Selective pulmonary vasodilation improves ventriculovascular coupling and gas exchange in a patient with unrepaired single-ventricle physiology.

We describe a 63-year-old patient with unrepaired tricuspid valve atresia and a hypoplastic right ventricle (single-ventricle physiology) who presented with progressive symptomatic hypoxia. Her anatomy resulted in parallel pulmonary and systemic circulations, pulmonary arterial hypertension, and uncoupling of the ventricle/pulmonary artery. Hemodynamic and coupling data were obtained before and after pulmonary vasoactive treatment, first inhaled nitric oxide and later inhaled treprostinil. The coupling ratio (ratio of ventricular to vascular elastance) shunt fractions and dead space ventilation were calculated before and after treatment. Treatment resulted in improvement of the coupling ratio between the ventricle and the vasculature with optimization of stroke work, equalization of pulmonary and systolic flows, a decrease in dead space ventilation from 75% to 55%, and a significant increase in 6-minute walk distance and improved hypoxia. Inhaled treprostinil significantly increased 6-minute walk distance and improved hypoxia. This is the first report to show that pulmonary vasoactive treatment can be used in a patient with unrepaired single-ventricle anatomy and describes the hemodynamic effects of inhaled therapy on ventriculovascular coupling and gas exchange in the pulmonary circulation in this unique physiology.

Transcatheter closure of residual atrial septal defect following implantation of buttoned device.

We report a case in which residual shunting after a buttoned device occlusion of atrial septal defect (ASD) was eliminated by transcatheter retrieval of a portion of the device, followed by implantation of a second device. This method may be helpful for those patients with residual ASDs who decline surgical device retrieval and defect closure.

The time required to perform pediatric transthoracic echocardiographic studies.

The purpose of this study was to determine the time required to perform and evaluate transthoracic pediatric echocardiographic procedures by two groups of pediatric cardiologists; one group was university based and the other group was based in a private practice. Methods consisted of measuring five periods including technician preparation time, technician procedure time, physician imaging time, physician review and reporting time, and physician time in interpretation of the results of the study to the parent or patient. The study evaluated data for 200 studies for the university-based group (all of which were complete studies) and 193 studies for the private practice group (84% of which were complete studies and the remainder were partial studies). Eleven pediatric cardiologists participated in the study. Although some variations in physician imaging and review time were encountered, data demonstrated that mean total physician time for a complete echocardiographic study was 31.9 minutes for both groups. Mean total technical time for complete studies was 42.4 minutes for the private group and 40.9 minutes for the university group. These are the first data evaluating the technical and physician work durations for pediatric echocardiography.

Gender differences in dehydration-induced mitral valve prolapse.

Mitral valve prolapse (MVP) is a common cardiac valve abnormality that affects women more frequently than men. We have previously shown that mild dehydration induces echocardiographic signs of MVP in approximately 50% of healthy asthenic women with previously normal cardiac findings. The present study was designed to investigate whether dehydration can induce MVP in normal men. Ten healthy male volunteers with a mean body mass index of 24.2 kg/m2, unremarkable history, and normal cardiac findings and echocardiogram were examined after mild diuresis with 20 mg furosemide. Significant decrease in weight, left ventricular end-diastolic dimension, and cardiac output were detected in all subjects after furosemide administration. In 1 (10%) of the 10 subjects echocardiographic MVP developed after furosemide administration. All furosemide-induced changes resolved with hydration. These results demonstrate that dehydration-induced MVP in men without characteristic body habitus of MVP occurs with substantially lower frequency than previously documented in women with the characteristic body habitus of MVP. This study suggests the importance of gender and body habitus in dehydration-induced MVP.

Furazolidone increases thapsigargin-sensitive Ca(2+)-ATPase in chick cardiac myocytes.

Furazolidone is a nitrofuran antibiotic that causes dilated cardiomyopathy in turkeys and chicks and serves as an important model of human dilated cardiomyopathy. The mechanism by which furazolidone produces cardiac injury remains unknown. We investigated the hypothesis that furazolidone alters Ca2+ homeostasis in cardiac muscle cells. Myocytes harvested from 7-day-old chick embryos were treated with furazolidone (0.02, 0.1, and 1 mM) for 24-52 h and then coloaded with seminaphthorhodafluor-1 (SNARF 1) and fura 2 to measure simultaneously intracellular pH (pHi) and intracellular Ca2+ concentration ([Ca2+]i), respectively. Furazolidone did not affect steady-state [Ca2+]i levels in cardiac myocytes. Na+ removal was associated with a rapid increase in [Ca2+]i due to the Na+/Ca2+ exchanger, which was similar in control and furazolidone-treated cells. The rate of [Ca2+]i recovery after Na+ removal was significantly increased in the furazolidone-treated cells compared with controls. In most cells, recovery from Ca2+ load is accomplished by the activity of Ca(2+)-adenosinetriphosphatases (ATPases). Thapsigargin, inhibitor of sarcoplasmic reticulum Ca(2+)-ATPase, prevented the furazolidone-induced changes. These results demonstrate that furazolidone increases the activity of thapsigargin-sensitive Ca(2+)-ATPase without affecting Na+/Ca2+ exchange. These data enhance our understanding of the mechanism of furazolidone-induced injury in cardiac myocytes and may be useful in determining mechanisms of injury in dilated cardiomyopathy.

Myocardial lipid composition in turkeys with dilated cardiomyopathy.

OBJECTIVE: The aim was to determine if reduced heart lipid peroxidation in turkeys with two forms of dilated cardiomyopathy, previously reported, was related to an alteration in the lipid composition of the ventricle. METHODS: Myocardial lipid composition was measured in turkeys with two types of dilated cardiomyopathy. Twenty six turkeys with naturally occurring dilated cardiomyopathy, six with furazolidone induced dilated cardiomyopathy, and 18 age matched control birds were used at 1 day, 9-10 days, and 38-78 days of age. Left ventricular fatty acid composition of the phospholipid, triglyceride, free fatty acid, and cholesterol ester fractions was analysed using gas chromatography. RESULTS: Significant age related changes were identified in the fatty acid composition of the heart. In the phospholipid fraction, linoleic acid (18:2 omega 6) values increased with age, while arachidonic acid values decreased. The saturated to unsaturated fatty acid ratio in control hearts was unchanged as a function of age in the phospholipid fraction. In the triglyceride fraction, however, this ratio decreased substantially between newly hatched and nine day old birds and then markedly increased in two month old controls. There was a striking alteration in the saturated to unsaturated fatty acid ratio in the triglyceride fraction of 2 month old cardiomyopathic birds; this ratio was markedly increased in the furazolidone induced cardiomyopathic turkey hearts (5.14 v 2.79 in controls) and markedly diminished (ie, 0.97 to 1.21) in the spontaneously cardiomyopathic turkeys. A significant increase in myristic (14:0) and decrease in linoleic (18:2 omega 6) acid concentration in the furazolidone group v control and a marked decrease in myristic and increase in linoleic acid concentrations in the spontaneously cardiomyopathic group v controls was present. CONCLUSIONS: (1) There is an age related alteration in the fatty acid composition of control turkey hearts. (2) Previously identified reduced lipid peroxidation in furazolidone induced and spontaneous cardiomyopathy in turkeys does not appear to be related to reduced concentration of polyunsaturated fatty acids. (3) The two forms of dilated cardiomyopathy are associated with markedly disparate alterations in the concentration of polyunsaturated fatty acids in the triglyceride fraction of 1-2 month old turkey hearts. The changes may be related, in part, to the pathogenesis in these two different forms of dilated cardiomyopathy.

Effects of hydration on mitral valve prolapse.

We investigated the effect of hydration on mitral valve prolapse (MVP). Ten subjects with documented diagnosis of MVP were studied before and after oral hydration with 1 L of fluid. Increased weight and cardiac output were present after hydration. Results showed that all 10 subjects with diagnosis of MVP before hydration continued to have MVP after hydration; however, subtle changes were detected, especially on auscultation. Seven of 9 subjects (with cardiac examination recorded before and after hydration) had auscultatory findings of MVP before hydration. No detectable auscultatory change after hydration was present in one subject; in six subjects a loss of either a click or a murmur was detected after hydration. All subjects had echocardiographically detected MVP before hydration; evidence of MVP on two-dimensional or M-mode examination persisted after hydration in all 10 subjects. Minor changes in the echocardiographic examination (M-mode n = 2, Doppler n = 1) were detected in three subjects. Thus we found that hydration of subjects with MVP did not alter the overall diagnosis; however, changes occurred, especially on auscultation. This suggests that alterations in hydration may affect auscultatory expression of MVP and could explain, in part, the variable auscultatory findings in patients with MVP.

Mild dehydration induces echocardiographic signs of mitral valve prolapse in healthy females with prior normal cardiac findings.

This study was designed to investigate the hypothesis that mitral valve prolapse (MVP) can be induced after diuresis in women without the abnormality who have characteristic body habitus. Fifteen tall, slim, healthy female volunteers with a normal cardiac findings, echocardiogram, and history were investigated after mild diuresis with furosemide and after placebo. All subjects lost weight after furosemide and placebo administration; but mean weight loss was significantly greater after furosemide administration than after placebo administration. Echocardiography showed MVP in none of the 15 patients before treatment, in seven after administration of placebo, and in seven after administration of furosemide. Coaptation point prolapsed superior to the anulus in seven subjects with echocardiographically determined MVP. Left ventricular end-diastolic dimensions decreased significantly after placebo or furosemide administration in subjects in whom MVP developed compared with the measurement in those in whom MVP did not develop. Murmurs characteristic of MVP disappeared in all four rehydrated subjects and echocardiographic changes resolved in two of the five rehydrated subjects. Thus echocardiographically determined MVP can be induced by mild dehydration in women with phenotypic body habitus of MVP; changes may resolve with rehydration. Results suggest an explanation for variable physical examination findings in persons with MVP.

Generation of furazolidone radical anion and its inhibition by glutathione.

Furazolidone is a nitrofuran drug which causes dilated cardiomyopathy in turkeys and serves as an important model of human dilated cardiomyopathy. Although extensively investigated, the chemical mechanism by which furazolidone produces injury remains unknown. In this work we used electron paramagnetic resonance (EPR) spectroscopy to show that furazolidone was reduced to its corresponding nitro anion radical by ascorbate and hypoxanthine. Glutathione prevented the generation of this anion radical. These results document directly, with EPR spectroscopy, the presence of furazolidone anion radical during biochemical reduction and suggest a protective role of glutathione in furazolidone-induced injury. These data enhance our understanding of furazolidone metabolism and may be useful in defining its role in furazolidone-induced dilated cardiomyopathy.

Effects of salt restriction on renal growth and glomerular injury in rats with remnant kidneys.

Male Munich-Wistar rats underwent right nephrectomy and infarction of two thirds of the left kidney. Rats were randomly assigned to ingest standard chow (REM) or a moderately salt restricted chow (LS). A third group of rats were fed the low salt diet and were injected with an androgen (LSA). Eight weeks after ablation, glomerular volume and glomerular capillary radius were markedly increased in REM. This increase was prevented by the low salt diet, however, the antihypertrophic effect of the diet was overcome by androgen. Values for glomerular volume and capillary radius were similar in LSA and REM. Morphologic studies revealed that approximately 25% of glomeruli were abnormal in REM. Much less injury was observed in salt restricted rats, however, the protective effect of the low salt diet was significantly abrogated when renal growth was stimulated in salt restricted rats by androgen. Micropuncture studies revealed that glomerular pressure was elevated in all three groups and not affected by diet or androgen. Serum cholesterol was also similar in the three groups. These findings indicate that renal and glomerular hypertrophy are correlated with the development of glomerular injury after reduction in renal mass and suggest that dietary salt restriction lessens renal damage, at least in part, by inhibiting compensatory renal growth.

Anisodamine increases blood flow to the retina-choroid and protects retinal and pancreatic cells against lipid peroxidation.

This study investigated the effect of anisodamine (2 and 5 mg/kg i.v.) on ocular and systemic blood flow distribution in awake lambs using the radioactive microsphere technique. In separate in vitro studies, the effects of anisodamine (at final concentrations of 0.01 to 2.5 mg/ml) were determined on arachidonic acid, alloxan and ultraviolet radiation-induced lipid peroxidation of isolated retinal cells from rabbits and on alloxan-induced lipid peroxidation of hamster pancreatic islet beta cells. Malondialdehyde production was used as an index of lipid peroxidation and measured by the thiobarbituric acid method. Anisodamine preferentially increased blood flow and oxygen delivery to the retina-choroid and iris-ciliary body of the eye by 50-100%. Anisodamine significantly attenuated lipid peroxidation in retinal cells induced by ultraviolet radiation, alloxan and arachidonic acid by 17-50% and protected pancreatic beta cells against alloxan-induced lipid peroxidation. These properties may, in part, account for the beneficial effect of anisodamine in certain patients with diabetes.

Reduced heart lipid peroxidation precedes cardiac dilatation in turkeys with naturally occurring cardiomyopathy.

STUDY OBJECTIVE: The aim of the study was to determine if reduced heart lipid peroxidation in 1-2 month old turkeys with furazolidone induced dilated cardiomyopathy is drug related and model dependent, a non-specific characteristic of the dilated turkey heart, or if alterations of heart lipid peroxidation can occur prior to onset of cardiac dilatation, and therefore may be involved in its pathogenesis. DESIGN: Ventricular lipid peroxidation capacity and superoxide dismutase activity were measured in controls and in turkeys with spontaneous cardiomyopathy at various ages (newly hatched, 7-10 d, and 1-2 months) and stages of the disease. SUBJECTS: 46 turkeys with naturally occurring dilated cardiomyopathy and 29 age matched controls were used at hatch, 7-10 d, and 1-2 months of age. MEASUREMENTS AND MAIN RESULTS: Heart lipid peroxidation, measured by thiobarbituric acid reactive substances (malondialdehyde), was found to be reduced not only in the dilated hearts of 1-2 months old cardiomyopathic turkeys [114(SEM 10) v 176(21) nmol.100 mg-1 protein, p = 0.023] but also in the non-dilated hearts of 9-10 day old cardiomyopathic turkeys [135(17) v 274(35) nmol.100 mg-1 protein, p = 0.004]. Ventricular superoxide dismutase activity was similar in control and cardiomyopathic turkeys at all stages and there was the expected increase with age. In control turkeys ventricular superoxide dismutase activity in 1-2 month old birds, at 718(52) nitrite units.100 mg-1 protein, was significantly higher than values in 7-10 day old turkeys [398(31) nitrite units.100 mg-1 protein, p = 0.001]. CONCLUSIONS: Decreased lipid peroxidation capacity is present in the dilated hearts of spontaneously cardiomyopathic turkeys. However, it is also decreased in cardiomyopathic turkeys at 9-10 d (the time of highest mortality) prior to the onset of cardiac dilatation. Therefore, alterations in heart lipid composition may be involved in the pathogenesis of this cardiomyopathy and not simply a result of the cardiac dilatation/hypertrophy process.

Occult pulmonary artery associated with failure to thrive and recurrent pneumonia--a case report.

Occult pulmonary artery is an uncommon cardiovascular defect. Associated symptoms include recurrent pulmonary infections and congestive heart failure. The authors describe a one-year-old boy initially diagnosed as having broncho-pulmonary dysplasia who developed severe failure to thrive, recurrent pneumonias, and pulmonary hypertension. The presence of an occult right pulmonary artery was suspected by lung perfusion scan and diagnosed by cardiac catheterization and angiography. After surgical repair, his clinical course improved and his growth and development were normal. This case demonstrates the importance of including occult pulmonary artery in the differential diagnosis of infants with failure to thrive associated with recurrent pulmonary infection.

Reduced lipid peroxidation in dilated hearts of cardiomyopathic turkeys.

Adverse pulmonary reactions to some nitrofuran antibiotics are thought, in part, to involve production of reactive oxygen radicals. Furazolidone, a nitrofuran antibiotic, causes a dilated cardiomyopathy in domestic turkeys. The mechanism of this drug induced cardiomyopathy is unknown. We investigated the possible role of free radical injury in this heart failure model. Left ventricular lipid peroxidation capacity, assessed by two methods (the thiobarbituric acid reactive substances and lipid hydroperoxides assays respectively), was investigated in five 5-8 week old cardiomyopathic turkeys with severe cardiac dilatation, left ventricular dysfunction and systemic hypotension, and in five control birds. Superoxide dismutase activity, total and manganese, was also measured in the crude left ventricular homogenates. Both lipid peroxidation products were reduced in the myopathic hearts: thiobarbituric acid reactive substances (malondialdehyde) 70(SEM 4) v 86(3) nmol.100 mg protein-1 in controls, p less than 0.02; and lipid hydroperoxides 29(7) v 74(14) nmol.100 mg protein-1, p less than 0.02. Total superoxide dismutase activity was similar in cardiomyopathic and control hearts: 670(26) v 657(105) nitrite units.100 mg protein-1. Although total superoxide dismutase activity was unchanged, we found decreased manganese superoxide dismutase in the dilated hearts compared with controls (54% v 84% of total activity, p less than 0.02). In separate in vitro experiments furazolidone (2-10 mg.g wet weight-1) did not increase malondialdehyde production in turkey (or rat) left ventricular homogenates. These results indicate that cardiomyopathy induced by furazolidone is associated with decreased myocardial lipid peroxidation. Although as yet unexplained, the decrease may be due to a diminished amount of heart lipid susceptible to peroxidation accompanying the process of cardiac hypertrophy and dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)