Atypical tamponade hemodynamic in a patient with temporary left ventricular assist device.

Postoperative bleeding and tamponade are considered major complications after implantation of left ventricular assist devices. Firstly, 40% of patients supported by ventricular assist devices experience early postoperative bleeding, and 20% developed tamponade requiring re-exploration. Secondly, we present a case of a patient with tamponade, on temporary left ventricular assist device (LVAD) support with atypical hemodynamic and echocardiographic manifestations demonstrated with computed tomography (CT)-M mode, conventional Doppler, color Doppler and echo imaging.

Focused review on transthoracic echocardiographic assessment of patients with continuous axial left ventricular assist devices.

Left ventricular assist devices (LVADs) are systems for mechanical support for patients with end-stage heart failure. Preoperative, postoperative and comprehensive followup with transthoracic echocardiography has a major role in LVAD patient management. In this paper, we will present briefly the hemodynamics of axial-flow LVAD, the rationale, and available data for a complete and organized echocardiographic assessment in these patients including preoperative assessment, postoperative and long-term evaluation.

Echocardiographic findings in stable outpatients with properly functioning HeartMate II left ventricular assist devices.

BACKGROUND: Continuous-flow left ventricular assist devices (LVADs) have become part of the standard of care for the treatment of advanced heart failure. However, knowledge of normal values for transthoracic echocardiographic examination and measurements in these patients are lacking. METHODS: All transthoracic echocardiographic examinations in 63 consecutive patients, performed 90 and 180 days after surgery with the implantation of a HeartMate II continuous-flow LVAD between February 2007 and January 2010, were retrospectively analyzed. All patients had to be outpatients at 3 and 6 months after surgery and considered stable on LVAD therapy (New York Heart Association class I or II and no need for inotropes, intravenous furosemide, or hospitalization). RESULTS: End-diastolic and end-systolic diameters and left ventricular mass decreased considerably compared with baseline measurements before LVAD implantation. Mitral inflow deceleration time increased (188 ± 70 vs 132.5 ± 27 msec, P = .009) and left atrial volume (84.1 ± 33 vs 141.7 ± 62 mL, P = .003) and E/e' ratio decreased (20.3 ± 9 vs 26 ± 11, P = .01), all consistent with decreased left ventricular filling pressure. Estimated right ventricular (RV) and right atrial pressure decreased significantly (34.1 ± 10 vs 51.7 ± 14 mm Hg and 9.5 ± 5 vs 14.4 ± 5 mm Hg, respectively, P < .0001 for both). Quantitatively estimated RV function (P = .02), RV fractional area change (27.9 ± 10% vs 37.4 ± 10.9%, P < .0001), and the RV index of myocardial performance (0.32 ± 0.1 vs 0.65 ± 0.2 vs 0.32 ± .01, P < .0001) improved, suggesting improved RV efficiency. LVAD therapy resulted in significant decreases in the severity of mitral regurgitation. Tricuspid regurgitation improved in patients who had concurrent tricuspid surgical correction and was unchanged otherwise. Aortic regurgitation severity increased 3 months after LVAD implantation. There were no significant differences in any of the echocardiographic parameters in the 6-month evaluation compared with the 3-month evaluation. CONCLUSIONS: This is the first report of selected typical echocardiographic values in a group of stable patients with normally functioning HeartMate II continuous-flow LVADs. A stable functioning continuous LVAD is associated with evidence of efficient unloading of the left ventricle, improved RV function, significant improvement in mitral regurgitation, improvement in tricuspid regurgitation only in patients undergoing repair, and increased aortic regurgitation. These normal data provide a basis for future echocardiographic studies after LVAD implantation.

Impairment of diaphragm muscle force and neuromuscular transmission after normothermic cardiopulmonary bypass: effect of low-dose inhaled CO.

Cardiopulmonary bypass (CPB) is associated with significant postoperative morbidity, but its effects on the neuromuscular system are unclear. Recent studies indicate that even relatively short periods of mechanical ventilation result in significant neuromuscular effects. Carbon monoxide (CO) has gained recent attention as therapy to reduce the deleterious effects of CPB. We hypothesized that 1) CPB results in impaired neuromuscular transmission and reduced diaphragm force generation; and 2) CO treatment during CPB will mitigate these effects. In adult male Sprague-Dawley rats, diaphragm muscle-specific force and neuromuscular transmission properties were measured 90 min after weaning from normothermic CPB (1 h). During CPB, either low-dose inhaled CO (250 ppm) or air was administered. The short period of mechanical ventilation used in the present study ( approximately 3 h) did not adversely affect diaphragm muscle contractile properties or neuromuscular transmission. CPB elicited a significant decrease in isometric diaphragm muscle-specific force compared with time-matched, mechanically ventilated rats ( approximately 25% decline in both twitch and tetanic force). Diaphragm muscle fatigability to 40-Hz repetitive stimulation did not change significantly. Neuromuscular transmission failure during repetitive activation was 60 +/- 2% in CPB animals compared with 76 +/- 4% in mechanically ventilated rats (P < 0.05). CO treatment during CPB abrogated the neuromuscular effects of CPB, such that diaphragm isometric twitch force and neuromuscular transmission were no longer significantly different from mechanically ventilated rats. Thus, CPB has important detrimental effects on diaphragm muscle contractility and neuromuscular transmission that are largely mitigated by CO treatment. Further studies are needed to ascertain the underlying mechanisms of CPB-induced neuromuscular dysfunction and to establish the potential role of CO therapy.

A role for Pin1 in mammalian germ cell development and spermatogenesis.

The peptidyl-prolyl isomerase Pin1 is proposed to have diverse functions in many vital aspects of the cell. Despite the multitude of proteins targeted by Pin1 and the proposed regulatory role it plays in critical cellular functions, Pin1 is an essential gene in some eukaryotic organisms, but is dispensable in metazoans. In two genetic models, Candida albicans and Drosophila melanogaster, Pin1 participates in distinct developmental processes regulated by the MAPK pathway. Pin1-deficient mice exhibit decreased primordial germ cell proliferation during embryonic development, along with several degenerative or proliferative defects in the adult testis, retina, mammary gland, and brain. The combination of primordial germ cell deficit and spermatogonial depletion contributes to severe fertility defects in Pin1-null mice. Since growth factor activated MAPK pathways are vital to germ cell proliferation and differentiation, a role for Pin1 in mammalian germ cell development and spermatogenesis is discussed in the context of the Ras/MEK/MAPK pathway.

Spermatogonial depletion in adult Pin1-deficient mice.

Spermatogonia in the mouse testis arise from early postnatal gonocytes that are derived from primordial germ cells (PGCs) during embryonic development. The proliferation, self-renewal, and differentiation of spermatogonial stem cells provide the basis for the continuing integrity of spermatogenesis. We previously reported that Pin1-deficient embryos had a profoundly reduced number of PGCs and that Pin1 was critical to ensure appropriate proliferation of PGCs. The current investigation aimed to elucidate the function of Pin1 in postnatal germ cell development by analyzing spermatogenesis in adult Pin1-/- mice. Although Pin1 was ubiquitously expressed in the adult testis, we found it to be most highly expressed in spermatogonia and Sertoli cells. Correspondingly, we show here that Pin1 plays an essential role in maintaining spermatogonia in the adult testis. Germ cells in postnatal Pin1-/- testis were able to initiate and complete spermatogenesis, culminated by production of mature spermatozoa. However, there was a progressive and age-dependent degeneration of the spermatogenic cells in Pin1-/- testis that led to complete germ cell loss by 14 mo of age. This depletion of germ cells was not due to increased cell apoptosis. Rather, detailed analysis of the seminiferous tubules using a germ cell-specific marker revealed that depletion of spermatogonia was the first step in the degenerative process and led to disruption of spermatogenesis, which resulted in eventual tubule degeneration. These results reveal that the presence of Pin1 is required to regulate proliferation and/or cell fate of undifferentiated spermatogonia in the adult mouse testis.

Pin1 regulates the timing of mammalian primordial germ cell proliferation.

Primordial germ cells (PGCs) give rise to male and female germ cells to transmit the genome from generation to generation. Defects in PGC development often result in infertility. In the mouse embryo, PGCs undergo proliferation and expansion during and after their migration to the gonads from 8.5 to 13.5 days post coitum (dpc). We show that a peptidyl-prolyl isomerase, Pin1, is involved in the regulation of mammalian PGC proliferation. We discovered that both the male and female Pin1(-/-) mice had profound fertility defects. Investigation of the reproductive organs revealed significantly fewer germ cells in the adult Pin1(-/-) testes and ovaries than in wild type or heterozygotes, which resulted from Pin1(-/-) males and females being born with severely reduced number of gonocytes and oocytes. Further studies in 8.5 to 13.5 dpc Pin1(-/-) embryos showed that PGCs were allocated properly at the base of the allantois, but their cell expansion was progressively impaired, resulting in a markedly reduced number of PGCs at 13.5 dpc. Analyses using markers of cell cycle parameters and apoptosis revealed that Pin1(-/-) PGCs did not undergo cell cycle arrest or apoptosis. Instead, Pin1(-/-) PGCs had a lower BrdU labeling index compared with wild-type PGCs. We conclude that PGCs have a prolonged cell cycle in the absence of Pin1, which translates into fewer cell divisions and strikingly fewer Pin1(-/-) PGCs by the end of the proliferative phase. These results indicate that Pin1 regulates the timing of PGC proliferation during mouse embryonic development.