Myocardial preservation during coronary surgery with and without cardiopulmonary bypass.

BACKGROUND: There is increased interest in coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), although the preservation of the myocardium under such circumstances has not been properly investigated. The aim of this randomized study was to compare the changes in myocardial metabolism during CABG with and without CPB. METHODS: Myocardial energy metabolism and tissue injury during CABG was monitored in a series of 22 patients (11 with and 11 without CPB). RESULTS: The maximum myocardial lactate production was significantly higher (p = 0.02) in the group operated with CPB (0.56 mmol/L) than without it (0.17 mmol/L). A similar phenomenon was seen in the transcardiac pH differences (0.085 and 0.034 with and without CPB, p = 0.007). The postoperative peak values of creatine kinase-MB mass (15.1 vs 6.3 microg/L) and troponin I (13.8 vs 5.2 microg/L) were significantly higher (p < 0.001 and p = 0.008) with than without CPB. CONCLUSIONS: CABG on a beating heart is associated with better myocardial energy preservation and less myocardial damage compared with conventional CABG with CPB and intermittent antegrade mild hypothermic blood cardioplegia.

Myocardial metabolism and hemodynamics during coronary surgery without cardiopulmonary bypass.

BACKGROUND: Although renewed interest has recently been shown in coronary artery bypass grafting without cardiopulmonary bypass, no reports are available on myocardial metabolism and hemodynamics during temporary coronary occlusion and rotation of the contracting heart. METHODS: Changes in myocardial energy metabolism and hemodynamics were monitored in 12 patients undergoing elective coronary artery bypass grafting without cardiopulmonary bypass, and the postoperative efflux of creatine kinase-MB mass and troponin T were also determined. RESULTS: There was a significant increase in myocardial production of ATP degradation products (p = 0.026) and lactate (p = 0.004) during the operation. Myocardial oxygen extraction decreased (p = 0.012) in correlation with use of the short-acting beta-blocker, esmolol (r = -0.71). Apart from a decrease in mean arterial blood pressure (p = 0.002), there were no significant hemodynamic changes during the operation. The overall postoperative troponin T and creatine kinase-MB mass changes remained nonsignificant during the first two postoperative days. One patient had a myocardial infarction, diagnosed by electrocardiography, on the second postoperative day, but otherwise there were no major complications. CONCLUSIONS: Coronary artery bypass grafting without cardiopulmonary bypass seems to be well tolerated as only minor changes in myocardial energy metabolism and hemodynamics are observed during the operation.

Myocardial protection during antegrade versus retrograde cardioplegia.

BACKGROUND: It has been suggested that the right ventricular myocardium is suboptimally protected during retrograde blood cardioplegia. METHODS: Twenty patients undergoing an elective coronary bypass procedure were randomized to receive antegrade or retrograde mild hypothermic blood cardioplegia. Transventricular differences in oxygen extraction, lactate production, and pH were monitored during aortic cross-clamping, and myocardial biopsy specimens were taken from both ventricles before cannulation and 15 minutes after aortic declamping for analysis of adenine nucleotides and their breakdown products. The extent of myocardial injury was estimated by monitoring postoperative leakage of troponin T and the MB isoenzyme of creatine kinase. Hemodynamic recovery and postoperative complications were noted. RESULTS: The preoperative characteristics of the two groups were similar. Oxygen extraction and lactate production in the right ventricular myocardium were higher in the retrograde group. In this group, the right ventricle also extracted more oxygen and produced more lactate and acid than did the left ventricle. Tissue levels of adenine nucleotides tended to decrease in both ventricles during operation, with no differences between them. The level of adenosine catabolites did increase somewhat in the right ventricular myocardium of the retrograde cardioplegia group after aortic declamping. There was a tendency for more prominent efflux of troponin T and the MB isoenzyme of creatine kinase in the retrograde group. Nevertheless, the postoperative course was uneventful in both groups. CONCLUSIONS: Retrograde mild hypothermic blood cardioplegia leads to metabolic changes compatible with right ventricular ischemia. Nevertheless, tissue levels of high-energy phosphates are well preserved, and the postoperative course seems to be unproblematic. Care should be taken when retrograde normothermic blood cardioplegia is provided for patients with right ventricular hypertrophy, poor right ventricular function, or severe preoperative myocardial ischemia.

Normothermic retrograde blood cardioplegia with or without preceding ischemic preconditioning.

BACKGROUND: Preconditioning has been suggested as the most powerful mechanism of myocardial protection against prolonged ischemia. However, whether preconditioning offers additional benefits over cardioplegia during coronary artery bypass grafting is not known. METHODS: Thirty patients undergoing coronary artery bypass grafting were randomized into two groups. After aortic cross-clamping, group 1 received antegrade blood and blood cardioplegia followed by normothermic retrograde blood cardioplegia (controls), whereas group 2 patients were subjected to 5 minutes of global ischemia followed by reperfusion with antegrade and retrograde blood cardioplegia (preconditioned). The transcardiac differences in oxygen saturation, pH, and lactate were measured during cardiopulmonary bypass. Myocardial biopsy specimens were taken from half of the patients for adenosine triphosphate determination. The extent of myocardial injury was estimated by monitoring the postoperative leakage of creatine kinase-MB and troponin T. Immediate hemodynamic recovery and postoperative complications were also observed. RESULTS: The 5-minute preconditioning induced marked lactate and acid production, and myocardial adenosine triphosphate levels tended to decrease. The heart continued to produce lactate and acid during retrograde cardioplegia, but the transcardiac pH and lactate differences were similar in both groups. Adenosine triphosphate level measured at the end of the cross-clamp period was decreased to a half and one third of the preclamp values in the control and preconditioned groups, respectively. The postoperative creatine kinase-MB and troponin T effluxes tended to be more elevated in the preconditioned group, yet hemodynamic recovery and the number of postoperative complications were similar in both groups. CONCLUSIONS: The results show that a 5-minute preconditioning ischemia does not offer any additional benefits over normothermic retrograde blood cardioplegia during coronary artery bypass grafting.

Sublingual triazolam versus peroral diazepam as a premedication for general anaesthesia.

Sublingual triazolam 0.2 mg (T) was compared with peroral diazepam 10 mg (D) as a premedicant in a randomised, double-blind study. Eighty-one ASA I-III patients aged 18-70 yr, scheduled for elective surgery and general anaesthesia were studied. The patients were premedicated about one hour preoperatively. The T-group subjects (n = 41) received triazolam sl after a placebo po and the D-group subjects (n = 40) diazepam po before a sl placebo. Anxiety and sedation were evaluated before premedication, every 15 min after that until the patient was removed to the operating room, just before the induction of anaesthesia and both 30 and 60 min after operation. Anxiety and sedation were evaluated by the patient using a visual analogue scale (VAS) and by the anaesthetist with a scale of 0-3 for anxiety and 0-4 for sedation. The patients' experience with regards to their premedication and visit to the operating unit were investigated after the operation. In both groups sedation and anxiolysis became different at 30-45 min after premedication, but at the time just before the induction of anaesthesia there was sedation and anxiolysis only in the T-group. There was no difference between the groups at any time. The T-group patients were more satisfied with their premedication and visit to the operating unit. The study drugs did not cause any cardiorespiratory or other side effects. We conclude that triazolam 0.2 mg sl is at least as effective a premedication as diazepam 10 mg po, that is suitable for patients that cannot swallow, and that the patients were more satisfied with it than with diazepam.

Efflux of adenosine and total adenylate catabolites during alterations of the cellular energy state. An NMR study of continuous and discontinuous ischemia.

Reperfusion after continuous or discontinuous ischemia has a bearing on clinical interventions. An important question is the washout of metabolites after periods of diminished energy state of the myocardial cell. We therefore set out to determine the washout of adenosine and its metabolites after periods of ischemia in an experimental set-up which allowed non-destructive monitoring of the cellular energy state and cytosolic pH over consecutive time intervals. Isolated rat hearts were perfused with hemoglobin-free saline in a nuclear magnetic resonance spectrometer equipped for 31P NMR spectroscopy of phosphorus-containing metabolites, which could be measured over 3-min time blocks. The response of the heart when subjected to 18 min of continuous ischemia and subsequent reperfusion was compared with that when subjected to three 6-min periods of ischemia separated by 3-min periods of reperfusion. The mechanical performance of the hearts, oxygen consumption and efflux of adenosine and its metabolites were measured. The consecutive ischemic periods produced no evidence of preconditioning as judged from the cellular energy state, although the mechanical recovery was better than after continuous ischemia. During the repetitive ischemia/reperfusion protocol the efflux of adenosine was smaller, although the efflux of combined adenylate catabolites did not differ from that after continuous ischemia. The results do not support the view of adenosine being a major effector in the phenomenon of preconditioning.

Adenosine inhibits the release of atrial natriuretic peptide from the perfused rat heart.

The effect of adenosine on atrial natriuretic peptide (ANP) release was studied in the perfused rat heart model. Adenosine had no effect on the heart rate of the spontaneously beating heart at a concentration of 1 microM, whereas at concentrations of 10 and 100 microM it dose-dependently decreased the frequency by 17 and 55% (P < 0.05 and P < 0.001, respectively). In the spontaneously beating hearts, immunoreactive ANP release was inhibited by adenosine at concentrations of 10 and 100 microM (P < 0.05 and P < 0.01). When heart rate was maintained constant by external pacing, inhibition of ANP release was observed only with 100 microM adenosine (P < 0.01). The results show that adenosine dose-dependently inhibits ANP release from the perfused rat heart. The effect of adenosine on ANP release was partially due to its negative chronotropic effect but the results suggest that adenosine may also have a direct inhibitory effect on ANP release in atrial myocardium.

5'-Nucleotidase activity and adenosine production in rat liver mitochondria.

The controversial subject of mitochondrial 5'-nucleotidase in the liver was studied employing density gradient fractionation combined with a method for analyzing the distribution profiles of marker enzymes based on multiple regression analysis. Triton WR-1339 was used to improve the separation of mitochondria from lysosomes by the gradient centrifugation technique. Adenosine production was examined further using acetate to increase intramitochondrial AMP, and thus adenosine production, in incubations with gradient centrifugation-purified mitochondria. Distribution analysis of the crude homogenate showed that 5'-nucleotidase activity exists in the mitochondrial fraction. To increase the resolution of this approach with respect to mitochondria, a crude mitochondrial fraction was also studied. In this case the relative mitochondrial activity decreased but 5'-nucleotidase activity was still clearly detectable. The mitochondrial 5'-nucleotidase exhibited a Km of 94 microM and a Vmax of 31 nmol/min per mg protein for AMP. The kinetic data for the Mg2+, ATP, ADP and AOPCP sensitivity of the enzyme showed that it differs from the plasma membrane, lysosome and cytosol 5'-nucleotidases. AOPCP was only a moderate inhibitor, and ATP was a more potent inhibitor than ADP at a 1 mM concentration. The enzyme also showed a requirement of Mg2+. Acetate caused the conversion of intramitochondrial adenylates to AMP and the formation of adenosine. Adenosine concentration increased in the extramitochondrial space in a time-dependent manner, but only trace amounts of nucleotides were detected. The data show that 5'-nucleotidase activity producing adenosine exists in rat liver mitochondria and a concentration-dependent adenosine output from mitochondria by diffusion or facilitated diffusion is also suggested.

Subcellular distribution of myocardial 5'-nucleotidase.

The controversial subject of the subcellular location of myocardial adenosine production was studied employing density gradient fractionation of heart muscle combined with a novel method for analyzing distribution profiles based on multiple regression (correlation) analysis. Bungarotoxin binding, N-acetyl-beta-D-glucosaminidase, cytochrome c oxidase, NADPH-dependent cytochrome c reductase and lactate dehydrogenase were used as markers for the plasma membrane, lysosomes, mitochondria, sarcoplasmic reticulum and cytosol, respectively. The normalized distribution frequencies (fraction of total) of 5'-nucleotidase in mitochondria, lysosomes, plasma membranes, sarcoplasmic reticulum and cytosol in the 50 x g supernatant of total homogenate of heart muscle were found to be 0, 0.25, 0.44, 0.08 and 0.23, respectively. To increase the resolution power of this approach with respect to mitochondria, a crude mitochondrial fraction was also studied, in which the normalized distribution of 5'-nucleotidase in the homogenate was 0, 0.16 and 0.84 in mitochondria, plasma membranes and lysosomes, respectively. This mainly lysosomal 5'-nucleotidase activity was 61% inhibited by the alpha,beta-methylene analog of ADP, indicating that although the latter has been considered specific to the plasma membrane enzyme, it also inhibits the lysosomal enzyme. The intercellular distribution of 5'-nucleotidase was not studied, but the lack of this enzyme in the mitochondria indicate that the adenosine production observed during mitochondrial AMP production, e.g. during acetate oxidation in intact heart muscle, must involve AMP transport out from the mitochondria.

Adenine nucleotide transport and adenosine production in isolated rat heart mitochondria during acetate metabolism.

In view of its vasodilatory effect on the coronary circulation (probably mediated by adenosine) and its metabolic compartmentalization (intramitochondrial activation to form acetyl-CoA), the metabolic effects of acetate were studied in isolated rat heart mitochondria. Acetate caused conversion of adenylates to AMP and the formation of adenosine. Adenylate efflux was inhibited by carboxyatractyloside but not by N-ethylmaleimide. The intramitochondrial accumulation of AMP was enhanced by carboxyatractyloside during acetate metabolism and the formation of extramitochondrial adenosine inhibited. A carboxyatractyloside-sensitive unidirectional AMP influx with a Km of 50 microM and Vmax of 11 nmol/min per mg mitochondrial protein was also observed. The mitochondrial adenosine content was high and constant during the experiments. The steep apparent concentration gradient of adenosine indicates that most of the mitochondrial adenosine is tightly bound to protein. Adenosine formation was proportional to the extramitochondrial AMP concentration, showing that the 5'-nucleotidase activity of cardiac mitochondrial preparations is extramitochondrial in origin. The data suggest that the mitochondrial ATP/ADP carrier is capable of transporting AMP and that intramitochondrial AMP is recycled during acetate metabolism in the myocardium partially by means of the ATP/ADP translocator, leading to an increase in extramitochondrial AMP and adenosine formation.

Acetate-induced changes in cardiac energy metabolism and hemodynamics in the rat.

The hemodynamic and metabolic effects of acetate were studied in rats in vivo and in the isolated perfused heart. Hemodynamic parameters, myocardial phosphagens, inorganic phosphate, and adenosine were measured in vivo. Acetate uptake, coronary flow, O2 consumption, parameters of the cellular energy state, and hypoxanthine compounds and their washout were measured in heart perfusion experiments. Heart rate (HR), cardiac output, and the peak derivative of the left ventricular pressure rise (dP/dtmax) increased significantly during acetate infusion in vivo, but mean arterial pressure, systolic arterial pressure, and systemic vascular resistance decreased. Heart muscle ATP concentrations decreased after 7 min of acetate infusion. In vivo cardiac work load (HR.(peak left ventricular pressure] showed a positive correlation with tissue adenosine concentration and a negative correlation with phosphorylation potential. Acetate uptake in the perfused hearts was about 2.5 mumol/min per gram wet weight. Acetate perfusion increased O2 consumption and coronary flow concomitantly with a decrease in tissue ATP concentration. Tissue AMP and perfusate effluent adenosine concentration and adenosine output increased significantly, perfusate adenosine showing a non-linear positive correlation with coronary flow. The results demonstrate that acetate induces considerable changes in hemodynamics and metabolism in the heart.

Role of cellular energy state and adenosine in the regulation of coronary flow during variation in contraction frequency in an isolated perfused heart.

Regulation of coronary flow as a function of myocardial energy expenditure was investigated in isolated perfused rat hearts electrically paced at the desired frequencies. The sinoatrial node was excised to lower the endogenous heart rate. The main covariants measured were phosphagen, inorganic phosphate, adenosine, inosine and hypoxanthine concentrations in the tissue, washout of nucleosides and hypoxanthine into the perfusate, oxygen consumption and coronary flow. Oxygen consumption was linearly correlated with heart rate and coronary flow, while the correlation between coronary flow and perfusate adenosine was nonlinear. The adenosine concentrations in the tissue and perfusate showed a mirror image curvilinearity reminiscent of a threshold pattern for adenosine washout. The tissue adenosine content had a negative linear correlation with the adenylate phosphorylation potential (long(ATP/ADP X Pi)). Adenosine output was linearly correlated with free AMP concentration in the tissue, the latter being calculated from the equilibrium of the adenylate kinase reaction. The results confirm the correlation between cellular energy state and coronary flow and support the notion that the mediators between the former and the vascular smooth muscle involve the concentration of free AMP in the tissue, suggesting that the formation of adenosine may be limited by the availability of AMP. The results are in agreement with the hypothesis that adenosine is the diffusible extracellular mediator in the energy-linked regulation of coronary flow.

Effects of ethanol metabolites on intermediary metabolism in heart muscle.

Isolated rat hearts were perfused by the Langendorff procedure to study the metabolic effects of ethanol, acetaldehyde and acetate on the myocardium. Ethanol caused a slight decrease in the work output of the heart and concomitant changes in the oxygen consumption and cellular redox state. A low-Km (1 microM) acetaldehyde dehydrogenase activity was found in rat heart mitochondria, but an acetaldehyde concentration of 50 microM or higher was necessary to reduce tissue NAD+ in the isolated perfused heart. One hundred microM or higher concentrations of acetaldehyde caused an increase in the work output of the heart, with a concomitant oxidation of NADH. Acetaldehyde at a 50 microM concentration did not affect myocardial lipid metabolism. Acetate caused a reduction of mitochondrial NAD+, an increase in the coronary flow and an increase in the O2 consumption of the perfused heart. Practically all of the oxygen consumption could be accounted for by acetate oxidation. A 2 mM concentration of acetate inhibited the oxidation of oleate by 35% and stimulated oleate incorporation into myocardial lipids by 90%; therefore, it appears that the acute metabolic derangements of the heart muscle during ethanol metabolism in vivo are probably mainly caused by acetate.