore, the potential regulatory roles of these variables in the intact cell were evaluated with 31P NMR and Langendorff perfused rat hearts; in this preparation, the tissue oxygen consumption rate (MVO2) can be varied over a wide range. When the exogenous carbon source was varied, none of the proposed regulatory parameters, i.e., the ATP/ADP ratio, PP, or cytosolic ADP level, were found to be uniquely related to MVO2. Rather, ADP levels at a given MVO2 decreased progressively for the exogenous carbon sources in the following order: glucose, glucose + insulin, palmitate + glucose, lactate, pyruvate + glucose, and octanoate + glucose. In the octanoate and pyruvate groups, MVO2(-1) was linearly dependent upon [ADP]-1 with apparent Km values being in the range previously observed in isolated mitochondria. A similar trend was observed in the MVO2-[Pi] relationship. The present findings suggest that exogenous carbon sources which effectuate deregulation of intramitochondrial NADH generation lower cytosolic ADP and Pi to levels which are limiting to the rate of oxidative phosphorylation. For other carbon sources, the processes controlling the rate of NADH generation also participate in determining the rate of oxidative ATP synthesis. However, this control must be exerted kinetically rather than through a near-equilibrium thermodynamic mechanism as indicated by the present data and prior kinetic studies of the ATP synthetic process in both isolated mitochondria and intact myocardium [La Noue, K. F., et al. (1986) Biochemistry 25, 7667-7675; Kingsley-Hickman, P., et al. (1987) Biochemistry 26, 7501-7510].

Alterations in oxidative function and respiratory regulation in the post-ischemic myocardium.

In the normal and post-ischemic, isovolumic Langendorff perfused rat hearts, 31P NMR spectra and mechanical performance were evaluated over a wide range of myocardial oxygen consumption rates (MVO2). Hearts were perfused with either glucose and insulin, palmitate and glucose, or pyruvate and glucose as exogenous carbon sources. After ischemia at 38 degrees C until the onset of ischemic contracture and subsequent reperfusion, the "free" ADP levels were significantly reduced as compared to controls. In the control palmitate + glucose and glucose + insulin groups, the ADP levels were virtually independent of approximately 2.5-fold variation in MVO2; in contrast, they changed 4-fold with a approximately 30% variation in MVO2 in the post-ischemic myocardium following ischemia to contracture. In the pyruvate + glucose group, ADP levels varied with MVO2 in controls and post-ischemia; however, MVO2-ADP relationship was significantly altered following ischemia. Analysis of these observations within the concept of kinetic regulation of oxidative phosphorylation yielded the following significant conclusions: 1) the mode of respiratory regulation changed from a non-ADP to an "ADP:Pi limited" domain with non-pyruvate carbon sources; 2) respiratory regulation was in the ADP:Pi limited domain before and after ischemia in the pyruvate + glucose group; however, the Km for the relationship between MVO2 and ADP was reduced following the ischemia/reperfusion insult; 3) the post-ischemic oxidative capacity (Vmax for MVO2) was significantly reduced in all groups and this reduction would limit maximal post-ischemic mechanical performance.