Angela Wang

Local infiltration of neuropeptide Y as a potential therapeutic agent against apoptosis and fibrosis in a swine model of hypercholesterolemia and chronic myocardial ischemia

While the angiogenic effects of Neuropeptide Y (NPY) in myocardial ischemia and hypercholesterolemia have been studied, its effects on altering oxidative stress, fibrosis and cell death are not known. We hypothesized that local infiltration of NPY in a swine model of chronic myocardial ischemia and hypercholesterolemia will induce nerve growth and cell survival, while reducing oxidative stress and fibrosis. Yorkshire mini-swine (n=15) were fed a high cholesterol diet for 5 weeks. Three weeks after surgical induction of focal myocardial ischemia, an osmotic pump was implanted, which delivered NPY (n=8, high cholesterol treated, HCT) or the vehicle (n=7, high cholesterol control, HCC) for 5 weeks. Then myocardium was harvested for analysis. Assessment of myocardial function and perfusion was made the last intervention. Immunoblotting demonstrated significantly decreased levels of MMP-9 (p=0.001) and TGF-β (p=0.05) and significantly increased levels of Ang-1 (p=0.002), MnSOD (p=0.006) and NGF (p=0.01) in HCT. Immunohistochemistry results revealed significantly decreased TUNEL staining (p=0.005) and GLUT4 translocation (p=0.004) in HCT. The functional data showed significantly improved blood flow reserve (p=0.02) and improved diastolic function -dP/dt (p=0.009) in the treated animals. Local infiltration of NPY results in positive remodeling in ischemic myocardium in the setting of hypercholesterolemia. By initiating angio and neurogenesis, NPY infiltration improves blood flow reserve and restoration of fatty acid metabolism. The associated increased cell survival and decreased fibrosis result in improved myocardial diastolic function. NPY may have a potential therapeutic role in patients with hypercholesterolemia associated coronary artery disease.

Ventriculo-atrial defect after bioprosthetic aortic valve replacement

We present a case of a 71-year-old Caucasian male with a ventriculo-atrial defect due to infective endocarditis, originating from his aortic root near a bioprosthetic aortic valve, implanted 4 years earlier. Ventriculo-atrial defects are rare and can occur after endocarditis with abscess formation, usually in native tissue. We report a ventriculo-atrial defect due to a paravalvular aortic prosthetic defect, secondary to inflammation, a novel third type of a Gerbode defect. Case presentation, clinical decision making and surgical approach are discusses in this report.

Echocardiographic Anatomy of the Mitral Valve: A Critical Appraisal of 2-Dimensional Imaging Protocols With a 3-Dimensional Perspective

OBJECTIVE To highlight the limitations of traditional 2-dimensional (2D) echocardiographic mitral valve (MV) examination methodologies, which do not account for patient-specific transesophageal echocardiographic (TEE) probe adjustments made during an actual clinical perioperative TEE examination. DESIGN Institutional quality-improvement project. SETTING Tertiary care hospital. PARTICIPANTS Attending anesthesiologists certified by the National Board of Echocardiography. INTERVENTION Using the technique of multiplanar reformatting with 3-dimensional (3D) data, ambiguous 2D images of the MV were generated, which resembled standard midesophageal 2D views. Based on the 3D image, the MV scallops visualized in each 2D image were recognized exactly by the position of the scan plane. Twenty-three such 2D MV images were created in a presentation from the 3D datasets. Anesthesia staff members (n = 13) were invited to view the presentation based on the 2D images only and asked to identify the MV scallops. Their responses were scored as correct or incorrect based on the 3D image. METHODS AND MAIN RESULTS The overall accuracy was 30.4% in identifying the MV scallops. The transcommissural view was identified correctly >90% of the time. The accuracy of the identification of A1, A3, P1, and P3 scallops was <50%. The accuracy of the identification of A2P2 scallops was ≥50%. CONCLUSION In the absence of information on TEE probe adjustments performed to acquire a specific MV image, it is possible to misidentify the scallops.

Oxidative Stress and Nerve Function After Cardiopulmonary Bypass in Patients With Diabetes

BACKGROUND Chronic hyperglycemia has been associated with increased oxidative stress in skeletal muscle and sympathetic nerve dysfunction. We investigated the effect of chronic hyperglycemia on the myocardium of patients with uncontrolled diabetes (UD) compared with patients with well-controlled diabetes (CD) and patients without diabetes (ND) after cardioplegic cardiopulmonary bypass (CP/CPB) with acute intraoperative glycemic control. METHODS Atrial tissue and serum were collected from 47 patients (ND=18 with glycated hemoglobin [HbA1c] of 5.8±0.2; CD=8 with HbA1c of 6.1±0.1; with UD=21 with HbA1c=9.6±0.5) before and after CP/CPB for immunoblotting, protein oxidation assays, immunohistochemical evaluation, and microarray analysis. RESULTS The uncontrolled group had increased total protein oxidation (p<0.05) and decreased levels of antioxidative enzyme manganese superoxide dismutase (MnSOD) (p<0.05) after CP/CPB compared with the controlled group. Collagen staining revealed increased fibrosis in patients with UD (p<0.05) compared with patients with CD and patients without diabetes. The uncontrolled group also showed a decrease in the neurogenic and angiogenic markers nerve growth factor (NGF) (p<0.05), neurotrophin (NT)-3 (p<0.05), and platelet-derived growth factor (PDGF)-β (p<0.05) compared with the other groups after CP/CPB. Atrial and serum microarray analysis showed increased oxidative stress and sympathetic nerve damage, increased fibrosis, and a decrease in angiogenesis in patients with UD (p<0.03) compared with patients without diabetes. CONCLUSIONS CP/CPB led to higher oxidative stress in patients with UD before surgical intervention, even after normal glucose levels were maintained intraoperatively. Thus, controlled HbA1C in addition to acute intraoperative glucose control may be a more suitable end point for patients with diabetes undergoing cardiac operations.

Systolic Anterior Motion of the Mitral Valve and Three-Dimensional Echocardiography

From the *Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; †Department of Anesthesia and Pain Medicine, Peking University People’s Hospital, Beijing, China; and ‡Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. Address reprint requests to Luyang Jiang, MD, Department of Anesthesia and Pain Medicine, Peking University People’s Hospital, 11 Xi Zhi Men South Street, Beijing, China 100044. E-mail: jiangly1018@hotmail.com

Percutaneous ventricular septal defect closure with Amplatzer devices resulting in severe tricuspid regurgitation.

While percutaneous intervention is an alternative for patients who are not surgical candidates, the rate of morbidity and mortality is comparable to open repair. Appending the reported complications associated with percutaneous intervention (device mal‐positioning, dislodgement, and entrapment in the sub‐valvular apparatus), we report mechanical damage to the tricuspid valve (TV). Percutaneous closure with an Amplatzer septal occluder device was attempted on three patients who developed a ventricular septal defects (VSD) after myocardial infarction. In all three cases, damage to the tricuspid leaflet was noted post‐procedure. The accompanying severe tricuspid regurgitation led to right ventricular failure, even in the patients where the VSD was considered successfully occluded. Despite successful deployment of the Amplatzer device, complications with catheter manipulation may still arise. Damage to the TV can occur during percutaneous VSD closure with Amplatzer device. Periprocedure TEE monitoring can detect damage to the tricuspid leaflets.

3-Dimensional Right Ventricular Volume Assessment

PURPOSE The purpose of this review was to evaluate new computer software available for 3-dimensional right ventricular (RV) volume estimation. DESCRIPTION Based on 2-dimensional echocardiography, various algorithms have been used for RV volume estimation. These are complex, time-consuming techniques and are prone to significant error. The current clinical paradigm of RV volume assessment is based on the visual quantitative assessment of chamber size and the use of tricuspid annular and RV internal diameters as a surrogate measure of RV volume. Hence, there is a need for a practical method for the intraoperative assessment of RV volume. EVALUATION The evaluation consists of an objective review of the capabilities of this software and its potential application in the operating room. The authors also performed a detailed review of the potential limitations and possible improvements. CONCLUSIONS This new software has the potential to be incorporated into the existing workflow environment of the ultrasound systems in the future, making it clinically feasible to perform perioperative RV volume analysis.

Intracardiac Wegener's Granulomatosis

A healthy 22-year-old woman presented with acute ventricular tachycardia. Cardiac magnetic resonance imaging revealed a mass in the left ventricular cavity. On the basis of these findings, a provisional diagnosis of rhabdomyosarcoma was made and the patient was scheduled to undergo an immediate cardiac surgical procedure. During intraoperative transesophageal echocardiography, the anterolateral papillary muscle (PM) was found to have an abnormal consistency and appeared thickened in the midesophageal (Fig 1A, Fig 1B) and transgastric mid–short axis (Fig 1C) views. The PM was excised, and the patient underwent a mitral valve replacement with a mechanical valve. Gross exam-

Erratum: Ventriculo-atrial defect after bioprosthetic aortic valve replacement

After publication of the article [1] it was discovered that this manuscript was mistakenly given a duplicated citation number. The correct citation of 9:199 has now been updated in all versions of this manuscript. We apologise for any inconvenience caused by this error.