Calcification and degeneration following mitral valve reconstruction in patients requiring chronic dialysis.

BACKGROUND AND AIM OF THE STUDY: Abnormal calcium homeostasis in patients with end-stage renal failure results in dystrophic calcification; this limits the use of heterograft tissue valve prostheses in patients on chronic dialysis. Mitral valve reconstruction offers advantages over mitral replacement in many patients without renal failure, and offers theoretical advantages in patients requiring dialysis. This study was performed to determine the outcome of mitral valve reconstruction in patients with renal failure requiring chronic dialysis. METHODS: Ten patients with end-stage renal failure and on chronic dialysis who underwent mitral valve repair were identified retrospectively and followed for clinical and echocardiographic outcome. All patients had good results immediately following surgical valve mitral repair, with no more than mild mitral regurgitation and low transmitral gradients on intraoperative transesophageal echocardiography. RESULTS: Clinical and echocardiographic follow up was available for eight patients at an average of 2.3 +/- 1.4 years after surgery. Despite there being no significant valve calcification at the time of surgery, visible mitral leaflet calcification was evident in seven of these patients, and the transmitral gradient for the group was significantly increased (from 4.8 +/- 1.7 mmHg to 8.3 +/- 3.9 mmHg, p = 0.04). Two patients required reoperation for failed mitral repair; one at six months due to chordal rupture, and one at 15 months due to mitral calcification with stenosis. CONCLUSION: Despite good early surgical results, there was accelerated calcification of the repaired mitral valve, a rapid increase in postoperative mitral gradients, and a high incidence of failure of the reconstruction. Additional prospective studies are required to evaluate the optimal intervention for patients with end-stage renal failure who require mitral valve surgery.

Reduced test time by early identification of patients requiring atropine during dobutamine stress echocardiography.

In a randomized, controlled clinical trial, we evaluated the ability of an algorithm to identify, before peak stress, patients who will ultimately require atropine during dobutamine stress echocardiography. The effects of early atropine administration on test duration, atropine dose, dobutamine dose, and heart rate response also were studied. Compared with conventional atropine administration at peak dobutamine infusion, early atropine administration reduced test duration 8% (1.1 minutes, p = 0.02) and total dobutamine use 11% (0.41 mg/kg, p = 0.02) but required 90% more atropine (0.36 mg, p < 0.001). Conventional atropine administration resulted in a late, rapid rise in both heart rate and rate-pressure product. However, the heart rate and rate-pressure product curves for patients receiving early atropine paralleled those seen in patients not requiring atropine during dobutamine stress echocardiography. In conclusion, early atropine administration provides a more balanced stress and reduces test duration, thus decreasing total exposure to dobutamine and potentially increasing test efficiency.

Cardiac noradrenergic nerve terminal abnormalities in dogs with experimental congestive heart failure.

BACKGROUND: We have shown previously that norepinephrine (NE) uptake activity is reduced in the failing right ventricle of animals with right heart failure (RHF) produced by tricuspid avulsion and progressive pulmonary constriction. However, it is unknown whether this defect in neuronal NE uptake is related to reduction of noradrenergic nerve terminals or whether these changes also occur in animals with left heart failure (LHF). It is also unknown whether increased NE release in heart failure contributes to the noradrenergic nerve abnormalities. METHODS AND RESULTS: We measured myocardial NE content. NE uptake function, and noradrenergic nerve profiles in dogs with either RHF or LHF induced by rapid ventricular pacing. NE uptake activity was measured using [3H]NE, and noradrenergic nerve profiles were visualized by glyoxylic acid (SPG)-induced histofluorescence and tyrosine hydroxylase immunocytochemical staining. To study the effects of excess NE, we exposed normal dogs to 8 weeks of chronic NE infusion using subcutaneous osmotic minipumps. RHF and LHF animals exhibited reduced myocardial contractile function and congestive heart failure, as evidence by reduced cardiac output and elevated right atrial pressure. However, unlike that in LHF, left atrial pressure was not increased in RHF. The animals also showed an increase in plasma NE and a decrease in cardiac NE. In addition, SPG-induced histofluorescence correlated significantly with NE uptake activity (r = .712, P < .001) and tyrosine hydroxylase immunoreactive profiles (r = .569, P < .001) in the right ventricles of RHF dogs and in both ventricles of LHF dogs. The numbers of catecholaminergic profiles and tyrosine hydroxylase profiles significantly correlated with cardiac filling pressures. Chronic infusion of NE decreased heart rate in normal dogs but had no effect on either mean aortic pressure or left atrial pressure; like heart failure, it resulted in significant decreases in myocardial NE uptake activity and numbers of SPG-induced catecholaminergic histofluorescence and immunoreactive tyrosine hydroxylase profiles. CONCLUSIONS: Myocardial NE uptake activity was reduced only in the failing ventricles with elevated filling pressure in RHF and LHF. These changes probably were caused by loss of noradrenergic nerve terminals in the failing ventricles, as evidenced by the reductions of catecholaminergic histofluorescence and tyrosine hydroxylase immunostained profiles. Furthermore, since similar reductions of myocardial NE uptake and noradrenergic nerve profiles could be produced by chronic NE infusion in normal dogs, elevated NE levels may play a role in the development of cardiac noradrenergic nerve abnormalities in congestive heart failure.

Immunoreactivity in Limulus: III. Morphological and biochemical studies of FMRFamide-like immunoreactivity and colocalized substance P-like immunoreactivity in the brain and lateral eye.

FMRFamide-like immunoreactivity (FLI) and the colocalization of FMRFamide and substance P-like (SPLI) immunoreactivities were examined in the brain and lateral eye of the horseshoe crab with FITC- and TRITC-labeled secondary antibody techniques. In the brain, fibers with FLI were localized in the neuropils of the lamina, medulla, central body, corpus pedunculatum, optic tract, circumesophageal connective, and central neuropil. An extensive network of reactive fibers innervatives the brain's vascular sheath. Somata with FLI were found in the dorsal medial group, dorsal lateral posterior groups #1 and #2, and ventral posterior lateral groups #1 and #2. Several distinct subgroups of reactive somata were noted in both the medullar and ventral medial groups. The distribution of fibers in the brain with colocalized FLI and SPLI includes those which innervate the vascular sheath and widespread populations of small-diameter beaded fibers in the central neuropil and circumesophageal connective. Somata with colocalized FLI and SPLI constitute minority populations in the medullar and dorsal medial groups but form the majority population of a subgroup in the ventral medial group. Overall localization of SPLI was reevaluated and is reported here according to the nomenclature of the new Chamberlain and Wyse brain atlas. In addition to those previously reported, somata with SPLI were found in the dorsal lateral posterior groups #1 and #2, the ventral lateral posterior groups #1 and #2, and several distinct subgroups of the medial and ventral medial groups. In the retina of the lateral eye, fibers with both FLI and SPLI ramify in the lateral plexus and ultimately innervate the corneal epidermis. Brain homogenates were examined for immunoreactive (ir) FMRFamide and ir-substance P with radioimmunoassay techniques. Ir-FMRFamide and ir-substance P eluted in different fractions from both gel filtration chromatography and HPLC. Furthermore, the binding curves for both substances were similar to those of the corresponding synthetic compounds. Brain homogenates were also bioassayed on the lateral eye. Three gel filtration fractions mimic natural circadian activity by increasing the sensitivity of the lateral eye, but they were not coincident with ir-FMRFamide or ir-substance P. Although it is not completely resolved what the active molecules in these fractions are, it is clear that neither ir-FMRFamide nor ir-substance P is a possible candidate.

Immunoreactivity in Limulus. II. Studies of serotoninlike immunoreactivity, endogenous serotonin, and serotonin synthesis in the brain and lateral eye.

Serotoninlike immunoreactivity was examined by the fluorescein-isothiocyanate-labeled secondary antibody technique in the lateral eye and brain of Limulus. Endogenous serotonin was measured with high-performance liquid chromatography and electrochemical detection. The synthesis of [3H]serotonin from [3H]tryptophan was measured in the presence and absence of reserpine. Fibers with serotoninlike immunoreactivity were found in the proximal stalks of the corpora pedunculata, in the neuropil of the central body, in the neuropils of the visual centers (lamina, medulla, and ocellar ganglion), in the optic tract that connects the ocellar ganglion with the posterior medial medulla, and in the central neuropil of the brain. Immunoreactive somata were found in four groups in the brain. Up to 50 somata were scattered through each side of the dorsal medial group that lies centered on the dorsal surface within the curve of the central body. These neurons innervate the central body neuropil and send processes into the central neuropil. Three or four reactive somata formed the ventral pole of each medullar group. These may provide the innervation of the proximal stalk of the corpora pedunculata. Five to ten reactive neurons were observed anteriorly in the ventral posterior lateral group #2 on each side that send processes into the central neuropil. Ten to 15 reactive somata were found on either side of the midline in the dorsal anterior part of the ventral medial group that contribute processes to the central neuropil. The remainder of the brain was not immunoreactive. No immunoreactive fibers or somata were found in the lateral eye or in the lateral optic nerve. Serotoninlike and substance P-like immunoreactivities were not found to be colocalized anywhere in the brain. Significant amounts of endogenous serotonin were detected in the lamina and medulla whose neuropils are rich in immunoreactive fibers and in the central body and dorsal medial group that are also rich in immunoreactive somata and fibers. No endogenous serotonin was detected in either the lateral eye or the lateral optic nerve. The lamina, medulla, and central body and dorsal medial group also synthesized and stored [3H]serotonin from [3H]tryptophan. It is likely that serotonin is a neurotransmitter in the brain, but not in the lateral eye of the horseshoe crab. In particular, it appears that serotoninergic neurons may play a role in central visual processing.