Unipolar atrial electrogram morphology is affected by age: evidence from high-resolution epicardial mapping.

BACKGROUND: It is unknown which features of unipolar atrial electrogram (U-AEGM) morphology are affected by ageing and whether age-related changes in U-AEGM morphology are equally distributed throughout the right and left atria. PATIENTS AND METHODS: Epicardial high-resolution mapping was performed in patients undergoing coronary artery bypass grafting surgery during sinus rhythm (SR). Mapping areas include the right atrium (RA), left atrium (LA), pulmonary vein area (PVA) and Bachmann's bundle (BB). Patients were categorized into a young (age < 60) and aged (age ≥ 60) group. U-AEGM were classified as single potentials (SPs, one deflection), short double potentials (SDPs, deflection interval ≤ 15ms), long double potentials (LDPs, deflection interval > 15ms) and fractionated potentials (FPs, ≥3 deflections). RESULTS: A total of 213 patients (age: 67 (59-73) years; young group N = 58, aged group N = 155) were included. Only at BB, the proportion of SPs (p = 0.007) was significantly higher in the young group, while the proportion of SDPs (p = 0.051), LDPs (p = 0.004) and FPs (p = 0.006) was higher in the aged group. After adjusting for potential confounders, older age was associated with a reduction in SPs [regression coefficient (ß): -6.33, 95% confident interval (CI): -10.37 to -2.30] at the expense of an increased proportion of SDPs (ß: 2.49, 95% CI: 0.09 to 4.89), LDPs (ß: 1.94, 95% CI: 0.21 to 3.68) and FPs (ß: 1.90, 95% CI: 0.62 to 3.18). CONCLUSIONS: Age-related remodeling particularly affects BB as indicated by the decreased amount of non-SP at this location in the elderly.Key MessagesAgeing preferentially affects the morphology of unipolar atrial electrograms recorded at Bachmann's bundle.At Bachmann's bundle, the proportion of short double-, long double- and fractionated potentials increase during ageing at the expense of a decrease in the proportion of single potentials, reflecting aggravation of abnormalities in conduction.The increase in abnormal unipolar atrial electrograms at Bachmann's bundle during ageing supports the concept that Bachmann's bundle may play an important role in development of age-related arrhythmias such as atrial fibrillation.

Case report: peri-device leakage after percutaneous left atrial appendage occlusion: plug, clip, or amputate?

Background: Although peri-device leakage is frequently observed after left atrial appendage occlusion (LAAO), there is no consensus on the optimal management strategy. It is unknown whether additional plugging should be preferred over surgical exclusion of the LAA, as experience with additional plugging is limited. Case summary: In this case report, we demonstrate the clinical implications of additional plugging and surgical exclusion in a 65-year-old male patient with peri-device leakage and recurrent thromboembolic events. After the recurrence of paroxysmal atrial fibrillation (AF) and a transient ischaemic attack despite adequate anticoagulation, the patient was opted for re-do pulmonary vein isolation and LAAO with a Watchman device. Due to multiple ischaemic strokes and recurrent AF in combination with significant peri-device leakage, additional plugging with a second device was performed. Post-procedurally, the patient had another ischaemic stroke and persisting peri-device leakage was observed during follow-up. Due to progressive symptoms of AF and patient's preference to discontinue DOAC, he underwent a Cox MAZE IV procedure, including amputation of the LAA with both devices. Within six months after surgery, the patient experienced two more ischaemic events. In the following two years, the patient remained free of any cerebrovascular accidents or recurrence of AF. Discussion: Additional plugging of peri-device leakage is not always successful in stroke prevention. In combination with recurrent AF, progressive symptoms, contraindication for oral anticoagulation, and patient's preference, surgical LAA exclusion could be preferred over additional plugging.

Detection of endo-epicardial atrial low-voltage areas using unipolar and omnipolar voltage mapping.

Background: Low-voltage areas (LVA) can be located exclusively at either the endocardium or epicardium. This has only been demonstrated for bipolar voltages, but the value of unipolar and omnipolar voltages recorded from either the endocardium and epicardium in predicting LVAs at the opposite layer remains unknown. The goal of this study was therefore to compare simultaneously recorded endo-epicardial unipolar and omnipolar potentials and to determine whether their voltage characteristics are predictive for opposite LVAs. Methods: Intra-operative simultaneous endo-epicardial mapping (256 electrodes, interelectrode distances 2 mm) was performed during sinus rhythm at the right atrium in 93 patients (67 ± 9 years, 73 male). Cliques of four electrodes (2 × 2 mm) were used to define maximal omnipolar (Vomni,max) and unipolar (Vuni,max) voltages. LVAs were defined as Vomni,max ≤0.5 mV or Vuni,max ≤1.0 mV. Results: The majority of both unipolar and omnipolar LVAs were located at only the endocardium (74.2% and 82.0% respectively) or epicardium (52.7% and 47.6% respectively). Of the endocardial unipolar LVAs, 25.8% were also located at the opposite layer and 47.3% vice-versa. In omnipolar LVAs, 18.0% of the endocardial LVAs were also located at the epicardium and 52.4% vice-versa. The combination of epicardial Vuni,max and Vomni,max was most accurate in identifying dual-layer LVAs (50.4%). Conclusion: Unipolar and omnipolar LVAs are frequently located exclusively at either the endocardium or epicardium. Endo-epicardial LVAs are most accurately identified using combined epicardial unipolar and omnipolar voltages. Therefore, a combined endo-epicardial unipolar and omnipolar mapping approach is favoured as it may be more indicative of possible arrhythmogenic substrates.

Characterization of pre-existing arrhythmogenic substrate associated with de novo early and late postoperative atrial fibrillation.

BACKGROUND: PoAF is the most common complication after cardiac surgery and may occur in patients with pre-existing arrhythmogenic substrate. Characterization of this substrate could aid in identifying patients at risk for PoAF. We therefore compared intra-atrial conduction parameters and electrogram morphology between patients without and with early- (≤5 days after surgery) and late- (up to 5 years) postoperative atrial fibrillation (PoAF). METHODS AND RESULTS: Epicardial mapping of the right and left atrium and Bachmann's Bundle (BB) was performed during sinus rhythm (SR) in 263 patients (207male, 67 ± 11 years). Unipolar potentials were classified as single, short or long double and fractionated potentials. Unipolar voltage, fractionation delay (time difference between the first and last deflection), conduction velocity (CV) and conduction block (CB) prevalence were measured. Comparing patients without (N = 166) and with PoAF (N = 97), PoAF was associated with lower CV and more CB at BB. Unipolar voltages were lower and more low-voltage areas were found at the left and right atrium and BB in PoAF patients. These differences were more pronounced in patients with late-PoAF (6%), which could even occur up to 5 years after surgery. Although several electrophysiological parameters were related to PoAF, age was the only independent predictor. CONCLUSIONS: Patients with de novo PoAF have more extensive arrhythmogenic substrate prior to cardiac surgery compared to those who remained in SR, which is even more pronounced in late-PoAF patients. Future studies should evaluate whether intra-operative electrophysiological examination enables identification of patients at risk for developing PoAF and hence (preventive) therapy.

Epicardial high-resolution mapping of advanced interatrial block: Relating ECG, conduction abnormalities and excitation patterns.

Background: Impairment of conduction across Bachmann's Bundle (BB) may cause advanced interatrial block (a-IAB), which in turn is associated with development of atrial fibrillation. However, the exact relation between a complete transverse line of conduction block (CB) across BB and the presence of a-IAB has not been studied. Objective: The aims of this study are to determine whether (1) a complete transversal line of CB across BB established by high resolution mapping correlates with a-IAB on the surface ECG, (2) conduction abnormalities at the right and left atria correlate with a-IAB, and (3) excitation patterns are associated with ECG characteristics of a-IAB. Methods: We included 40 patients in whom epicardial mapping revealed a complete transverse line of CB across BB. Pre-operative ECGs and post-operative telemetry were assessed for the presence of (a) typical a-IAB and de novo early post-operative AF (EPOAF), respectively. Total atrial excitation time (TAET) and RA-LA delay were calculated. Entry site and trajectory of the main sinus rhythm wavefront at the pulmonary vein area (PVA) were assessed. Results: Thirteen patients were classified as a-IAB (32.5%). In the entire atria and BB there were no differences in conduction disorders, though, patients with a-IAB had an increased TAET and longer RA-LA delay compared to patients without a-IAB (90.0 ± 21.9 ms vs. 74.9 ± 13.0 ms, p = 0.017; 160.0 ± 27.0 ms vs. 136.0 ± 24.1 ms, p = 0.012, respectively). Patients with typical a-IAB solely had caudocranial activation of the PVA, without additional cranial entry sites. Prevalence of de novo EPOAF was 69.2% and was similar between patients with and without a-IAB. Conclusion: A transverse line of CB across BB partly explains the ECG characteristics of a-IAB. We found atrial excitation patterns underlying the ECG characteristics of both atypical and typical a-IAB. Regardless of the presence of a-IAB, the clinical impact of a complete transverse line of CB across BB was reflected by a high incidence of de novo EPOAF.

Atrial electrophysiological characteristics of aging.

INTRODUCTION: Advancing age is a known risk factor for developing atrial fibrillation (AF), yet it is unknown which electrophysiological changes contribute to this increased susceptibility. The goal of this study is to investigate conduction disturbances and unipolar voltages (UV) related to aging. METHODS: We included 216 patients (182 male, age: 36-83 years) without a history of AF undergoing elective coronary artery bypass surgery. Five seconds of sinus rhythm were recorded intraoperatively at the right atrium (RA), Bachmann's bundle (BB), the left atrium and the pulmonary vein area (PVA). Conduction delay (CD), -block (CB), -velocity (CV), length of longest CB lines and UV were assessed in all regions. RESULTS: With aging, increasing conduction disturbances were found, particularly at RA and BB (RA: longest CB line rs = .158, p = .021; BB: CB prevalence rs = .206, p = .003; CV rs = -.239, p < .0005). Prevalence of low UV areas (UV <5th percentile) increased with aging at the BB and PVA (BB: rs = .237, p < .0005 and PVA: rs = .228, p = .001). CONCLUSIONS: Aging is accompanied by an increase in conduction disturbances during sinus rhythm and a higher prevalence of low UV areas, particularly at BB and in the RA. These electrophysiological alterations could in part explain the increasing susceptibility to AF development associated with aging.

Classification of sinus rhythm single potential morphology in patients with mitral valve disease.

AIMS: The morphology of unipolar single potentials (SPs) contains information on intra-atrial conduction disorders and possibly the substrate underlying atrial fibrillation (AF). This study examined the impact of AF episodes on features of SP morphology during sinus rhythm (SR) in patients with mitral valve disease. METHODS AND RESULTS: Intraoperative epicardial mapping (interelectrode distance 2 mm) of the right and left atrium (RA, LA), Bachmann's bundle (BB), and pulmonary vein area (PVA) was performed in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal AF (PAF). Unipolar SPs were classified according to their differences in relative R- and S-wave amplitude ratios. A clear predominance of S-waves was observed at BB and the RA in both the no AF and PAF groups (BB 88.8% vs. 85.9%, RA 92.1% vs. 85.1%, respectively). Potential voltages at the RA, BB, and PVA were significantly lower in the PAF group (P < 0.001 for each) and were mainly determined by the size of the S-waves amplitudes. The largest difference in S-wave amplitudes was found at BB; the S-wave amplitude was lower in the PAF group [4.08 (2.45-6.13) mV vs. 2.94 (1.40-4.75) mV; P < 0.001]. In addition, conduction velocity (CV) at BB was lower as well [0.97 (0.70-1.21) m/s vs. 0.89 (0.62-1.16) m/s, P < 0.001]. CONCLUSION: Though excitation of the atria during SR is heterogeneously disrupted, a history of AF is characterized by decreased SP amplitudes at BB due to loss of S-wave amplitudes and decreased CV. This suggests that SP morphology could provide additional information on wavefront propagation.

Persistence and Distortion of Electrical Activity in the LAA 5 Years After Endovascular Occlusion.

This is the first report demonstrating persistence and distortion of electrical activity in the left atrial appendage 5 years after endovascular occlusion with a Watchman device. Electrical conduction is impaired providing an arrhythmogenic substrate for atrial tachyarrhythmias. Localized inflammation may result in structural and electrical remodeling in these patients. (Level of Difficulty: Intermediate.).

The Optic UK Lecture: bench-to-bedside adventures of a diabetes researcher: results past, results present.

This presentation covers two topics. First is a basic laboratory study, designed to explore the mechanism for the phenomenon of 'early worsening,' in which individuals with type 1 diabetes and early to moderate retinopathy are rapidly placed on 'tight' blood glucose control, after which about 10% of these individuals develop a worsening of retinopathy with the appearance of multiple 'cotton wool' spots. Our studies on cultured retinal cells used vascular endothelial growth factor (VEGF) production as an index of cellular ischaemia. VEGF production increases substantially when cells are cultured in low oxygen, but VEGF production in these hypoxic cultures decreases when the medium contains a fivefold excess glucose concentration. Cultures with no medium glucose also show increased VEGF production. In the clinical situation, we infer from these results that retinas with early retinopathy have a reduced blood supply and are therefore relatively ischaemic, thus increasing their VEGF production. Adding glucose provides an alternative energy supply, thus reducing the demand for VEGF and hence, reducing the likelihood of 'early worsening.' However, reducing the glucose supply to these already compromised retinas further increases their ischaemia and, therefore, the stimulus to produce more VEGF. The second part of this presentation is a clinical exploration of possible reasons for the frequent, wide discrepancy between measured central macular thickness by optical coherence tomography (OCT) and visual acuity in eyes with diabetic macular oedema. I explore the influence of different diseases in which macular oedema appears, the presence or absence, and size, of cystoid cavities; duration of the oedema; age of the subject, different anatomic derangements including epiretinal membranes and disruptions of the photoreceptor layer, and various biochemical and physiological mechanisms.

John Tileston Edsall: some selected biography and personal reminiscences.

This paper has been written in honor of John T. Edsall. Its purpose is to review briefly the status of science during his active years and the combination of personal qualities and upbringing which resulted in his enormous impact on the field of biochemistry. There was an unusual combination of deep knowledge and interest in many intellectual areas by no means restricted to science; the large number of individuals he met by intent or by chance, many to become fast friends for life, who themselves became distinguished in science; and last but not least his influence on science policy through very clear statements and his moral positions on questions of the day.

Antioxidants attenuate early up regulation of retinal vascular endothelial growth factor in streptozotocin-diabetic rats.

AIMS/HYPOTHESIS: A strong positive correlation has been found between lipid peroxidation product and vascular endothelial growth factor concentrations in the vitreous of patients with proliferative diabetic retinopathy. To establish a causal relation between diabetes-associated enhanced oxidative stress and vascular endothelial growth factor production, we evaluated two antioxidants, DL-alpha-lipoic acid and taurine, on retinal vascular endothelial growth factor protein and mRNA expression and on parameters of oxidative stress in streptozotocin-diabetic rats. METHODS: Our experiments were on control rats and streptozotocin-diabetic rats with a 6-week duration of diabetes, treated with or without DL-alpha-lipoic acid (100 mg x kg(-1) x d(-1), i.p.) or taurine (1% in the diet) starting from induction of diabetes. Vascular endothelial growth factor protein in retinal homogenates was assessed by sandwich ELISA with an affinity-purified polyclonal antibody and vascular endothelial growth factor mRNA by ribonuclease protection assay. Retinal lipid peroxidation products i.e. malondialdehyde plus 4-hydroxyalkenals were quantified with N-methyl-2-phenylindole. Retinal reduced and oxidized glutathione, ascorbate, dehydroascorbate, and sorbitol pathway intermediates were measured spectrofluorometrically, and taurine by reverse-phase HPLC. RESULTS: Vascular endothelial growth factor protein concentration (means +/- SD) was increased in diabetic rats compared with control rats (33+/-7 vs 19+/-5 pg/mg total protein, p < 0.01) This increase was attenuated by taurine (26+/-8, p < 0.05) and prevented by DL-alpha-lipoic acid (21+/-4, p < 0.01). Vascular endothelial growth factor mRNA abundance was reduced by 1.4-fold in diabetic rats compared with control rats and this decrease was attenuated but not completely prevented by both antioxidants. Malondialdehyde plus 4-hydroxyalkenal concentration was increased in diabetic rats compared with control rats, and both antioxidants arrested accumulation of lipid peroxidation products. Taurine, reduced glutathione, oxidized glutathione, ascorbate, dehydroascorbate and sorbitol pathway intermediate concentrations as well as oxidized glutathione/reduced glutathione and dehydroascorbate/ascorbate ratios were similar in control and diabetic rats treated with or without taurine. CONCLUSION/INTERPRETATION: Oxidative stress is directly involved in up regulation of vascular endothelial growth factor protein in the retina during early diabetes.

Glucose-specific regulation of aldose reductase in human retinal pigment epithelial cells in vitro.

PURPOSE: To test the hypothesis that pathophysiological levels of glucose regulate aldose reductase (AR2) gene expression, protein production, and activity in human retinal pigment epithelial (RPE) cells in vitro. METHODS: Primary cultures of human RPE cells were grown for up to 72 hours in media supplemented with various concentrations of glucose (5, 20, or 75 mM), or in 5 mM glucose containing media supplemented with one of the following: galactose, the transported but nonmetabolized glucose analogue 3-O-methylglucose (3-OMG), or the impermeant hexitol mannitol-so that the final hexose concentrations were equimolar to those of the various glucose concentrations used. Changes in the transcript levels for AR2 mRNA, AR2 protein content, and AR2 enzyme activity were determined. RPE glucose utilization and lactate production were determined in media containing 5 and 20 mM glucose. RESULTS: Glucose utilization and lactate production increased 4.8-fold and 4.4-fold, respectively, when RPE cells were grown in media containing 20 mM versus 5 mM glucose. Glucose was more effective than any other hexose in the induction of AR2 mRNA or increased AR2 protein expression. When RPE cells were grown in media containing 20 mM mannitol, 3-OMG, or galactose they had lower levels of AR2 mRNA expression than when cells were grown in medium containing 5 mM glucose. RPE cells grown in medium supplemented with 20 or 75 mM galactose did not show a greater increase in AR2 protein expression than cells grown in medium containing 5 mM glucose. Hyperosmotic induction of AR2 mRNA was the same in medium containing 75 mM glucose or 75 mM mannitol, but was at least 50% lower when RPE cells were grown in 75 mM galactose or 3-OMG. CONCLUSIONS. These data indicate that elevations in ambient glucose result in greater metabolism of glucose through glycolysis and polyol metabolism. Induction of AR2 was greatest when RPE cells were grown in pathophysiological concentrations of glucose. Hyperosmolar stress is not a necessary determinant of AR2 mRNA, AR2 protein, or AR2 protein activity in cells that form the outer blood-retinal barrier. Increased facilitative glucose transport or glucose metabolism appears to be requisite for glucose-specific and nonosmotic regulation of AR2 in the RPE cell in vitro.

Race, iris color, and age-related macular degeneration.

PURPOSE: While most observers agree that age-related macular degeneration (AMD) is much more common in white persons than in persons of black African ancestry, the influence of iris color has been more controversial. We reexamined relationships between race, iris color, and AMD in a series of patients from our retina clinic. METHODS: We evaluated, in masked fashion, stereoscopic photographs of the retinas and irides in 306 sequential patients 60 years of age or older from our retina clinics. Four readers judged whether AMD was present, absent, or questionable in the retinal photographs and labeled iris color as blue, hazel, or brown. Presence or absence of AMD and presence and severity of the various macular lesions were determined by "majority vote" of the readers. We evaluated inter-rater agreement using the kappa statistic. We compared the prevalence of AMD and of specific AMD lesions as a function of race, sex, and iris color by contingency table analysis. RESULTS: The kappa statistic showed good inter-observer agreement, being 0.466 (P < 10(-6)) for definite or questionable AMD and ranging from 0.185 to 0.522 (P = 0.0047 to P < 10(-6)) for most lesions. We found significantly more AMD in white patients than in black patients (X2 = 27.54, P < 10(-4)). There was no significant difference in AMD prevalence by sex. In white patients, AMD was significantly more prevalent in individuals with blue or hazel irides than in those with brown irides (X2 = 15.04, P = .02). CONCLUSIONS: We confirm previous findings of a higher prevalence of AMD in white persons than in black persons. We also agree with those observers who claim that white subjects with light-colored irides have a higher prevalence of AMD than those with dark-colored irides. We suggest that differences in the association between iris pigmentation and AMD in different studies using different research methods may reflect genetic difference in the groups being studied.

Subnormal retinal oxygenation response precedes diabetic-like retinopathy.

PURPOSE: Determining which patients are at risk for the development of diabetic retinopathy is expected to greatly improve existing prevention and treatment options. In this study, using an animal model of diabetic retinopathy, the hypothesis was tested that magnetic resonance imaging (MRI) and a carbogen inhalation challenge provides important diagnostic information regarding the risk of developing diabetic retinopathy. METHODS: MRI was used to measure noninvasively the change in oxygen tension along the entire inner retina (i.e., from superior ora serrata to inferior ora serrata) during a carbogen (95% O2/5% CO2) inhalation challenge (IOVS 1996;37:2089). Two animal groups were examined by this MRI method at two time points: (1) rats fed either normal rat chow (n = 20) or a 50% galactose diet (n = 20) for 3.5 months (i.e., before the appearance of extensive retinal lesions) or (2) rats fed either normal rat chow (n = 3) for 15 months or a 30% galactose diet (n = 4) for 15 to 18 months (i.e., when lesions are present). Retinal biochemical and morphometric measurements were also obtained. RESULTS: After 3.5 months of galactosemia, before the appearance of extensive retinal morphologic lesions, a significant (P < 0.05) reduction in the panretinal oxygenation response was observed in the galactosemic group compared with its age-matched control. These galactose-fed animals also displayed a significantly (P < 0.05) larger oxygenation response in the inferior hemiretina than in the superior hemiretina. After 15 to 18 months of galactosemia, during the period when lesions are present, the panretinal oxygenation response remained significantly (P < 0.05) lower in the galactose-fed animals than in their age-matched controls. In contrast to the 3.5-month results, the oxygenation response in galactosemic animals at 15 to 18 months was significantly (P < 0.05) larger in the superior than in the inferior hemiretina. Hemiretinal oxygenation responses were not different in normal controls at either duration. CONCLUSIONS: MRI measurement of the retinal oxygenation response to a carbogen challenge appears to be a powerful new and noninvasive approach that may be useful for assessing aspects of pathophysiology underlying the development of diabetic retinopathy in galactosemic rats. These results support our working hypothesis and suggest that further research into the diagnostic potential of this MRI approach for predicting the development of diabetic retinopathy is warranted.

Antioxidant enzymes in the macular retinal pigment epithelium of eyes with neovascular age-related macular degeneration.

PURPOSE: To test the hypothesis that neovascular age-related macular degeneration is related to oxidative stress involving the macular retinal pigment epithelium. This study investigated, as a function of age, levels of enzymes that defend tissues against oxidative stress in the macular retinal pigment epithelium of human eyes with this disease. METHODS: Surgical specimens of macular choroidal neovascular membranes from eyes with age-related macular degeneration and the macular regions of whole donor eyes with neovascular age-related macular degeneration or without evident ocular disease were studied by quantitative electron microscopic immunocytochemistry with colloidal gold-labeled second antibodies. Relative levels in retinal pigment epithelium cell cytoplasm and lysosomes were determined of five enzymes believed to protect cells from oxidative stress, as well as levels of the retinal pigment epithelium marker cytoplasmic retinaldehyde-binding protein, for comparison with the enzymes. RESULTS: Copper, zinc superoxide dismutase immunoreactivity increased and catalase immunoreactivity decreased with age in cytoplasm and lysosomes from macular retinal pigment epithelium cells of normal eyes and eyes with age-related macular degeneration. Cytoplasmic retinaldehyde-binding protein immunoreactivity showed no significant relationship to age or the presence of neovascular age-related macular degeneration. Glutathione peroxidase immunoreactivity was absent from human retinal pigment epithelium cells. Both heme oxygenase-1 and heme oxygenase-2 had highly significantly greater immunoreactivity in retinal pigment epithelium cell lysosomes than in cytoplasm, differing from the much greater cytoplasmic immunoreactivity of the other proteins studied. This immunoreactivity decreased with age, particularly in the lysosomes of retinal pigment epithelium cells from eyes with neovascular age-related macular degeneration. These decreases were of borderline significance (P = .067 for heme oxygenase-1; P = .12 for heme oxygenase-2) when eyes with age-related macular degeneration were compared with normal eyes by multivariable logistic regression. CONCLUSIONS: The high heme oxygenase-1 and heme oxygenase-2 lysosomal antigen levels in macular retinal pigment epithelium cells of eyes with neovascular age-related macular degeneration suggest that oxidative stress causes a pathologic upregulation of these enzymes. Increased lysosomal disposal may indicate that the reparative functions of these enzymes are accompanied by deleterious effects, necessitating their rapid removal from the cell. The much higher heme oxygenase-1 and heme oxygenase-2 antigen levels in macular retinal pigment epithelium cells from younger individuals suggest that protective mechanisms against oxidation and, hence, presumably to the development of age-related macular degeneration, decrease with age.

An aldose reductase inhibitor and aminoguanidine prevent vascular endothelial growth factor expression in rats with long-term galactosemia.

OBJECTIVE: To study the effects of an aldose reductase inhibitor (ARI-509, Wyeth-Ayerst, Princeton, NJ) and aminoguanidine (AMG), agents that have been reported to prevent or delay diabetic retinopathy, on retinal vascular abnormalities and the immunocytochemical expression in the retina of vascular endothelial growth factor (VEGF) in rats maintained for up to 2 years on a 50% galactose diet. METHODS: Albino rats were placed on a control diet, a diet containing 50% galactose, or the 50% galactose diet containing either ARI-509 or AMG. Treatment with ARI-509 or AMG was initiated at the beginning of the experiment or after 12 months of galactose feeding. After 22 to 24 months, the rats were killed and the retinal vasculature from half of one eye was isolated by trypsin-elastase digestion for semiquantitative evaluation of retinal vascular lesions. The other half of the retina was prepared for immunocytochemistry and stained for the presence of VEGF, factor VIII, vimentin, and glial fibrillary acidic protein. Red blood cells, sciatic nerves, and a portion of the retina from the second eye were assayed for glucose, galactose, fructose, sorbitol, galactitol, and myo-inositol. Red blood cells were also assayed for galactosylated hemoglobin. RESULTS: Galactose-fed animals developed a vascular retinopathy characterized by severe cellular loss in the retinal capillaries and intensification of periodic acid-Schiff staining of the vascular basement membranes. Some animals also displayed dilation and hypercellularity of vessels in the posterior retina. These changes were substantially reduced in animals receiving ARI-509 from the beginning of the galactose diet, but were unaffected in all of the other treatment groups. None of the rats receiving ARI-509 or AMG treatment, whether initiated from the onset or after 12 months of galactosemia, demonstrated VEGF immunoreactivity. With the exception of the animals receiving ARI-509 from the beginning of the experiment, all of the galactose-fed animals developed dense cataracts within 6 weeks of the beginning of the galactose diet. Galactitol levels in animals receiving ARI-509 were 86% to 93% lower in red blood cells, retina, and sciatic nerve than those in the other galactose-fed groups. CONCLUSIONS: Although ARI-509 and AMG have different abilities to delay or prevent the diabetic-like retinopathy in galactosemic rats, even when substantial retinal microvascular acellularity occurs, both drugs prevent the immunocytochemical expression of VEGF. These results suggest that factors other than hypoxia may be responsible for VEGF expression in the retina, and that aldose reductase inhibitors and AMG have potential roles in preventing such expression and, thus, perhaps preventing retinal neovascularization.

Vascular endothelial growth factor is present in glial cells of the retina and optic nerve of human subjects with nonproliferative diabetic retinopathy.

PURPOSE: To determine whether vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), which have been implicated in the development of retinal and choroidal neovascularization, are present in the retinas and optic nerves of patients with diabetes before proliferative retinopathy appears. METHODS: Light microscopic immunocytochemistry using antibodies to VEGF, bFGF, vimentin, glial fibrillary acidic protein (GFAP), and factor VIII on frozen sections from eyes of patients with diabetes without proliferative retinopathy, eyes of patients without diabetes and without known ocular disease, and eyes with disciform age-related macular degeneration (ARMD). Retinal vascular digest preparations to evaluate microvascular abnormalities. RESULTS: Based on morphology and on GFAP and vimentin immunopositivity, retinas from all subjects with diabetes immunostained strongly to VEGF in elongated processes that appeared to be Müller cells. Glial cells within septa surrounding axons in the anterior optic nerve also immunostained for VEGF, as did endothelial cells of some posterior retinal blood vessels and some retinal pigment epithelial cells. Retinas from eyes with disciform ARMD immunostained for VEGF, though less extensively than did those of subjects with diabetes. Retinas and optic nerves from subjects without ocular disease were VEGF negative. Basic fibroblast growth factor was expressed minimally in the inner retinal layers of subjects with and without diabetes, but it was substantial in the photoreceptor layer of all eyes. Vascular endothelial growth factor immunopositivity was present in eyes with no, or little, retinal vascular anatomic abnormality in digest preparations. CONCLUSIONS: Vascular endothelial growth factor expression precedes retinal neovascularization in the retinas and the optic nerves of humans with diabetes. Its localization to glial cells of the inner retina and the anterior optic nerve suggests a relationship to neovascularization in these sites. That VEGF immunopositivity may occur when there is no anatomic evidence of retinal nonperfusion and little likelihood of retinal neovascularization suggests the possibility that ischemia may not be the sole stimulus for VEGF expression.