Transhepatic venous approach to permanent pacemaker placement in a patient with limited central venous access.

The end-stage renal disease population poses a challenge for obtaining venous access required for life-saving invasive cardiac procedures. In this case report, we describe an adult patient with end-stage renal disease in whom the hepatic vein was the only available access to implant a single-lead permanent cardiac pacemaker. A 63-year-old male with end-stage renal disease on maintenance hemodialysis and permanent atrial fibrillation/atrial flutter presented with symptomatic bradycardia. Imaging studies revealed all traditional central venous access sites to be occluded/non-accessible. With the assistance of vascular interventional radiology, a trans-hepatic venous catheter was placed. This was then used to place a right ventricular pacing lead with close attention to numerous technical aspects. The procedure was completed successfully with placement of a single-lead permanent cardiac pacemaker.

Urotensin II alters vascular reactivity in animals subjected to volume overload.

Congestive heart failure (CHF) alters vascular reactivity and up regulates in urotensin II (UTII), a potent vasoactive peptide. The aim of this study was to investigate the interaction between CHF and UTII in altering vascular reactivity in a rat model of volume overload heart failure. Animals were divided into 4 groups: control, UTII infused (UTII), volume overload only (VO) or volume overload+UTII (VO+UTII). Volume overload was established by the formation of an aortocaval fistula. Following fistula formation animals were administered UTII at a rate of 300 pmol/kg/h for 4 weeks subcutaneously with mini-osmotic pumps. Thoracic aorta rings, with/without endothelium, were subjected to cumulative dose-responses to phenylephrine, sodium nitroprusside (SNP), acetylcholine (ACH), UTII, and the Rho-kinase inhibitor HA-1077. Aortas from VO animals exhibited increased sensitivity to phenylephrine and UTII with a decreased relaxation response to ACH and HA-1077. Aortas from animals subjected to chronic UTII with volume overload (VO + UTII) retained their sensitivity to phenylephrine and UTII while they improved their relaxation to HA-1077 but not ACH. The constrictive response to UTII was dose-dependent and augmented at concentrations <0.01 µM in VO animals. The changes in vascular reactivity paralleled an elevation of both the UTII and α(1A)-adrenergic receptor while the Rho and Rho-kinase signalling proteins were diminished. We found that volume overload increased sensitivity to the vasoconstrictor agents that was inversely related to changes in the Rho-kinase expression. The addition of UTII with VO reversed the constrictive vascular response through alterations in the Rho-kinase signalling pathway.

PPAR-gamma expression in animals subjected to volume overload and chronic Urotensin II administration.

Activation of PPAR-gamma through the administration of glitazones has shown promise in preserving function following cardiac injury, although recent evidence has suggested their use may be contraindicated in the case of severe heart failure. This study tested the hypothesis that PPAR-gamma expression increases in a time dependent manner in response to chronic volume overload (VO) induced heart failure. Additionally, we attempted to determine what effect 4 week administration of Urotensin II (UTII) may have on PPAR-gamma expression. VO induced heart failure was produced in Sprague-Dawley rats (n=32) by aorta-caval fistula. Animals were sacrificed at 1, 4, and 14 weeks following shunt creation. In a separate set of experiments, animals were administered 300 pmol/kg/h of UTII for 4 weeks, subjected to 4 weeks of volume overload, or given UTII+VO. Densitometric analysis of left ventricular (LV) protein demonstrated PPAR-gamma expression was significantly ((*)p<0.05) upregulated at 4 and 14 weeks (31.5% and 37%, respectively) post-fistula formation compared to control values. PPAR-gamma activation was decreased in the 4 and 14 week (39.16% and 42.4%, respectively), but not in the 1-week animals, and these changes did not correlate with NF-kappaB activity. Animals given UTII either with or without VO demonstrated increased expression of PPAR-gamma as did animals subjected to 4 week VO alone. Animals given UTII either with or without VO had decreased activity vs. control. These data suggest PPAR-gamma may play a role in the progression of heart failure, however, the exact nature has yet to be determined.

Hemodynamic effects of chronic urotensin II administration in animals with and without aorto-caval fistula.

Urotensin II (UTII) is a potent vasoactive peptide. Recent studies have demonstrated increased expression of both UTII and its receptor (UTR) expression in end-stage congestive heart failure (CHF), but it is unclear whether UTII and UTR are late stage markers of decompensation, or earlier adaptive responses. The purpose of this study was to measure the effects of chronic UTII administration in normal and volume overloaded animals. Chronic 4 weeks administration of UTII produced decreases in hemodynamic function in animals not subjected to volume overload while returning function to control levels in animals with overload. Expression levels of calcium regulatory proteins phospholamban (PLN), sarcoplasmic reticulum Ca(2+) ATPase (SERCA2), and Na(+)/Ca(2+) exchanger (NCX) were measured to determine if administration of UTII resulted in aberrant Ca(2+) handling. Changes in protein expression revealed that UTII influenced Ca(2+) handling proteins in normal animals although these changes are not seen in the volume overload.

PPAR-gamma agonists induce the expression of VEGF and its receptors in cultured cardiac myofibroblasts.

OBJECTIVES: Myofibroblasts (myoFb) are the major cell types that appear at the site of myocardial infarction (MI) in response to injury and play a vital role in tissue repair/remodeling. Since vascular endothelial growth factor (VEGF) plays a crucial role in the infarcted/ischemic heart, we hypothesized that activation of the peroxisome proliferator-activated receptor (PPAR)-gamma by its agonists induces VEGF expression while simultaneously decreasing inflammation (NF-kappaB). Such an increase in myoFb VEGF expression by PPAR-gamma agonists may play a role in angiogenesis. METHODS: Rat myoFb were treated with PPAR-gamma agonists and VEGF expression was measured by ELISA. The effect of these agonists on VEGF receptors was determined by qRT-PCR and flow-cytometric analysis. VEGF produced by these cells was also used for analysis of in vitro tubule formation (Matrigel assay). RESULTS: The PPAR-gamma activators troglitazone (TZ) and 15-deoxy-prostaglandin J2 (15J2) induced the expression of VEGF and its receptors (Flt-1 and KDR) in myoFb. TZ and 15J2 elicited a significant increase in the expression of KDR (14.7+/-1.0% and 9.6+/-2.1% respectively) and Flt-1 (24.5+/-2.0%, and 14.0+/-2.2% respectively) when compared to untreated myoFb. MyoFb treated with PPAR-gamma agonists increased extracellular VEGF, augmenting tubule formation on a Matrigel. The PPAR-gamma activator 15J2 significantly decreased the NF-kappaB activity in myoFb. CONCLUSION: This study demonstrates the induction of the VEGF accompanied by a reduction of NF-kappaB activity (inflammatory signaling) by PPAR-gamma agonists in cardiac myoFb. These results may further the understanding of the beneficial effects of PPAR-gamma agonists on infarcted tissue repair and angiogenesis.

Comparison of measured and predicted residual lung volume in determining body composition of collegiate wrestlers.

This investigation compared percent fat obtained via underwater weighing using measured and predicted residual lung volume (RLV) in euhydrated and hypohydrated collegiate wrestlers (N = 67). RLV was measured using O(2) rebreathing or O(2) dilution and predicted using 3 equations-Equation 1: (0.019 x height [cm]) + (0.0115 x age [years]) - 2.24; Equation 2: (0.017 x age [years]) + (0.06858 x height [in.]) - 3.477; and Equation 3: (0.0275 age [years]) + (0.0189 height [cm]) - 2.6139. Percent fat determined using RLV Equation 2 did not differ from the value obtained using measured RLV in the euhydrated (10.9 +/- 5.1 vs. 11.5 +/- 5.6% fat) or hypohydrated (10.8 +/- 5.1 vs. 12.3 +/- 5.6% fat) trials. All other percent fat values differed (p < 0.05) from the value obtained using measured RLV in euhydrated subjects. The use of RLV Equation 2 may be a practical alternative to measured RLV in determining percent fat in euhydrated and hypohydrated collegiate wrestlers.

Evaluation of air displacement for assessing body composition of collegiate wrestlers.

PURPOSE: To evaluate the accuracy of air displacement plethysmography (ADP) by using the BOD POD in comparison with hydrostatic weighing (HW) in a collegiate wrestling population in hydrated and acutely dehydrated states. METHODS: Body composition was determined by ADP, HW, and three-site skinfolds (SK) in 66 NCAA Division I collegiate wrestlers before and after acute dehydration (2.6% reduction in body mass). For all methods, body density (D(b)) was converted to percent body fat (%BF) by using the Brozek equation for Euro-Americans and the Schutte equation for African-Americans. RESULTS: There were no significant differences between ADP and HW for D(b), %BF, and fat-free mass (FFM) in either the hydrated or dehydrated states. The standard errors of the estimate for %BF estimated from ADP with HW as the reference method were 2.12% (hydrated) and 2.16% (dehydrated); prediction errors were 2.35% (hydrated) and 2.49% (dehydrated). Bland-Altman plots of D(b) and %BF showed no systematic bias, and 64 out 66 subjects fell within the 95% limits of agreement (mean difference +/- 2 SD) for both variables. For SK, %BF was significantly higher than HW in both the hydrated and dehydrated state. All methods (ADP, HW, and SK) showed a significant decrease in FFM from the hydrated to the dehydrated state. CONCLUSIONS: This study demonstrates that the BOD POD air displacement method provides similar estimates of D (b), %BF, and FFM when compared with HW in a heterogeneous collegiate wrestling population during hydrated and acutely dehydrated states. Pretest guidelines to ensure normal hydration status before body composition assessment using any method must be followed to minimize measurement error in %BF.