Is the diagnostic yield of myocardial stress perfusion MRI impaired by three-vessel coronary artery disease?

BACKGROUND: Three-vessel coronary artery disease (CAD) comes along with globally reduced myocardial perfusion potentially restricting the demarcation of regional hypoperfusion in stress perfusion cardiac magnetic resonance imaging (MRI). PURPOSE: To evaluate whether stress perfusion cardiac MRI is capable of detecting myocardial hypoperfusion in patients with 3-vessel CAD reliably. MATERIAL AND METHODS: Two hundred and five patients with symptoms of CAD were included. The examination protocol comprised imaging of myocardial perfusion at stress (0.14 mg/kg/min adenosine for 4 min) using a 2D saturation recovery gradient echo sequence after administration of gadobutrol (0.1 mmol/kg body weight). Perfusion sequences were assessed qualitatively by two experienced observers. Coronary angiography served as standard of reference. RESULTS: Sensitivity and specificity for hemodynamically relevant stenoses in patients with 0-, 1-, 2-, 3-vessel coronary artery disease were 100%/91%, 91%/73%, 90%/71%, 92%/64%; positive/negative predictive value, 67%/100%, 91%/73%, 83%/81%, 93%/58%; diagnostic accuracy, 93%/87%/83%/87%, respectively. The negative predictive value in patients with 3-vessel CAD was lower than in patients with 0- and 2-vessel CAD and the specificity lower than in patients with no CAD whereas the positive predictive value was higher than in patients with no CAD. The other proportions did not differ significantly between the groups. CONCLUSION: The diagnostic value of stress perfusion cardiac MRI in patients with 3-vessel CAD is comparable to results in patients with 1- or 2-vessel CAD. In the rare event that stress perfusion images do not depict regional hypoperfusion in patients with severe 3-vessel CAD, myocardial ischemia could be identified by reduced semi-quantitative perfusion parameters.

Is myocardial stress perfusion MR-imaging suitable to predict the long term clinical outcome after revascularization?

INTRODUCTION: Aim of our study was to evaluate, whether myocardial ischemia or myocardial infarction (MI) depicted by myocardial stress perfusion MR imaging (SP CMR) can predict the clinical outcome in patients with coronary artery disease (CAD). MATERIALS AND METHOD: 220 patients were included. Myocardial perfusion was assessed at stress and at rest, using a 2D saturation recovery gradient echo sequence (SR GRE) and myocardial viability by late gadolinium enhancement magnetic resonance images (LGE CMR). MR-images were assessed in regard of presence and extent of MI and ischemia. Patients were monitored for major adverse cardiac events (MACE) (monitoring period: 5-7 years). MACE were correlated with the initial results of SP CMR. RESULTS: Ischemia was found in 143 patients, MI in 107 patients. Number of MACE was in patients with normal SP CMR 0 (51 patients), with ischemia 21 (62 patients), with MI 14 (26 patients), with ischemia and MI 52 (81 patients). In all patients with severe MACE (MI, death) and in 63 of those with recurring symptoms LGE CMR revealed MI at baseline. CONCLUSION: Negative SP CMR indicates low risk for MACE. In patients with stress induced ischemia, MACE might occur even after myocardial revascularization. The presence of MI proved by LGE CMR is associated with a significantly increased risk for MACE.

Hemostasis in Danio rerio: is the zebrafish a useful model for platelet research?

New scientific models have been established in the past few years to identify novel factors of hemostasis and thrombosis and to analyze their function in greater detail. One fairly new animal model is the zebrafish, Danio rerio, which shares most of the central factors of platelet adhesion, activation, aggregation and release reaction with humans. Examples include GPIIb-IIIa, many other integrins, coagulation factors, inflammatory and cytokine-like proteins as well as arachidonic acid metabolism enzymes. Yet the zebrafish genome has undergone a teleost-specific genome duplication, causing the existence of duplicated paralogues in some instances, and a few genes have not been identified in the zebrafish genome. Taken together the high fecundity of the zebrafish, the possibility to observe transparent developing embryos in real time, the availability of a large number of mutants and transgenics as well as the possibility to knock down gene function by microinjection of morpholino antisense oligonucleotides and the similarity of the hemostatic system are important assets of the zebrafish, promising that it will be an attractive model to study thrombocyte function, thrombosis and hemostasis. This review provides an overview of the central factors of thrombocyte function identified so far in the zebrafish genome and a compilation of methods and tools available for the study of thrombocyte development and function in zebrafish.

Magnetic resonance myocardial perfusion imaging-First experience at 3.0T.

OBJECTIVE: MR myocardial perfusion imaging (MRMPI) is an established technique for the evaluation of the hemodynamical relevance of coronary artery disease. Perfusion imaging at 3.0T provides certain advantages compared to 1.5T. Aim of this study was to evaluate myocardial MR perfusion imaging at 3.0T. MATERIALS AND METHODS: Twelve patients with stable Angina pectoris and known or suspected coronary artery disease were examined at 3.0T. Myocardial perfusion was assessed using a saturation recovery gradient echo 2D sequence (TR 1.9ms, TE 1.0ms, FA 12 degrees ) with 0.05mmol Gd-DTPA per kg body weight at stress during injection of 140microg adenosine/kg body weight/min and at rest in short axis orientation. Perfusion analysis was based on a least square fit of the signal/time curve (peak signal intensity, slope). Perfusion series were assessed by two independent observers. Reference for the presence of relevant coronary artery stenoses was invasive coronary angiography. Two experienced observers evaluated the coronary angiograms in biplane projections for the presence and grade of stenoses. Results were compared with the MR perfusion analysis. RESULTS: All MR examinations could be safely performed and yielded high image quality. In eight patients stress-induced hypoperfusion was detected (stenosis >70% in coronary angiography). In four patients myocardial hypoperfusion was ruled out (stenosis <70%). The myocardial perfusion reserve index was significantly reduced in hypoperfused myocardium with 1.9+/-1.6 compared to 2.5+/-1.6 in regularly perfused myocardium (p<0.05). In coronary angiography, eight patients were found to suffer from coronary artery disease, whereas in four patients coronary artery disease was ruled out. CONCLUSION: Our initial results show that MRMPI at 3.0T provides reliably high-image quality and diagnostic accuracy.

Animal serum-free culture conditions for isolation and expansion of multipotent mesenchymal stromal cells from human BM.

BACKGROUND: Multipotent mesenchymal stromal cells (MSC) have become important tools in regenerative and transplantation medicine. Rapidly increasing numbers of patients are receiving in vitro-expanded MSC. Culture conditions typically include FSC because human serum does not fully support growth of human MSC in vitro (MSC(FCS)). Concerns regarding BSE, other infectious complications and host immune reactions have fueled investigation of alternative culture supplements. METHODS: As PDGF has long been identified as a growth factor for MSC, we tested media supplementation with platelet lysate for support of MSC proliferation. RESULTS: We found that primary cultures of BM-derived MSC can be established with animal serum-free media containing fresh frozen plasma and platelets (MSC(FFPP)). Moreover, MSC(FFPP) showed vigorous proliferation that was superior to classical culture conditions containing FCS. MSC(FFPP) morphology was equivalent to MSC(FCS), and MSC(FFPP) expressed CD73, CD90, CD105, CD106, CD146 and HLA-ABC while being negative for CD34, CD45 and surface HLA-DR, as expected. In addition to being phenotypically identical, MSC(FFPP) could efficiently differentiate into adipocytes and osteoblasts. In terms of immune regulatory properties, MSC(FFPP) were indistinguishable from MSC(FCS). Proliferation of PBMC induced by IL-2 in combination with OKT-3 or by PHA was inhibited in the presence of MSC(FFPP). DISCUSSION: Taken together, FCS can be replaced safely by FFPP in cultures of MSC for clinical purposes.

Platelet-leukocyte aggregates during hemodialysis: effect of membrane type.

Hemodialysis is associated with the formation of platelet-leukocyte aggregates. Whether this phenomenon is hemodialysis (HD) membrane dependent is unclear. To evaluate this process, we examined respectively platelet activation (anti-CD41, anti-CD62, and antifibrinogen monoclonal antibodies [MoAb] binding), leukocyte activation (CD11b expression), and the appearance of platelet specific antigens on leukocytes as an index of platelet-leukocyte aggregation during HD using 3 different membrane materials, Cuprophan, Hemophan, and polysulfone. Flow cytometric techniques and specific MoAb were used. All parameters were assayed 5 min after initiation of HD to avoid the confounding variable of leukopenia and resultant cell subpopulation analysis. Platelet activation (anti-CD62 and antifibrinogen binding) occurred only with Cuprophan. All 3 membranes induced equivalent increases in CD11b expression on neutrophils and similarly increased the binding of anti-CD41 to neutrophils, reflecting an increment in the formation of platelet neutrophil aggregates. However, only Cuprophan induced an increase in anti-CD62 binding to neutrophils, suggesting that the aggregated platelets linked to neutrophils were activated. Increased anti-CD41 binding by monocytes was similarly observed with all 3 membranes. However, only polysulfone induced an increase in CD11b expression and fibrinogen binding to monocytes. We conclude that while the formation of platelet leukocyte aggregates appears to be a universal phenomenon in HD occurring with a variety of membrane types, subtypes of this phenomenon consisting of activated platelets and fibrinogen binding may be membrane dependent. This phenomenon may serve as a new biocompatibility parameter and may shed light on some of the biologic consequences of hemodialysis.

Effects of ATP on ligand recognition of platelet fibrinogen receptor on GPIIb-IIIa.

The recent discovery of 8-azido-ATP binding sites on the platelet fibrinogen receptor glycoprotein complex GPIIb-IIIa suggests that extracellular ATP may directly modulate function of GPIIb-IIIa. In this study we investigated the effect of ATP on ligand binding to GPIIb-IIIa. Fibrinogen-mediated aggregation of washed platelets was inhibited by ATP and 8-azido-ATP in a dose-dependent manner, independent of the agonist (thrombin, collagen, epinephrine, phorbol 12-myristate 13-acetate) used to induce platelet activation. In addition, 8-azido-ATP and ATP inhibited binding of 125I-labeled fibrinogen to thrombin- and phorbol ester-activated platelets. Interaction of nonstimulated platelets with solid-phase fibrinogen was also reduced by 8-azido-ATP and ATP. Moreover, fibrinogen mimetic peptide-induced conformational change of GPIIb-IIIa on resting platelets was reduced in the presence of both nucleotides. Finally, photoincorporation of 8-azido-[gamma-32P]ATP into GPIIb-IIIa was suppressed by GRGDSP but not by the biologically inactive GRGESP peptide. Thus interaction of ATP with 8-azido-ATP binding sites present on GPIIb-IIIa modulate receptor function, which may play a role in regulation of in vivo platelet aggregation.

Platelet-leukocyte aggregation during hemodialysis.

Hemodialysis is associated with simultaneous changes in leukocytes and platelets, but it is unclear whether these alterations affect the interactions between these cell types. To evaluate this process, we examined the appearance of platelet specific antigens (CD41) on leukocytes as an index of platelet-leukocyte aggregation during hemodialysis using three different synthetic membranes. Patients with end-stage renal disease (ESRD) on long-term hemodialysis treatment were enrolled. Flow cytometric techniques and platelet specific monoclonal antibodies (MoAb) that recognize the glycoprotein complex on resting and activated platelets (anti-CD41), the activated GPIIb-IIIa complex receptor (anti-LIBS1), and the p selectin GMP140, that is exposed on platelet plasma membrane after activation and platelet degranulation (anti-CD62), were used. Subjects with ESRD had a lower predialysis platelet surface expression of CD41 and LIBS1 compared to normal controls, but unchanged CD62 expression. In parallel, patients with ESRD manifested a uniformly reduced platelet-leukocyte microaggregates predialysis compared to normal controls. When examined across the dialyzer, however, an increase in platelet-neutrophil and platelet-monocyte microaggregates was observed with all three synthetic membranes at both 15 and 30 minutes after initiation of dialysis. This phenomenon could be duplicated in vitro by physiologic concentrations of the platelet specific agonist ADP, but not by the complement factors C3a or C5a. We conclude that platelet-leukocyte aggregates occur during dialysis likely related to a primary platelet activation mechanism. This phenomenon may serve as a new biocompatibility parameter and may shed light on some of the biologic consequences of hemodialysis.

Impaired function of platelet membrane glycoprotein IIb-IIIa in end-stage renal disease.

Impaired platelet function and a bleeding tendency are well-recognized complications of chronic renal failure. Because the fibrinogen receptor GPIIb-IIIa plays a central role in platelet aggregation and adhesion to the subendothelium, it was reasoned that a defect in this receptor may underlie the impaired platelet function in uremia. To test this hypothesis, the function of this receptor in the platelets of 11 uremic patients was studied. Aggregation studies were performed with flow cytometric techniques with anti-GPIIb-IIIa conformation-specific monoclonal antibodies (mAb) (anti-LIBS1 and anti-PMI-1). Antifibrinogen and antithrombospondin mAb were used to characterize fibrinogen binding to GPIIb-IIIa and the release of alpha-granules, respectively. Platelets from patients with chronic renal failure showed significantly decreased binding of conformation-dependent anti-LIBS1 mAb after ADP, phorbol myristate acetate, or RGD-peptide stimulation compared with normal controls, suggesting a defect related to the ability of the fibrinogen receptor to undergo a conformational change. Moreover, antifibrinogen and antithrombospondin binding to activated platelets were reduced in uremic patients, implying impairment of both ligand-binding and alpha-granule release. Hemodialysis partially restored GPIIb-IIIa function, which may account for the observed effects of this therapy in restoring platelet aggregation. These findings indicate that platelets of patients with chronic renal failure reveal an aggregation defect at least partially due to an intrinsic GPIIb-IIIa dysfunction and the presence of a putative uremic toxin that inhibits fibrinogen binding to GPIIb-IIIa.

Single-donor platelet concentrates: changes of surface glycoproteins during storage.

Storage of single-donor platelet concentrates is currently limited to 5 days. During this period, however, numerous morphologic and biochemical changes have been observed. These changes result in functional impairment of stored platelets. The present study describes increased binding of a monoclonal antibody against GMP 140 on the surface of stored single-donor platelets revealing an activation process. In contrast, binding of monoclonal antibodies directed against glycoprotein complex (GP) IIb-IIIa and ligand-induced binding site (LIBS1) is slightly diminished during storage. When platelets are stimulated with ADP GMP 140, GP IIb-IIIa, and LIBS1 are expressed to a higher extent than on the surface on nonstimulated platelets. The quantity exposed, however, depends upon the storage time. It is significantly reduced when platelets are stored for longer than 1-2 days. The present data indicate that storage of single-donor platelet concentrates affects fibrinogen binding, cell to cell cohesion, and release reaction. The results are in good agreement with conventional aggregation and in vitro bleeding time measurements.

Flow-cytometric analysis of mepacrine-labelled platelets in patients with end-stage renal failure.

Platelet dysfunction and increased bleeding tendency has been the most consistently described haemostatic abnormality in patients with renal failure. Besides abnormalities in platelet membrane glycoproteins, a reduced amount of platelet-dense granule content has been demonstrated in patients with end-stage renal failure (ESRD) indicating an acquired storage pool deficiency (SPD) present in uraemia. To study dense granules, platelets were labelled with mepacrine, a fluorescent probe which is specifically incorporated into dense bodies. MepaPlatelets of 13 patients with ESRD and of 11 healthy controls were studied. The results showed that mepacrine-labelled platelets of patients with ESRD reveal a significantly (p < 0.05) reduced fluorescence compared to the control group. This implies a reduced number or content of dense granules present in ESRD platelets. Thus, the current data indicate that ESRD is associated with an acquired platelet SPD which may be a useful and rapid method for screening patients with suspected acquired or inherited SPD.

Characterization of a gain of function mutation of integrin alpha IIb beta 3 (platelet glycoprotein IIb-IIIa).

Integrin alpha IIb beta 3 (platelet glycoprotein IIb-IIIa) is a prototype of integrins involved in cellular adhesive functions. As part of a structure-function analysis of this molecule, we constructed a mutant, designated alpha IIb beta 3 (beta 1-2), by replacing 6 amino acids within a putative ligand binding domain of the beta 3 subunit with sequences derived from beta 1. The alteration did not affect the capacity of beta 3(beta 1-2) to combine with transfected alpha IIb, nor did it cause it to combine with endogenous alpha 5. Integrin alpha IIb beta 3(beta 1-2) was in a "resting" state on Chinese hamster ovary cells as judged by minimal binding of an activation-specific anti-alpha IIb beta 3, PAC1. Nevertheless, cells expressing alpha IIb beta 3(beta 1-2) spontaneously bound fibrinogen with low affinity (Ka = (4.85 +/- 0.84) x 10(6) M-1). Activation with an anti-beta 3 antibody (monoclonal antibody 62) resulted in a 10-fold increase in fibrinogen binding affinity (Ka = (4.55 +/- 0.77) x 10(7) M-1), which was 3-fold greater than fibrinogen binding to activated wild type alpha IIb beta 3 (Ka = (1.66 +/- 0.33) x 10(7) M-1, F = 7.46, p = 0.008). The mutant receptor also bound fibrinogen mimetic peptide ligands with enhanced affinity as measured by the conformation-specific antibody, anti-LIBS1. This indicates that the increased affinity for fibrinogen was caused by enhanced interaction of alpha IIb beta 3(beta 1-2) with known recognition sequences in fibrinogen. Thus, this gain of function mutant augments ligand binding function, supporting a role for this region of the beta subunit in ligand binding to integrins.

Ligand bridging mediates integrin alpha IIb beta 3 (platelet GPIIB-IIIA) dependent homotypic and heterotypic cell-cell interactions.

The aggregation of cells bearing recombinant integrin alpha IIb beta 3 (platelet GPIIb-IIIa) has been analyzed by two-color flow cytometry. As in normal platelets, aggregation requires functional alpha IIb beta 3, "activation" of alpha IIb beta 3, and fibrinogen (fg) binding to alpha IIb beta 3. Cellular aggregation required that both interacting cells express functional alpha IIb beta 3, because a binding defective mutant, alpha IIb beta 3 (D119----Y), failed to support interaction with wild type alpha IIb beta 3-bearing cells. In addition, cells bearing resting alpha IIb beta 3 were incorporated into aggregates formed by cells bearing a constitutively active mutant, alpha IIb beta 3 (beta 1-2), indicating that only one of the cells in an interacting pair must be activated. Finally, heterotypic interactions occurred between cells bearing activated alpha IIb beta 3 and cells bearing alpha V beta 3, a fg-binding integrin present on endothelial and tumor cells. Thus, ligand bridging between fg-binding integrins represents a mechanism of cell-cell interaction, cells bearing resting alpha IIb beta 3 (e.g., resting platelets) may be incorporated into aggregates formed by cells bearing activated alpha IIb beta 3, and alpha IIb beta 3 mediates heterotypic interactions with cells bearing other fg receptors.

Effects of hemodialysis on platelet-derived thrombospondin.

The effects on platelet-derived thrombospondin (TSP) of hemodialysis with a cellulose membrane were studied in patients during routine hemodialysis and in normal subjects using an ex vivo model. Plasma and platelet-bound TSP were determined pre- and post-dialysis, in blood entering and leaving the dialyzer after 1, 3, 5, 15, and 30 minutes of dialysis, and in blood leaving the ex vivo module after 5, 10, 15, 20, and 25 minutes of perfusion. Plasma concentrations of beta-thromboglobulin (beta TG) and thromboxane B2 (TxB2), and platelet membrane expression of the alpha-granule protein GMP-140, were also measured. Significant increases in plasma concentrations of TSP and beta TG occurred between the inlet and outlet of the dialyzer after 5, 15, and 30 minutes of dialysis, accompanied by a slow, but significant, increase in their arterial plasma concentrations. In contrast, initiation of dialysis was associated with an immediate increase in plasma TxB2 concentration between the inlet and outlet of the dialyzer and an abrupt increase in arterial plasma TxB2 concentration which plateaued at 250% of the pre-dialysis value after five minutes. Transit of platelets through the dialyzer had no effect on platelet-membrane-associated TSP or GMP-140. Plasma TSP and beta TG concentrations at the outlet of the ex vivo module also increased significantly during perfusion, but plasma TSP concentrations were twofold greater than those during hemodialysis. In vitro stimulation of platelets with thrombin and immunoblotting studies of platelet release proteins showed reduced TSP release by platelets of hemodialysis patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Serum level of digoxin-like immunoreactive substances in newborn infants in the first two weeks of life, in umbilical cord blood and in pregnant patients at the time of labor]. / Serumspiegel von digoxin-ähnlichen immunreaktiven Substanzen (DLIS) bei Neugeborenen im Verlauf der ersten beiden Lebenswochen, im Nabelschnurblut und bei Schwangeren zum Zeitpunkt der Geburt.

A digoxin-like immunoreactivity (DLIS) was measured by two routinely used clinical digoxin-immunoassays (radio- and enzymeimmunoassay) in cord blood of 255 newborns, in sera of their mothers at birth and in sera of 211 newborns during the first two postpartal weeks. The highest DLIS levels were found in serum of neonates at the first day of life (median: 0.23 ng/ml, 25% and 75% percentile: 0.19 and 0.28 ng/ml) and in cord blood (median: 0.21 ng/ml, 25% and 75% percentile: 0.19 and 0.24 ng/ml); maternal serum was shown to have three times less DLIS (median: 0.08 ng/ml, 25% and 75% percentile: 0.05 and 0.10 ng/ml). There was no significant correlation between DLIS concentrations in serum of newborns, cord blood or pregnants. The DLIS serum levels of preterms with birthweight less than 2500 g and gestational age less than 37 weeks were significantly lower than those of normal neonates at term (p less than 0.01); concomitantly the lowest DLIS levels were found in maternal serum of preterms (p less than 0.01). These observations strongly suggest rather a DLIS origin in the newborn than in the mother. During the first two postpartal weeks the DLIS concentration of a vast majority of the 211 newborns (91%) decreased continuously to one half of the starting value. Within the second postpartal week preterms were found to have a significantly delayed decrease in the DLIS serum levels (p less than 0.01). Small for date newborns showed no difference in their postpartal DLIS time course compared to normal neonates.(ABSTRACT TRUNCATED AT 250 WORDS)

The isolation and reconstitution of the ADP/ATP carrier from wild-type Saccharomyces cerevisiae. Identification of primarily one type (AAC-2).

Methods for isolation of the ADP/ATP carrier (AAC) from yeast (Saccharomyces cerevisiae) are described which allow separation of the carrier from the initially copurified porin which poses a specific problem in yeast. The procedure varies according to whether one wishes to obtain a stable CAT-AAC complex, the free and active AAC for reconstitution, or the SDS-denatured pure AAC peptide. CNBr cleavage of AAC enabled us to differentiate clearly between isogenes AAC-1 and AAC-2 recently found in yeast, due to the exclusive occurrence of a methionine (M-115) residue at the end of the first domain in AAC-2. Thus the AAC isolated from wild-type yeast is primarily or exclusively AAC-2. The isolated AAC is active in ADP/ATP exchange in reconstituted liposomes with a Vmax of 1100 mumol/min per g protein and Km = 15 microM for ADP, and a Vmax of 900 mumol/min per g protein and Km = 9 microM for ATP.