Deanne Mickelsen

decomplexification in critical illness and injury: Relationship between heart rate variability, severity of illness, and outcome

Abstract Objectives: To determine if decomplexification of heart rate dynamics occurs in critically ill and injured pediatric patients. We hypothesized that heart rate power spectra, a measure of heart rate dynamics, would inversely correlate with measures of severity of illness and outcome. Design: A prospective clinical study. Setting: A 12‐bed pediatric intensive care unit (ICU) in a tertiary care childrens hospital. Patients: One hundred thirty‐five consecutive pediatric ICU admissions. Interventions: None. Measurements and Main Results: We compared heart rate power spectra with the Pediatric Risk of Mortality (PRISM) score, the Pediatric Cerebral Performance Category (PCPC), and the Pediatric Overall Performance Category (POPC). We found significant negative correlations between minimum low‐frequency and high‐frequency heart rate power spectral values recorded during ICU stay and the maximum PRISM score (log low‐frequency heart rate power vs. PRISM, r2 = .293, p < .001; and log high‐frequency heart rate power vs. PRISM, r2 = .243, p < .001) and outcome at ICU discharge (log low‐frequency heart rate power vs. POPC or PCPC, r2 = .429, p < .001; and log high‐frequency heart rate power vs. POPC or PCPC, r2 = .271, p < .001). Conclusions: Our data support the hypothesis that measures of heart rate power spectra are inversely related and negatively correlated to severity of illness and outcome in critically ill and injured children. The phenomenon of decomplexification of physiologic dynamics may have important clinical implications in critical illness and injury. (Crit Care Med 1998; 26:352‐357) For years, physicians have believed that physiologic systems existed in a so‐called “steady” or “homeostatic” state and that these systems exhibited a linear response when stimulated. It is now clear that physiologic systems exist in a nonlinear, dynamic state [1‐4]. In other words, physiologic systems constantly change over time and respond to stimuli in a nonlinear manner. Furthermore, healthy physiologic systems exhibit marked signal variability, while aging or diseased systems show a loss of variability [2,5]. This decreased variability, or increased regularity, in physiologic dynamics has been termed “decomplexification” [1]. Commonly monitored physiologic signals, including mean heart rate, blood pressure, and cardiac output, correlate poorly with survival in both experimental models of circulatory shock and in critically ill patients [6]. These first‐order linear measures do not adequately describe dynamic changes. Power spectral analysis of heart rate variability, a second‐order linear measure, allows for quantification in the frequency domain of dynamic changes in beat‐to‐beat heart rate oscillations [1,5‐10]. Power spectral analysis of heart rate variability has been used to quantify physiologic changes in many diseases, including hypovolemia, congestive heart failure, hypertension, diabetes mellitus, renal failure, cardiac transplantation, traumatic quadriplegia, and sepsis [10‐19]. We hypothesized that decomplexification of heart rate dynamics would occur over a broad range of critical illness and injury, and would inversely correlate with disease severity and outcome in a pediatric population. To test this hypothesis, we prospectively studied 135 consecutive admissions to the Strong Childrens Critical Care Center. We compared heart rate power spectra with a previously validated measure of severity of illness, the Pediatric Risk of Mortality (PRISM) score [20], and with validated measures of outcome from pediatric intensive care, the Pediatric Overall Performance Category (POPC) [21] and Pediatric Cerebral Performance Category (PCPC) [21] scores.

New approaches in small animal echocardiography: imaging the sounds of silence

Systolic and diastolic dysfunction of the left ventricle (LV) is a hallmark of most cardiac diseases. In vivo assessment of heart function in animal models, particularly mice, is essential to refining our understanding of cardiovascular disease processes. Ultrasound echocardiography has emerged as a powerful, noninvasive tool to serially monitor cardiac performance and map the progression of heart dysfunction in murine injury models. This review covers current applications of small animal echocardiography, as well as emerging technologies that improve evaluation of LV function. In particular, we describe speckle-tracking imaging-based regional LV analysis, a recent advancement in murine echocardiography with proven clinical utility. This sensitive measure enables an early detection of subtle myocardial defects before global dysfunction in genetically engineered and rodent surgical injury models. Novel visualization technologies that allow in-depth phenotypic assessment of small animal models, including perfusion imaging and fetal echocardiography, are also discussed. As imaging capabilities continue to improve, murine echocardiography will remain a critical component of the investigators armamentarium in translating animal data to enhanced clinical treatment of cardiovascular diseases.

Capture and enrichment of CD34-positive haematopoietic stem and progenitor cells from blood circulation using P-selectin in an implantable device

Clinical infusion of haematopoietic stem and progenitor cells (HSPCs) is vital for restoration of haematopoietic function in many cancer patients. Previously, we have demonstrated an ability to mimic physiological cell trafficking in order to capture CD34‐positive (CD34+) HSPCs using monolayers of the cell adhesion protein P‐selectin in flow chambers. The current study aimed to determine if HSPCs could be captured directly from circulating blood in vivo. Vascular shunt prototypes, coated internally with P‐selectin, were inserted into the femoral artery of rats. Blood flow through the cell capture device resulted in a wall shear stress of 4–6 dynes/cm2. After 1‐h blood perfusion, immunofluorescence microscopy and flow cytometric analysis revealed successful capture of mononuclear cells positive for the HSPC surface marker CD34. Purity of captured CD34+ cells showed sevenfold enrichment over levels found in whole blood, with an average purity of 28%. Robust cell capture and HSPC enrichment were also demonstrated in devices that were implanted in a closed‐loop arterio‐venous shunt conformation for 2 h. Adherent cells were viable in culture and able to differentiate into burst‐forming units. This study demonstrated an ability to mimic the physiological arrest of HSPCs from blood in an implantable device and may represent a practical alternative for adult stem cell capture and enrichment.

Novel role of C terminus of Hsc70-interacting protein (CHIP) ubiquitin ligase on inhibiting cardiac apoptosis and dysfunction via regulating ERK5-mediated degradation of inducible cAMP early repressor

Growing evidence indicates a critical role of ubiquitin-proteosome system in apoptosis regulation. A cardioprotective effect of ubiquitin (Ub) ligase of the C terminus of Hsc70-interacting protein (CHIP) on myocytes has been reported. In the current study, we found that the cardioprotective effect of insulin growth factor-1 (IGF-1) was mediated by ERK5-CHIP signal module via inducible cAMP early repressor (ICER) destabilization. In vitro runoff assay and Ub assay showed ICER as a substrate of CHIP Ub ligase. Both disruption of ERK5-CHIP binding with inhibitory helical linker domain fragment (aa 101-200) of CHIP and the depletion of ERK5 by siRNA inhibited CHIP Ub ligase activity, which suggests an obligatory role of ERK5 on CHIP activation. Depletion of CHIP, using siRNA, inhibited IGF-1-mediated reduction of isoproterenol-mediated ICER induction and apoptosis. In diabetic mice subjected to myocardial infarction, the CHIP Ub ligase activity was decreased, with an increase in ICER expression. These changes were attenuated significantly in a cardiac-specific constitutively active form of MEK5α transgenic mice (CA-MEK5α-Tg) previously shown to have greater functional recovery. Furthermore, pressure overload-mediated ICER induction was enhanced in heterozygous CHIP(+/-) mice. We identified ICER as a novel CHIP substrate and that the ERK5-CHIP complex plays an obligatory role in inhibition of ICER expression, cardiomyocyte apoptosis, and cardiac dysfunction.

Platelet factor 4 mediates vascular smooth muscle cell injury responses

Activated platelets release many inflammatory molecules with important roles in accelerating vascular inflammation. Much is known about platelet and platelet-derived mediator interactions with endothelial cells and leukocytes, but few studies have examined the effects of platelets on components of the vascular wall. Vascular smooth muscle cells (VSMCs) undergo phenotypic changes in response to injury including the production of inflammatory molecules, cell proliferation, cell migration, and a decline in the expression of differentiation markers. In this study, we demonstrate that the platelet-derived chemokine platelet factor 4 (PF4/CXCL4) stimulates VSMC injury responses both in vitro and in vivo in a mouse carotid ligation model. PF4 drives a VSMC inflammatory phenotype including a decline in differentiation markers, increased cytokine production, and cell proliferation. We also demonstrate that PF4 effects are mediated, in part, through increased expression of the transcription factor Krüppel-like factor 4. Our data indicate an important mechanistic role for platelets and PF4 in VSMC injury responses both in vitro and in vivo.

Effect of N(G)-nitro-L-arginine methyl ester on autonomic modulation of heart rate variability during hypovolemic shock

OBJECTIVE To study the changes in neuroautonomic regulation of heart rate and the effects of N(G)-nitro-L-arginine methyl ester (L-NAME), a competitive inhibitor of nitric oxide synthase, on efferent sympathetic cardiac activity and blood pressure during hypovolemic shock. Hypotension during hypovolemic shock may be attributable, in part, to the failure of neuroautonomic regulation of heart rate and blood pressure. In addition, the release of nitric oxide may contribute to hypotension through vasodilation and inhibition of efferent sympathetic activity. DESIGN Prospective, controlled trial. SETTING Experimental laboratory in a university hospital. SUBJECTS Seventeen anesthetized adult male New Zealand White rabbits. INTERVENTIONS The rabbits were divided into four groups: control (n = 3), control plus L-NAME (n = 5), hypovolemic (n = 4), and hypovolemic plus L-NAME (n = 5). Hypovolemic rabbits were bled of 10% of their circulating blood volume (85 mL/kg) every 10 mins until 30% cumulative hypovolemia was reached. Rabbits received either three doses of saline 1 mL/kg every 10 mins or L-NAME 10 mg/kg in 1 mL/kg of saline solution administered after each hemorrhage for a total of three doses. Changes in heart rate, respiratory rate, mean arterial pressure, plasma catecholamine levels, and heart rate power spectra were recorded every 10 mins during serial hypovolemia and during a 30-min recovery period. MEASUREMENTS AND MAIN RESULTS During hypovolemic shock there was a decrease in log low-frequency heart rate power (p = .001) and in systolic (p = .003), diastolic (p < .001), and mean (p < .001) blood pressures compared with control rabbits. Treatment with L-NAME during hypovolemia resulted in increased log low-frequency heart rate power (p = .03) and systolic (p = .01), diastolic (p = .007), and mean (p = .009) blood pressures compared with hypovolemic rabbits who received saline placebo. CONCLUSIONS We found that treatment with L-NAME increased efferent sympathetic cardiac activity and mean arterial pressure during hypovolemic shock compared with control rabbits. We conclude that L-NAME may blunt hypotension during hypovolemic shock by inhibiting nitric oxide synthase and may act to restore neuroautonomic cardiovascular reactivity. Spectral analysis of heart rate variability may allow for insights into the pathophysiology of shock and provide a means of monitoring the neuroautonomic cardiovascular response to therapy.

PDE1C deficiency antagonizes pathological cardiac remodeling and dysfunction

Significance Heart failure is the leading global cause of death; therefore developing a greater understanding of disease etiology and identifying novel therapeutic targets is critical. Here, we describe the role of the cyclic nucleotide-degrading protein phosphodiesterase 1C (PDE1C) in the context of pathological cardiac remodeling. In cardiac myocytes, we found that PDE1C regulates both cyclic AMP- and cyclic GMP-mediated signaling pathways under different conditions. In both isolated cells and mice we found that inhibition of PDE1C could potentiate protective signaling and prevent the development of many aspects of heart failure, potentially by signaling through multiple cell types. PDE1 inhibition therefore may represent a viable therapeutic strategy for treatment of heart failure. Cyclic nucleotide phosphodiesterase 1C (PDE1C) represents a major phosphodiesterase activity in human myocardium, but its function in the heart remains unknown. Using genetic and pharmacological approaches, we studied the expression, regulation, function, and underlying mechanisms of PDE1C in the pathogenesis of cardiac remodeling and dysfunction. PDE1C expression is up-regulated in mouse and human failing hearts and is highly expressed in cardiac myocytes but not in fibroblasts. In adult mouse cardiac myocytes, PDE1C deficiency or inhibition attenuated myocyte death and apoptosis, which was largely dependent on cyclic AMP/PKA and PI3K/AKT signaling. PDE1C deficiency also attenuated cardiac myocyte hypertrophy in a PKA-dependent manner. Conditioned medium taken from PDE1C-deficient cardiac myocytes attenuated TGF-β–stimulated cardiac fibroblast activation through a mechanism involving the crosstalk between cardiac myocytes and fibroblasts. In vivo, cardiac remodeling and dysfunction induced by transverse aortic constriction, including myocardial hypertrophy, apoptosis, cardiac fibrosis, and loss of contractile function, were significantly attenuated in PDE1C-knockout mice relative to wild-type mice. These results indicate that PDE1C activation plays a causative role in pathological cardiac remodeling and dysfunction. Given the continued development of highly specific PDE1 inhibitors and the high expression level of PDE1C in the human heart, our findings could have considerable therapeutic significance.

Platelet Extracellular Regulated Protein Kinase 5 Is a Redox Switch and Triggers Maladaptive Platelet Responses and Myocardial Infarct Expansion.

Background— Platelets have a pathophysiologic role in the ischemic microvascular environment of acute coronary syndromes. In comparison with platelet activation in normal healthy conditions, less attention is given to mechanisms of platelet activation in diseased states. Platelet function and mechanisms of activation in ischemic and reactive oxygen species–rich environments may not be the same as in normal healthy conditions. Extracellular regulated protein kinase 5 (ERK5) is a mitogen-activated protein kinase family member activated in hypoxic, reactive oxygen species–rich environments and in response to receptor-signaling mechanisms. Prior studies suggest a protective effect of ERK5 in endothelial and myocardial cells after ischemia. We present evidence that platelets express ERK5 and that platelet ERK5 has an adverse effect on platelet activation via selective receptor-dependent and receptor-independent reactive oxygen species–mediated mechanisms in ischemic myocardium. Methods and Results— Using isolated human platelets and a mouse model of myocardial infarction (MI), we found that platelet ERK5 is activated post-MI and that platelet-specific ERK5–/– mice have less platelet activation, reduced MI size, and improved post-MI heart function. Furthermore, the expression of downstream ERK5-regulated proteins is reduced in ERK5–/– platelets post-MI. Conclusions— ERK5 functions as a platelet activator in ischemic conditions, and platelet ERK5 maintains the expression of some platelet proteins after MI, leading to infarct expansion. This demonstrates that platelet function in normal healthy conditions is different from platelet function in chronic ischemic and inflammatory conditions. Platelet ERK5 may be a target for acute therapeutic intervention in the thrombotic and inflammatory post-MI environment.

Mechanosensitive Gene Regulation by Myocardin-Related Transcription Factors is Required for Cardiomyocyte Integrity in Load-Induced Ventricular Hypertrophy

Background: Hypertrophic cardiomyocyte growth and dysfunction accompany various forms of heart disease. The mechanisms responsible for transcriptional changes that affect cardiac physiology and the transition to heart failure are not well understood. The intercalated disc (ID) is a specialized intercellular junction coupling cardiomyocyte force transmission and propagation of electrical activity. The ID is gaining attention as a mechanosensitive signaling hub and hotspot for causative mutations in cardiomyopathy. Methods: Transmission electron microscopy, confocal microscopy, and single-molecule localization microscopy were used to examine changes in ID structure and protein localization in the murine and human heart. We conducted detailed cardiac functional assessment and transcriptional profiling of mice lacking myocardin-related transcription factor (MRTF)-A and MRTF-B specifically in adult cardiomyocytes to evaluate the role of mechanosensitive regulation of gene expression in load-induced ventricular remodeling. Results: We found that MRTFs localize to IDs in the healthy human heart and accumulate in the nucleus in heart failure. Although mice lacking MRTFs in adult cardiomyocytes display normal cardiac physiology at baseline, pressure overload leads to rapid heart failure characterized by sarcomere disarray, ID disintegration, chamber dilation and wall thinning, cardiac functional decline, and partially penetrant acute lethality. Transcriptional profiling reveals a program of actin cytoskeleton and cardiomyocyte adhesion genes driven by MRTFs during pressure overload. Indeed, conspicuous remodeling of gap junctions at IDs identified by single-molecule localization microscopy may partially stem from a reduction in Mapre1 expression, which we show is a direct mechanosensitive MRTF target. Conclusions: Our study describes a novel paradigm in which MRTFs control an acute mechanosensitive signaling circuit that coordinates cross-talk between the actin and microtubule cytoskeleton and maintains ID integrity and cardiomyocyte homeostasis in heart disease.

Model-based vascular elastography improves the detection of flow-induced carotid artery remodeling in mice

Increased arterial thickness measured with ultrasound correlates with future cardiovascular events, but conventional ultrasound imaging techniques cannot distinguish between intima, media, or atherosclerotic plaque in the carotid artery. In this work, we evaluated how well vascular elastography can detect intimal changes in a mouse model of carotid remodeling. We ligated the left external and internal branches of the carotid artery of male FVB mice and performed sham operations for 2 weeks. High-resolution ultrasound imaging accurately detected lower blood velocities and low blood volume flow in the carotid arteries after ligation in FVB mice. However, ultrasound could not detect differences in the carotid wall even at 2 weeks post-surgery. The Young’s modulus was measured based on displacements of the carotid artery wall, and Young’s modulus was 2-fold greater in shams at 1 week post ligation, and 3-fold greater 2 weeks after ligation. Finally, the higher Young’s modulus was most associated with higher intimal thickness but not medial or adventitial thickness as measured by histology. In conclusion, we developed a robust ultrasound-based elastography method for early detection of intimal changes in small animals.