Judith C. Rembert

Myocardial Blood Flow Distribution in Concentric Left Ventricular Hypertrophy

Regional myocardial blood flow during both control conditions and ischemia-induced vasodilatation was studied in eight chronically instrumented awake dogs. Seven of these animals had coarctation-banding of the ascending aorta performed at 6 wk of age, and the other dog had congenital subvalvular aortic stenosis. The mean left ventricular weight for the group was 157+/-7.6 g, and the left ventricular body weight ratio was 8.76+/-0.47 g/kg. None of the animals exhibited signs of congestive heart failure. During the control state, the mean left ventricular systolic pressure was 249+/-12 mm Hg and the left ventricular end-diastolic pressure was 11.5+/-0.5 mm Hg. The aortic diastolic pressure was 74+/-6 mm Hg. Mean left circumflex coronary artery blood flow was 71+/-6 cm(3)/min. In the animals with coarctation-banding, 52+/-6% of the flow occurred during systole. In the dog with congenital subvalvular aortic stenosis, 5% of the coronary flow was systolic. Mean transmural blood flow during resting conditions was 0.97+/-0.08 cm(3)/min per g, and the ratio of endocardial to epicardial flow (endo/epi) was 0.88+/-0.07. During reactive hyperemia, the mean transmural blood flow increased to 3.5+/-0.30 cm(3)/min per g; however, the endo/epi decreased to 0.52+/-0.06.THESE STUDIES DOCUMENT A DIFFERENCE IN TRANSMURAL BLOOD FLOW DISTRIBUTION BETWEEN THE NORMAL AND THE HYPERTROPHIED LEFT VENTRICLE: during resting conditions, in the normal ventricle, the highest flow occurs in the endocardial layer, whereas in the hypertrophied ventricle, the highest flow is in the middle layers with the endocardial flow less than the epicardial flow. During ischemia-induced vasodilatation, the abnormal endo/epi becomes accentuated markedly. These data demonstrate that, in situations requiring high flow, the endocardial layer of a heart with marked concentric left ventricular hypertrophy may not be perfused adequately.

Pressure-Flow Studies in Man: Effect of Respiration on Left Ventricular Stroke Volume

The pressure gradient technique was used to evaluate effects of respiration on left ventricular stroke volume in 22 patients: 11 normal patients; eight patients with airway obstruction; and three patients with pericardial tamponade. In normals, stroke volume, systolic pressure, and pulse pressure fell an average of 7, 3 and 11% (P < 0.01), respectively, during inspiration. In patients with airway obstruction, these parameters decreased by 25, 12 and 23% (P < 0.001), respectively. After breath-holding, stroke volume also fell immediately with the onset of inspiration in both groups. These results are consistent with a reduction in left ventricular filling during inspiration as the factor primarily responsible for the fall in stroke volume. In patients with pericardial tamponade, variations in left ventricular stroke volume, systolic pressure and pulse pressure were related to: (1) an immediate fall in stroke volume with the onset of inspiration; and (2) a subsequent increase in stroke volume presumably due to an inspiratory increase in right ventricular stroke volume.

Transient changes in cerebral vascular resistance during the Valsalva maneuver in man.

Measurements of cerebral spinal fluid pressure, arterial pressure, and internal carotid artery blood flow were obtained in a series of patients during a Valsalva maneuver. During straining (phase II), an 11% reduction in mean arterial pressure was associated with a 21 % decrease in internal carotid flow from control values; and following release (phase IV), the 19% increase in mean arterial pressure produced a 22% increase in internal carotid artery flow. Perfusion pressure computed as the mean arterial pressure minus cerebral spinal fluid pressure and internal carotid artery blood flow were used to calculate an index of cerebral vascular resistance. The data indicate that a modest but significant decrease in vascular resistance occurred during phases II and III followed by return to control levels during phase IV. These changes in vascular resistance were not rapid enough or of sufficient magnitude to maintain constant cerebral perfusion during the Valsalva maneuver. Stroke Vol 15, No I, 1984

Effects of nitroglycerin on transmural myocardial blood flow in the unanesthetized dog.

This study was designed to determin the effect of nitroglycerin upon transmural distribution of myocardial blood flow in the awake dog during normal conditions and in the presence of ischemia-induced coronary vasodilation. Studies were performed in chronically prepared dogs with electromagnetic flowmeters and hydraulic occluders on the left circumflex coronary artery. Regional myocardial blood flow was estimated by using radionuclide-labeled microspheres, 7-10 mum in diameter, injected into the left atrium. During control conditions endocardial flow (0.86 plus or minus SEM 0.05 ml/min per g) slightly exceeded epicardial flow (0.72 plus or minus 0.03 ml/min per g, P smaller than 0.05), and this distribution of flow was not significantly altered by nitroglycerin. After a 5-s coronary artery occlusion, reactive hyperemia occurred with excess inflow of arterial blood effecting 360 plus or minus 15% repayment of the blood flow debt incurred during occlusion. When arterial inflow was limited to the preocclusion rate during coronary vasodilation after a 5-s total coronary artery occlusion, flow to the subepicardial myocardium was increased at the expense of underperfusion of the subendocardial myocardium, and the delayed reactive hyperemia was markedly augmented (mean blood flow debt repayment =775plus or minus 105%, P smaller than 0.01). Tese data suggested that subendocardial underperfusion during the interval of coronary vasodilation in the presence of a flow-limiting proximal coronary artery stenosis caused continuing subendocardial ischemia which resulted in augmentation of the reactive hyperemic response. In this experimental model both the redistribution of myocardial blood flow which occurred during an interval of restricted arterial inflow after a 5-s coronary artery occlusion and augmentation of the subsequent reactive hyperemic response were returned toward normal by nitroglycerin. This effect of nitroglycerin may have resulted, at least in part, from its ability to vasodilate the penetrating arteries which deliver blood from the epicardial surface to the subendocardium.

Studies of Blood Flow in Aorta-to-Coronary Venous Bypass Grafts in Man

Pressure-flow measurements were obtained from the vein graft of 57 patients undergoing a single aorta-to-coronary bypass procedure. The flow contour was similar to phasic left coronary artery flow in dogs except for a transient increase during systole possibly related to elongation of the graft. Flow was highest during bypass and decreased to a stable value 30 min after bypass. In 42 patients, flow at this time was 35+/-2 cm(3)/min (mean+/-sem).NO CORRELATIONS WERE DEMONSTRATED BETWEEN FLOW AND THE FOLLOWING: left vs. right grafts, presence or absence of collaterals, total vs. partial block, or the presence or absence of ventricular dyskinesis. In 32 patients, no correlation between these anatomic findings and the presence of reactive hyperemia was demonstrated. In 17 patients, occlusion of the graft for 10 sec resulted in a mean 51.5% flow debt repayment. In nine patients, injection of 0.3 mug of isoproterenol into the graft increased flow from 45+/-6 to 69+/-9 cm(3)/min within 4-7 sec without changes in rate, pressure, time derivative of left ventricular pressure (LV dp/dt), or left ventricular end diastolic pressure (LVEDP). Maximum increases to 87+/-10 cm(3)/min occurred 12-20 sec after injection with concomitant changes in these parameters. Intravenous infusion of norepinephrine did not change vascular resistance, whereas phenylephrine did. In six patients, injection of 0.2 mug of norepinephrine into the graft decreased flow from 49+/-6 to 25+/-5 cm(3)/min within 5-8 sec. Intravenous infusion of 0.15 mg of nitroglycerin decreased coronary vascular resistance from 2.7+/-0.4 to 2.3+/-0.3 mm Hg/cm(3) per min. In five patients, 0.12 mg of nitroglycerin injected into the graft increased flow from 46+/-7 to 71+/-13 cm(3)/min and lasted 20-40 sec.

Effects of exercise- and pacing-induced tachycardia on coronary collateral flow in the awake dog.

Collateral blood flow was studied in chronically instrumented awake dogs 11-12 weeks after implantation of ameroid constrictors on the right and left circumflex coronary arteries. Using 7-10 fim radionuclide-labeled microspheres, transmural myocardial blood flow was measured during resting conditions and at similar heart rates during ventricular pacing and treadmill exercise. The absence of significant myocardial fibrosis was verified histologically. Control transmural flow was distributed normally in all dogs. In five dogs a marked maldistribution of flow occurred in the collateral region during pacing and exercise. During pacing, flow to the epicardial layers increased while flow to the endocardial layers was unchanged, resulting in a marked endocardial perfusion deficit. During exercise, flow increased substantially to all transmural layers, but the endocardial perfusion deficit remained. Mean transmural blood flow increased similarly in the collateral and noncoUateral regions during pacing; however, during exercise, mean flow in the collateral region was significantly lower than in the noncollateral region. These data demonstrate that the collateral vessels became flow limiting and functioned inadequately during tachycardia produced by pacing and exercise; i.e., a marked perfusion deficit occurred in the endocardial layer. Blood flow to all layers in the collateral-dependent region was higher during exercise than during pacing, possibly due to exercise-induced vasodilation of the collateral channels. Circ Res 46: 214-220, 1980

Regional myocardial blood flow after sudden aortic constriction in awake dogs.

Hemodynamk and regional myocardial Mood flow responses were studied 5 seconds (early) and 30 seconds (late) after abrupt proximal aortic constriction in chronically instrumented awake dogs. During the early phase, left ventricular end-diastolic pressure (LVEDP) increased and stroke volume (SV) decreased significantly. During the late phase, there was a positive inotropic response manifested by a decrease in LVEDP and increase in SV (Anrep effect). The late inotropic response was closely associated with a recovery from subendocardial underperfusion. Hemodynamic and regional flow responses after 0-adrenergic blockade with propronolol (0.4 mg/kg) were similar to those observed during control. Studies during coronary vasodilation induced by adenosine (0.75- 1.0 mg/kg per minute) showed that, if subendocardial flow was elevated during the early phase, the early increase of LVEDP and decrease of SV were less than control; however, if subendocardial flow did not change from control in the early phase and did not subsequently increase, there was no late inotropic response. These data suggest that the Anrep effect in the awake dog is closely related to a recovery from subendocardial ischemia.

Relation of left ventricular mass to geometry of the proximal coronary arteries in the dog

Proximal epicardial coronary artery luminal diameters were measured from silicone casts formed in situ in freshly excised hearts under a constant pressure of 100 mm Hg. Twenty-five coronary arteries from 15 normal dogs and 22 coronary arteries in 13 dogs with either chronic pressure or volume overload hypertrophy were studied. Mean left ventricular (LV) body weight ratios were 4.75 +/- 1.01 g/kg in the normal dogs, 8.4 +/- 1.7 g/kg in the pressure-overload dogs, and 6.2 +/- 0.6 g/kg in the volume-overload dogs. The cross-sectional area of the left circumflex (LC) coronary artery was determined at 11 branch sites. The ratio of the area of the branches to the area of the parent vessel was 1.095 +/- 0.105, indicating that the cross-sectional area after a branch point increased. A poor correlation existed between LV mass and coronary artery diameter in both normal and hypertrophy groups for the LC (r = 0.44), the left anterior descending (LAD) (r = 0.63), and the combined LC and LAD (r = 0.52). The mean cross-sectional area of the combined LC and LAD was 0.12 cm2 in the normal group and 0.15 cm2 in the hypertrophy group; this increase was not statistically significant (p = 0.13). When the mean cross-sectional area of the combined vessels was adjusted for heart weight, there was a decrease in the cross-sectional area/100 g of myocardium in the hypertrophy group compared with the control group. These data demonstrate that coronary artery luminal diameter in the dog does not increase commensurately with the increase in mass associated with myocardial hypertrophy.

Effects of acute cellular injury on coronary vascular reactivity in awake dogs.

SUMMARY The study was designed to examine effects of acute cellular injury on regional myocardial blood flow (RMBF) and coronary vascular reactivity. Before myocardial infarction in 14 dogs, RMBF was measured using 7-lO,u microspheres during the hyperemic response following a 60 sec transient ischemic stimulation (TIS). Myocardial infarction was induced by complete occlusion for two hours and then inflow to the injured area was re-established. RMBF was measured four hours later during basal conditions, following a 60 sec TIS and during infusion of adenosine, 1.0 mg/kg/min. Effects of acute cellular injury were examined by measuring RMBF in multiple myocardial samples, grouped according to extent of histologic necrosis. Four hours after reperfusion, RMBF was decreased when infarction exceeded 50%. The decrements in flow were directly proportional to the extent of infarction. The vasculature was capable of delivering additional flow to the injured area since both TIS and adenosine infusion effected increases in RMBF in excess of 100% in each region of the ischemic zone. Blood flow responses to these stimuli, however, fell in proportion to the extent of infarction. RMBF responses to TIS and adenosine infusion were comparable, indicating ischemia which effects irreversible myocardial injury also directly alters vasomotor properties of the intramural vasculature.

Mitochondrial function in canine experimental cardiac hypertrophy

Concentric left ventricular hypertrophy was produced in puppies by coarctation banding of the aorta at age 7 weeks. Hemodynamic, morphologic and biochemical studies were carried out 18 months after the operation. Systolic blood pressure proximal to the aortic constriction was 216 +/- 16 mmHg in experimental dogs compared with 115 +/- 5 mmHg in littermate control dogs. Ejection fraction of control and experimental dogs were 59 +/- 4 and 64 +/- 7, respectively. The left ventricular end-diastolic pressure was 6.0 +/- 0.4 in control and 8.4 +/- 1.1 in experimental dogs. There was no sign of overt heart failure in the experimental dogs. Anatomical analysis of different regions of the heart indicated that LV mass in the experimental dogs was increased by about 60%. Ultrastructure of mitochondria in situ, as observed under electron microscope, was normal both in control and hypertrophic hearts. Mitochondria isolated from epicardial and endocardial regions of the stable hypertrophic hearts showed normal rates of respiration, phosphorylation, citrate synthase, and cytochrome c oxidase activities compared to those isolated from hearts of littermate control dogs. It was, therefore, concluded that mitochondrial function is adequately preserved to meet the increased demand for energy in this model of stable cardiac hypertrophy of long duration.