Multiple left heart obstructions (Shone's anomaly) with mitral valve involvement: long-term surgical outcome.

BACKGROUND: The outcome of children with multilevel left heart obstructions (Shone's anomaly) is generally poor. Literature is scarce, consisting mainly of case reports. The mitral disease may be the predominant factor affecting outcome. METHODS: Surgical results in 19 consecutive patients are presented, with a median follow-up of 8 years. Mitral stenosis was present in all, with parachute deformity in 12 patients. Supramitral rings were found in 9 patients. Other features included subaortic stenosis (15 patients), valvar aortic stenosis (9), bicuspid aortic valve (16), and coarctation (13 patients). The patients underwent 46 surgical procedures, including 18 mitral operations (9 replacements, 9 repairs). RESULTS: There were three in-hospital (16%) and two late (10.5%) deaths. Of the 5 nonsurvivors, 4 patients (80%) had predominant mitral disease and moderate to severe pulmonary hypertension, versus 4 (28.5%) and 5 (36%) survivors, respectively (p = not significant). Valve repair was the final procedure in 9 survivors. The other 5 patients had repeated valve replacements (1), aortoventriculoplasty with valve replacements (2), or no mitral operation (2). Freedom from mitral reoperation was 78% (7 of 9 patients) after repair procedures and 43% (3 of 7 patients) after replacement. At follow-up, 10 patients (71.4%) are in New York Heart Association functional class I and the other 4 in class II and III. Six (43%) await reoperation due to recurrent aortic (4) or subaortic (1) stenosis and recoarctation (2). Echocardiography reveals mild mitral stenosis or regurgitation in 3 patients after repair (33%). Four are considered free of residual disease (21% of all). CONCLUSIONS: Late outcome in Shone's anomaly seems to correlate with the predominance of mitral valve involvement and the degree of pulmonary hypertension. Valve repair is indicated whenever feasible and should be considered before the occurrence of pulmonary hypertension.

Intracoronary adenovirus-mediated transfer of immunosuppressive cytokine genes prolongs allograft survival.

BACKGROUND: Intracoronary transfer and expression of recombinant genes in the intact heart is now feasible. In the transplant setting, local modulation of host immune responses by a genetically modified allograft may offer an attractive alternative to systemic immunosuppression. METHODS: We tested the efficacy and in vivo effect of intracoronary transfer of two immunosuppressive cytokine genes. First-generation E1-deleted adenoviral vectors expressing the Epstein-Barr virus interleukin-10 (AdSvIL10) or human transforming growth factor--beta 1 (AdCMVTGF-beta) were used. Rabbit cardiac allografts were transduced during cold preservation by slow (1 ml/min) intracoronary infusion of 10(10) pfu/gm diluted viral vectors and then implanted heterotopically. Controls included E1-deleted adenovirus (Ad5dI434) and AdCMVLacZ. Beating allografts were collected on day 4 for analysis of gene transfer efficacy and distribution. Additional grafts were used for evaluation of alloreactivity (n = 34). RESULTS: Mean allograft viral uptake was 81% (up to 91%). Polymerase chain reactions and reverse transcription-polymerase chain reactions confirmed the presence and expression of both genes in the grafts. beta-Galactosidase staining in AdCMVLacZ-infected grafts demonstrated efficient gene expression, which was highest (100%) in subepicardial regions. More homogeneous transmyocardial distribution of the transgene (in 25% to 40% of cells) could be achieved by pulsatile slow delivery. Allograft survival was 6.9 +/- 0.9 days in controls (n = 12), 11.1 +/- 1.7 days in AdCMVTGF-beta-infected grafts (n = 11, p < 10(-4)), and 11.2 +/- 3 days in AdSvIL10-infected grafts (n = 11, p < 10(-4)). Histologic scores (blinded) showed significantly (p < 0.005) higher regression coefficients for rejection in controls compared with both cytokine-transduced groups. Perioperative administration of cyclosporine A (INN: ciclosporin) to recipients had no effect on survival of AdCMVTGF-beta-infected grafts but reduced survival of AdSvIL10-infected grafts. CONCLUSIONS: Intracoronary gene transfer of immunosuppressive cytokines to cardiac allografts is efficient and effectively prolongs graft survival. Vectors that would induce long-term expression of such genes may make this approach clinically applicable.

Recovery from Photoinhibition in Peas (Pisum sativum L.) Acclimated to Varying Growth Irradiances (Role of D1 Protein Turnover).

D1 protein turnover and restoration of the photochemical efficiency of photosystem II (PSII) after photoinhibition of pea leaves (Pisum sativum L. cv Greenfeast) acclimated to different light intensities were investigated. All peas acclimated to different light intensities were able to recover from photoinhibition, at least partially, at light intensities far above their growth light irradiance. However, the capacity of pea leaves to recover from photoinhibition under increasing high irradiances was strictly dependent on the light acclimation of the leaves; i.e. the higher the irradiance during growth, the better the capacity of pea leaves to recover from photoinhibition at moderate and high light. In our experimental conditions, mainly D1 protein turnover-dependent recovery was monitored, since in the presence of an inhibitor of chloroplast-encoded protein synthesis, lincomycin, only negligible recovery took place. In darkness, neither the restoration of PSII photochemical efficiency nor any notable degradation of damaged D1 protein took place. In low light, however, good recovery of PSII occurred in all peas acclimated to different light intensities and was accompanied by fast degradation of the D1 protein. The rate of degradation of the D1 protein was estimated to be 3 to 4 times faster in photoinhibited leaves than in nonphotoinhibited leaves under the recovery conditions of 50 [mu]mol of photons m-2 s-1. In moderate light of 400 [mu]mol of photons m-2 s-1, the photoinhibited low-light peas were not able to increase further the rate of D1 protein degradation above that observed in nonphotoinhibited leaves, nor was the restoration of PSII function possible. On the other hand, photoinhibited high-light leaves were able to increase the rate of D1 protein degradation above that of nonphotoinhibited leaves even in moderate and high light, ensuring at least partial restoration of PSII function. We conclude that the capacity of photoinhibited leaves to restore PSII function at different irradiances was directly related to the capacity of the leaves to degrade damaged D1 protein under the recovery conditions.

Turnover of the photosystem II D1 protein in higher plants under photoinhibitory and nonphotoinhibitory irradiance.

The turnover in vivo of the Photosystem II (PS II) reaction center D1 protein was investigated by [35S] methionine labeling of leaf discs of Brassica napus and subsequent analysis after thylakoid SDS-gel electrophoresis. The rate of D1 protein degradation was found to have a t1/2 of approximately 2 h, at an irradiance corresponding to the growth irradiance. The rate of D1 protein degradation was not increased further by prior photoinhibitory treatment which inactivated 40% of the PS II centers, but the amount of [35S]methionine label incorporated into the D1 protein during 1 h was increased 3-fold. Whether photoinhibited or not, the incorporation of label into the D1 protein increased with irradiance only up to approximately the growth irradiance and above that it decreased with increasing incident light. These data indicate that a high rate of D1 protein degradation occurs not only after photoinhibition but also under conditions where no net decrease in the number of functional PS II centers occurs and that the number of PS II centers that undergo D1 protein turnover varies depending on prior photoinhibitory damage and on incident irradiance. A down-regulation of PS II in leaves at high irradiances is discussed.

Photoinhibition and D1 Protein Degradation in Peas Acclimated to Different Growth Irradiances.

The relationship between the susceptibility of photosystem II (PSII) to photoinhibition in vivo and the rate of degradation of the D1 protein of the PSII reaction center heterodimer was investigated in leaves from pea plants (Pisum sativum L. cv Greenfeast) grown under widely contrasting irradiances. There was an inverse linear relationship between the extent of photoinhibition and chlorophyll (Chl) a/b ratios, with low-light leaves being more susceptible to high light. In the presence of the chloroplast-encoded protein synthesis inhibitor lincomycin, the differential sensitivity of the various light-acclimated pea leaves to photoinhibition was largely removed, demonstrating the importance of D1 protein turnover as the most crucial mechanism to protect against photoinhibition. In the differently light-acclimated pea leaves, the rate of D1 protein degradation (measured from [35S]methionine pulse-chase experiments) increased with increasing incident light intensities only if the light was not high enough to cause photoinhibition in vivo. Under moderate illumination, the rate constant for D1 protein degradation corresponded to the rate constant for photoinhibition in the presence of lincomycin, demonstrating a balance between photodamage to D1 protein and subsequent recovery, via D1 protein degradation, de novo synthesis of precursor D1 protein, and reassembly of functional PSII. In marked contrast, in light sufficiently high to cause photoinhibition in vivo, the rate of D1 protein degradation no longer increased concomitantly with increasing photoinhibition, suggesting that the rate of D1 protein degradation is playing a regulatory role. The extent of thylakoid stacking, indicated by the Chl a/b ratios of the differently light-acclimated pea leaves, was linearly related to the half-life of the D1 protein in strong light. We conclude that photoinhibition in vivo occurs under conditions in which the rate of D1 protein degradation can no longer be enhanced to rapidly remove irreversibly damaged D1 protein. We suggest that low-light pea leaves, with more stacked membranes and less stroma-exposed thylakoids, are more susceptible to photoinhibition in vivo mainly due to their slower rate of D1 protein degradation under sustained high light and their slower repair cycle of the photodamaged PSII centers.

Mechanistic differences in photoinhibition of sun and shade plants.

Leaf discs of the shade plant Tradescantia albiflora Kunth grown at 50 µmol · m(-2) · s(-1), and the facultative sun/shade plant Pisum sativum L. grown at 50 or 300 µmol · m(-2), s(-1), were photoinhibited for 4 h in 1700 µmol photons m(-2) · s(-1) at 22° C. The effects of photoinhibition on the following parameters were studied: i) photosystem II (PSII) function; ii) amount of D1 protein in the PSII reaction centre; iii) dependence of photoinhibition and its recovery on chloroplast-encoded protein synthesis; and, iv) the sensitivity of photosynthesis to photoinhibition in the presence or absence of the carotenoid zeaxanthin. We show that: i) despite different sensitivities to photoinhibition, photoinhibition in all three plants occurred at the reaction centre of PSII; ii) there was no correlation between the extent of photoinhibition and the degradation of the D1 protein; iii) the susceptibility to photoinhibition by blockage of chloroplas-tencoded protein synthesis was much less in shade plants than in plants acclimated to higher light; and iv) inhibition of zeaxanthin formation increased the sensitivity to photoinhibition in pea, but not in the shade plant Tradescantia. We suggest that there are mechanistic differences in photoinhibition of sun and shade plants. In sun plants, an active repair cycle of PSII replaces photoinhibited reaction centres with photochemically active ones, thereby conferring partial protection against photoinhibition. However, in shade plants, this repair cycle is less important for protection against photoinhibition; instead, photoinhibited PSII reaction centres may confer, as they accumulate, increased protection of the remaining connected, functional PSII centres by controlled, nonphotochemical dissipation of excess excitation energy.