Superiority of substrate enhancement over oxygen free-radical scavengers during extended periods of cold storage for cardiac transplantation

When cold storage techniques used in cardiac transplantation are extended beyond 3 hours, there is significant depression in ventricular function. This study was undertaken to determine whether the addition of the amino acid L-glutamate or the oxygen free-radical scavengers superoxide dismutase (SOD) and catalase (CAT) during extended periods of cold storage would improve ventricular function. Fifteen rabbit hearts were placed on a Langendorff apparatus, arrested with crystalloid potassium cardioplegia, stored in iced saline solution (3 degrees C) for 5 hours, and then reperfused at 37 degrees C for 1 hour. In five hearts L-glutamate (4 mmol/L) was added to the cardioplegic and reperfusate solutions, and five hearts received SOD (1500 units/kg/L) and CAT (3500 units/kg/L), whereas in five others the cardioplegic and reperfusate solutions were unmodified. Hearts treated with L-glutamate had the best recovery of positive dP/dt (79%* glutamate vs 49%* SOD and CAT vs 36% unmodified), negative dP/dt (76%* glutamate vs 53% SOD and CAT vs 45% unmodified), developed pressure (67%* glutamate vs 51% SOD and CAT vs 45% unmodified), and coronary flow (81%* glutamate vs 79%* SOD and CAT vs 62% unmodified). We conclude that substrate enhancement with L-glutamate provides superior myocardial protection than is possible with the oxygen free-radical scavengers SOD and CAT during extended periods of cold storage for cardiac transplantation.     

Maintenance of the myocardial thiol pool by N-acetylcysteine. An effective means of improving cardioplegic protection.

The reduced thiol pool of myocardial tissue represents an important defense mechanism against oxygen toxicity. Since the ischemia-induced depletion of this pool might favor the cytotoxicity of oxygen-derived free radicals produced during reperfusion, we assessed the effects of the thiol group donor N-acetylcysteine in an isolated buffer-perfused rat heart model of ischemia/reperfusion. Fifty hearts were studied. A first series of experiments that consisted of two groups (n = 10) was designed to simulate the conditions of standard cardioplegic arrest. Hearts were subjected to 180 minutes of cold (15 degrees to 18 degrees C) global ischemia and 1 hour of reperfusion. The control group received crystalloid hyperkalemic cardioplegic solution given every 30 minutes during arrest, and the treated group received the same solution supplemented with N-acetylcysteine (0.04 mol/L). On the basis of comparisons of postreperfusion left ventricular developed pressure, maximal dP/dt, and diastolic pressure, N-acetylcysteine-containing cardioplegic solution afforded significantly better protection. A second series of experiments was then undertaken to assess the effects of N-acetylcysteine in hearts subjected to the sequence of ischemic events that is inherent in transplantation procedures. Hearts were cardioplegically arrested, stored for 5 hours at 2 degrees C, subjected to 1 additional hour of ischemic arrest at 15 degrees to 18 degrees C, and reperfused for 60 minutes. Three groups (n = 10) were studied that differed by the modalities of cardioplegic preservation used during the poststorage ischemic interval. One group received multidose unmodified cardioplegic solution. A second group received multidose cardioplegic solution supplemented with N-acetylcysteine (0.04 mol/L), and the third group was given only a single dose of N-acetylcysteine-enriched (0.07 mol/L) cardioplegic reperfusate at the end of arrest. Multidose N-acetylcysteine-containing cardioplegic solution resulted in a significantly better hemodynamic recovery than unmodified cardioplegic solution. The protection afforded by N-acetylcysteine was lost when the drug was given only at the time of reperfusion. We conclude that supplementation of cardioplegic solution with N-acetylcysteine markedly improves postarrest recovery of function, presumably through an enhancement of the reduced thiol pool, which increases the capacity of reperfused myocardium to handle the postischemic burst of free radical production. The clinical relevance of these findings stems from the fact that thiol-containing drugs are available for human use.     

Improved myocardial preservation during cold storage using substrate enhancement

This study was undertaken to determine whether substrate enhancement with L-glutamate during periods of cold storage would improve ventricular function in transplanted hearts. Thirty-one rabbit hearts were rapidly excised and perfused with Krebs-Henseleit buffer (37 degrees C) on a Langendorff apparatus. They were arrested with hypothermic (4 degrees C), crystalloid, potassium (25 mEq/L) cardioplegia and stored at 3 degrees C for three hours, followed by reperfusion with Krebs-Henseleit buffer for one hour. Hearts were treated in one of several ways: Group 1 (n = 8) did not receive any L-glutamate and serve as controls; group 2 (n = 8) had L-glutamate (4 mmol/L) added to both the cardioplegic and reperfusate solutions; group 3 (n = 5) received L-glutamate only before ischemia; group 4 (n = 5) received L-glutamate only in the cardioplegic solution; and group 5 (n = 5) received L-glutamate only in the reperfusate. Hearts receiving L-glutamate in the reperfusate with or without its addition to the cardioplegic solution (groups 2 and 5) had the best recovery of the first derivative of positive and negative change in left ventricular peak systolic pressure and no significant changes in left ventricular compliance. Pretreatment with L-glutamate alone (group 3) resulted in no better recovery than in group 1 hearts. We conclude that addition of L-glutamate to reperfusate solutions after periods of cold storage for transplantation enhances the recovery of ventricular function.     

A comparative study of free radical scavengers in cardioplegic solutions. Improved protection with peroxidase

Oxygen-derived free radicals play an important role in the myocardial injury associated with ischemia and reperfusion. This study was designed to assess whether the protection afforded by a K+ rich, Mg2+ rich cardioplegic solution could be enhanced by the addition of free radical scavengers acting at different levels of the radical generating pathway. Forty isolated isovolumic rat hearts were divided into five groups (n = 8). Four groups of hearts were subjected to 90 minutes of normothermic cardioplegic arrest followed by 45 minutes of reperfusion. Hearts were given an initial bolus of either unmodified cardioplegic solution or cardioplegic solution enriched with superoxide dismutase (200,000 U/L) reduced glutathione (0.1 mmol/L), or peroxidase (6,000 U/L). One group of hearts was aerobically perfused throughout the experimental protocol and served as nonischemic controls. Based on comparisons of postreperfusion ventricular pressure development, maximal ventricular dP/dt, left ventricular compliance and coronary flow, peroxidase-containing cardioplegic solution afforded the best myocardial protection, with values of these indicators not significantly different from those of nonischemic perfused control heart. Glutathione afforded protection slightly inferior to that of peroxidase but still markedly better than in groups receiving superoxide dismutase or unmodified cardioplegic solution. This study confirms that cardioplegic protection can be enhanced by the addition of free radical scavengers, in particular peroxidase.     

Intracellular free calcium accumulation in ferret vascular smooth muscle during crystalloid and blood cardioplegic infusions.

OBJECTIVE: The effects of magnesium- and potassium-based crystalloid and blood-containing cardioplegic solutions on coronary smooth muscle intracellular free calcium ([Ca2+]i) accumulation and microvascular contractile function were examined. METHODS: Isolated ferret hearts were subjected to hyperkalemic (25 mmol/L K+) blood cardioplegic infusion, hypermagnesemic (25 mmol/L Mg2+, K+-free) crystalloid cardioplegic infusion, or hyperkalemic crystalloid cardioplegic infusion for 1 hour. Coronary arterioles were isolated, cannulated, and loaded with fura 2. Reactivity and [Ca2+]i were assessed with videomicroscopy. [Ca2+]i was measured at baseline and after application of 50 mmol/L KCl. In addition, [Ca2+]i and vascular contraction were measured during exposure to Mg2+ and K+ cardioplegic solution at both 4 degrees C and 37 degrees C. RESULTS: From a baseline [Ca2+]i of 177 +/- 52 nmol/L, K+ cardioplegic infusion (302 +/- 80 nmol/L potassium) markedly increased [Ca2+]i, whereas blood cardioplegic infusion (214 +/- 53 nmol/L) and Mg2+ cardioplegic infusion (180 +/- 42 nmol/L) did not alter [Ca2+]i. Although a difference between groups in percentage contraction after application of 50 mmol/L KCl was not observed, [Ca2+]i increased significantly more in vessels in the control group (764 +/- 327 nmol/L) and the K+ crystalloid cardioplegic infusion group (698 +/- 215 nmol/L) than in vessels in the blood cardioplegic infusion group (402 +/- 45 nmol/L) and the Mg2+ cardioplegic infusion group (389 +/- 80 nmol/L). Mg2+ cardioplegic solution induced no microvascular contraction at either 4 degrees C or 37 degrees C, nor was an increase in [Ca2+]i observed. K+ cardioplegic solution induced microvascular contraction at 37 degrees C but not at 4 degrees C; it increased [Ca2+]i at both 4 degrees C and 37 degrees C. CONCLUSION: An Mg2+-based cardioplegic solution, or appropriate Mg2+ or blood supplementation of a K+ crystalloid cardioplegic solution, may decrease the accumulation of [Ca2+]i in the vascular smooth muscle during ischemic arrest.     

The effect of supplementing hypothermic crystalloid cardioplegia with catalase plus allopurinol in the isolated rabbit heart

The effect of adding allopurinol and catalse to hypothermic cardioplegia for ischemic-reperfusion injury was investigated in the isolated rabbit heart. Hearts were divided into two groups, namely: Group C (n=7), which received a hypothermic crystalloid cardioplegic solution alone (4°C), and group T (n=7), which received the hypothermic cardioplegic solution with allopurinol (148 mol/L)¹³ and catalase (37 nmol/L).¹² The cardioplegic solution was infused continuously into the isolated hearts, which had been placed in ice-cold saline, during a 12 h preservation. Subsequently, the hearts were mounted on a noncirculating, nonpulsatile perfusion circuit using Krebs-Henseleit buffer solution at 37°C for 1 h at a constant perfusion pressure of 75 mm Hg. The left ventricular developed pressure (LVDP), maximum rate of pressure change (max dp/dt), and percent recovery of coronary flow were higher, while the creatine phosphokinase concentration and left ventricular end diastolic pressure (LVEDP) were lower in group T. The tissue malondialdehyde concentration and water content were similar in both groups. Thus, cardiac function after a 12 h preservation was enhanced by the added combination of allopurinol and catalase to the cardioplegic solution, supporting its role in the prevention of free radical reperfusion injury in cardiac preservation.     

Long-term preservation of explanted hearts perfused with L-aspartate-enriched cardioplegic solution. Improved function, metabolism, and ultrastructure.

The effects of supplementing oxygenated St. Thomas' Hospital cardioplegic solution No. 2 with L-aspartate and/or D-glucose for the long-term preservation of excised rat hearts were determined with isolated working heart preparations. Left ventricular function was assessed at 37 degrees C with a crystalloid perfusate, before cardioplegic arrest and after 20 hours of low-flow perfusion (1.5 ml/min) with continuing arrest at 4 degrees C, and after this period, again at 37 degrees C with a crystalloid perfusate. Four groups (n = 8/group) of hearts were studied with four cardioplegic solutions: St. Thomas' Hospital solution alone, St. Thomas' Hospital solution with aspartate 20 mmol/L, St. Thomas' Hospital solution with glucose 20 mmol/L, and St. Thomas' Hospital solution plus both aspartate and glucose (20 mmol/L each). The addition of glucose to St. Thomas' Hospital solution made no significant difference in the recovery of aortic flow rates (17.7% +/- 8.6% and 21.6% +/- 7.8% of prearrest values), but when aspartate or aspartate and glucose were present, hearts showed significant improvements (89.8% +/- 5.2% and 85.0% +/- 6.2%, respectively). These improvements were associated with a reduction in the decline of myocardial high-energy phosphates during reperfusion, a reduction in cellular uptake of Na+ and Ca++, and a reduction in ultrastructural damage. These results indicate that low-flow perfusion with St. Thomas' Hospital solution plus aspartate can considerably extend the duration of safe storage of explanted hearts.     

Protection of the neonatal heart following normothermic ischemia: a comparison of oxygenated saline and oxygenated versus nonoxygenated cardioplegia

Optimal methods of myocardial preservation in the neonate remain unknown. Hypothermia and cardioplegia have been shown to protect neonatal hearts, but few studies have examined the effects of cardioplegia when administered at normothermia. Accordingly, the role of 37 degrees C St. Thomas' cardioplegic solution in protecting the neonatal heart during 1 hour of ischemia in an isolated working rabbit heart model was examined. Both oxygenated and nonoxygenated cardioplegic solutions (CSs) were evaluated and compared with an oxygenated physiological saline solution (PSS). Following ischemia, control hearts were characterized by severely impaired left ventricular function, whereas all three treatment groups recovered well, indicating that the treatments provided substantial protection. Aortic flow recovered to 62, 63, and 57% of preischemic values for the oxygenated CS, nonoxygenated CS, and oxygenated PSS groups, respectively. Similarly, rate of change of pressure recovered to 76, 80, and 76% of preischemic values for oxygenated CS, nonoxygenated CS, and oxygenated PSS groups. All values were significantly greater than those for the control group. Recovery of developed pressure was significantly improved in all three groups. End-diastolic pressure rose markedly following ischemia in control hearts, was not increased after ischemia in hearts receiving oxygenated and nonoxygenated CS, but was increased in the oxygenated PSS group. These data indicate that crystalloid cardioplegia and oxygenated PSS provide substantial protection in neonatal rabbit hearts, even when delivered at 37 degrees C. No additional benefit was seen when the cardioplegic solution was oxygenated. Therefore, either method of balancing the oxygen supply/demand ratio appears to be beneficial: supplying oxygen intermittently during ischemia (oxygenated PSS group) or decreasing oxygen demand during the ischemic period (cardioplegia groups).     

Nitric oxide attenuates cardiomyocytic apoptosis via diminished mitochondrial complex I up-regulation from cardiac ischemia-reperfusion injury under cardiopulmonary bypass

OBJECTIVE: This study tested the hypothesis that cardioplegic solution supplemented with a nitric oxide donor agent attenuates postischemic cardiomyocytic apoptosis by reduction of mitochondrial complex I up-regulation during global cardiac arrest under cardiopulmonary bypass. METHODS: Twenty-four anesthetized dogs supported by total vented bypass were divided evenly into 4 groups (n = 6) and subjected to 60 minutes of hypothermic ischemia followed by 4 degrees C multidose crystalloid cardioplegic solution infusion. Hearts received either standard crystalloid cardioplegic solution (control), crystalloid cardioplegic solution supplemented with 2 mmol/L L-arginine (L-Arg group), crystalloid cardioplegic solution supplemented with 400 micromol/L N(G)-monomethyl-L-arginine (L-NMMA group), or crystalloid cardioplegic solution supplemented with 100 micromol/L of NO donor compound (3-morpholinosydnonimine; SIN-1 group). After 60 minutes of cardioplegic arrest, the heart was reperfused for a total of 240 minutes after discontinuation of bypass. The occurrence of cardiomyocytic apoptosis was assessed by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling and Western blot analysis of caspase-3. RESULTS: The occurrence of cardiomyocytic apoptosis was significantly reduced in SIN-1 and L-Arg groups compared with the control group. Mitochondrial complex I mRNA was up-regulated in the control group, and its expression was significantly higher in the L-NMMA group but significantly reduced in the SIN-1 and L-Arg groups. Western blot analysis of Bcl-2 and cytochrome c, an index of mitochondrial damage in postischemic myocardium, revealed a similar pattern. CONCLUSION: Nitric oxide-supplemented crystalloid cardioplegic solution diminished postischemic cardiomyocytic apoptosis after global cardiac arrest under cardiopulmonary bypass, possibly via prevention of mitochondrial complex I up-regulation.     

Harvesting hearts for long-term preservation. Detrimental effects of initial hypothermic infusion of cardioplegic solutions

Current procedure for harvesting human donor hearts for long-term storage before transplantation involves direct infusion of a hypothermic (4 degrees C) crystalloid cardioplegic solution into the normothermic (37 degrees C) heart in situ. We used the isolated perfused working rat heart preparation to investigate whether infusing cold crystalloid solutions into normothermic blood-containing hearts was consistent with maximal myocardial protection. Hearts (n = 6 per group) were excised and subjected to a primary (1 minute) infusion with either the St. Thomas' Hospital cardioplegic solution or a bicarbonate buffer solution, at 7.5 degrees C, 22 degrees C, or 37 degrees C. This was followed by a secondary infusion (2 minutes) with cold (7.5 degrees C) cardioplegic solution, after which all hearts were stored at 7.5 degrees C for 6 hours and then reperfused at 37 degrees C for 60 minutes, during which time creatine kinase leakage and cardiac function were measured. Primary infusion with warm solutions resulted in (1) decreased coronary vascular resistance during cardioplegic infusion and (2) greater postischemic cardiac function. This suggests that their use, before the standard cold infusion, might be beneficial to the long-term preservation of transplant donor hearts.     

Prevention of free radical-induced myocardial reperfusion injury with allopurinol

Growing evidence supports the concept that oxygen free radicals are an important cause of myocardial ischemic and reperfusion injury. This study was designed to determine if toxic oxygen metabolites may exacerbate ischemic injury upon reoxygenation. Left ventricular function was studied in a group of seven dogs receiving intermittent, 4 degrees C, hyperosmolar, hyperkalemic (KCI 25 mEq/L) saline cardioplegic solution. This group was compared to a group (n = 7) receiving a hyperkalemic (KCI 25 mEq/L) cardioplegic solution designed to scavenge superoxide anion and hydroxyl radical: superoxide dismutase (3,000 U/ml) and mannitol (325 mOsm/L). A third group of five animals received allopurinol pretreatment (50 mg/kg/day) for 72 hours and hyperkalemic saline cardioplegic solution. After 60 minutes of ischemia (10 degrees to 15 degrees C) and 45 minutes of reperfusion, left ventricular mechanical function was better in the groups receiving free radical scavengers and allopurinol pretreatment than in the group receiving only hyperkalemic saline cardioplegic solution. Free radical scavengers preserved myocardial function in this model of hypothermic global ischemia and reperfusion. Our data support the concept that injury occurs primarily during reperfusion with the generation of oxygen free radicals via the hypoxanthine-xanthine oxidase reaction. Allopurinol has potential clinical application in the prevention of reperfusion injury.     

The addition of glutathione (YM737) to a crystalloid cardioplegic solution enhances myocardial protection

The effectiveness of a glutathione preparation, YM737, as a free radical scavenger when added to hypothermic (4°C) crystalloid cardioplegic solution was evaluated in this study. Rabbit hearts were preserved for 3 h in cardioplegic arrest by infusing 20 ml crystalloid cardioplegic solution initially, with additional 10-ml boluses administered every 30 min, while maintaining a myocardial temperature of 10°C. They were then reperfused with Krebs-Henseleit bicarbonate buffer at 37°C in a perfusion circuit for 60 min. The hearts were divided into two groups of six: One in which crystalloid cardioplegic solution was perfused (group 1); and one in which crystalloid cardioplegic solution containing YM737 1 mg/ml was perfused (group 2). The postischemic developed pressure (mmHg) in group 2 was significantly greater than that in group 1 after 60 min of reperfusion, being 44.8 ± 8.4 versus 87.8 ± 5.2 in groups 1 and 2, respectively (P < 0.01). Moreover, group 2 exhibited significantly lower postischemic left ventricular compliance after 60 min than group 1 (P < 0.01) and a significantly higher postischemic peak LV dp/dt (mmHg/sec) after 60 min of reperfusion, being 925 ± 213 versus 1,550 ± 111 in groups 1 and 2, respectively (P < 0.05). Based on the comparisons of postischemic hemodynamics it was concluded that the addition of glutathione to crystalloid cardioplegic solution does in fact enhance myocardial protection.     

Long-term neonatal heart preservation

Donor availability is a major limiting factor in neonatal heart transplantation. Prolonging donor heart preservation would facilitate distant heart procurement. Forty-two neonatal (1 to 5 days) piglet hearts in seven groups were arrested with cold cardioplegic solutions, stored for 12 hours at 4 degrees C in storage solutions, and reperfused with blood from an adult support pig. The cardioplegic solutions used were a crystalloid solution with potassium chloride 30 mEq/L and bicarbonate (Stanford), the Stanford cardioplegic solution with the addition of calcium (1.2 mmol/L), or an intracellular solution (Sacks) with added glucose. Storage solutions were normal saline, Sacks II, or Sacks II with glucose 20 gm/L. Reperfusion was done with normal blood or modified blood for 20 minutes with superoxide dismutase, catalase, aspartate, glutamate, citrate-phosphate-dextrose, potassium, tromethamine, and 50% dextrose followed by normal blood. Evaluation of stroke work index after 60 minutes of recovery (as percent of control) was performed using the isolated, blood perfused, working heart preparation in all groups: Group I (Stanford cardioplegia, saline storage, normal blood reperfusion) had a recovery of 11%; group II (Stanford + calcium, saline, normal blood) 8%; group III (Stanford + calcium, saline, modified blood, superoxide dismutase 35,000 U/L, catalase 35,000 U/L) 37%; group IV (Stanford + calcium, Sacks II, modified blood, superoxide dismutase 35,000 U/L, catalase 35,000 U/L), 47%; group V (Stanford + calcium, Sacks + glucose, modified blood, superoxide dismutase 35,000 U/L, catalase 105,000 U/L) 89%; group VI (Stanford + calcium, Sacks + glucose, modified blood, superoxide dismutase 150,000 U/L, catalase 150,000 U/L) 107%; group VII (Sacks + glucose, Sacks + glucose, modified blood, superoxide dismutase 35,000 U/L, catalase 105,000 U/L) 115%. Conclusions: The neonatal heart stored hypothermically for 12 hours tolerates normal blood reperfusion poorly. Modified blood reperfusion markedly improves the recovery. Complete functional recovery was achieved by the intracellular Sacks plus glucose storage solution and modified blood reperfusion with oxygen-derived free radical scavengers (high catalase). Extended preservation of the neonatal heart is feasible.     

Evaluation of a new calcium containing cardioplegic solution in the isolated rabbit heart in comparison to a calcium-free, low sodium solution

Isolated perfused rabbit hearts were studied to compare the effects of 3 hour ischemic arrest following either calcium-free or calcium-containing cardioplegia, on the recovery of isovolumic function of the left ventricle, coronary flow, release of creatine phosphokinase and myocardial water content. The hearts perfused with the calcium-containing solution (Ca 0.5 mmol/L) showed better recovery of the developed pressure in the left ventricle, and its first derivative and compliance. Coronary flow at a constant perfusion pressure was better restored during reperfusion in the hearts with calcium-containing solution. The release of less CPK and a lower water content were also observed in the hearts reperfused with calcium-containing solution. We concluded that calcium-containing cardioplegic solution with a high concentration of magnesium (10 mmol/L) was superior to calcium-free solution for myocardial protection.     

Evaluation of a new calcium containing cardioplegic solution in the isolated rabbit heart in comparison to a calcium-free,low sodium solution

Isolated perfused rabbit hearts were studied to compare the effects of 3 hour ischemic arrest following either calcium-free or calcium-containing cardioplegia, on the recovery of isovolumic function of the left ventricle, coronary flow, release of creatine phosphokinase and myocardial water content. The hearts perfused with the calcium-containing solution (Ca 0.5 mmol/L) showed better recovery of the developed pressure in the left ventricle, and its first derivative and compliance. Coronary flow at a constant perfusion pressure was better restored during reperfusion in the hearts with calcium-containing solution. The release of less CPK and a lower water content were also observed in the hearts reperfused with calcium-containing solution. We concluded that calcium-containing cardioplegic solution with a high concentration of magnesium (10 mmol/L) was superior to calcium-free solution for myocardial protection.     

Methods of cardiac preservation alter the function of the endothelium in porcine coronary arteries

This study was undertaken to determine whether clinical methods for preservation and storage of hearts explanted for transplantation affect the responsiveness of coronary arteries to vasoactive agents. Porcine hearts were perfused with crystalloid or blood cardioplegic solution. Rings of coronary arteries were suspended in organ chambers for measurement of isometric force (1) immediately after perfusion and (2) after 5 hours' storage of the hearts at 4 degrees C in the same cardioplegic solution (n = 6 in each group). The maximal contraction of the smooth muscle to potassium chloride, 40 mmol/L, was reduced significantly after perfusion with crystalloid cardioplegic solution (10.8 +/- 1.2 gm) compared with blood cardioplegic solution (17.3 +/- 0.8 gm) and nonperfused coronary arteries (control group 16.9 +/- 1.8 gm). The sensitivity of the arteries with endothelium to the contractile effects of prostaglandin F2 alpha increased after perfusion with crystalloid cardioplegic solution (ED50, [-log mol/L] 5.8 +/- 0.04) compared with blood cardioplegic solution (5.3 +/- 0.02) and the control group (5.7 +/- 0.03). In addition, relaxations to the calcium ionophore A23187, bradykinin, and the alpha 2-agonist BHT-920, which depend on the presence of endothelial cells, were significantly reduced after perfusion with crystalloid compared with blood cardioplegic solution or the control group. The responsiveness of the endothelium and smooth muscle after 5 hours' cold storage was unaltered in the blood cardioplegia group, whereas storage resulted in functional recovery in the crystalloid cardioplegia group, with the result that all groups were comparable. These data suggest an immediate and reversible change in vascular function with crystalloid cardioplegia, which was not apparent with blood cardioplegia.     

Free radical scavengers and myocardial preservation during transplantation

The efficacy of oxygen radical scavengers in preservation of left ventricular (LV) function after prolonged hypothermic global ischemia was investigated in a model of orthotopic cardiac transplantation in sheep. Group 1 hearts (N = 8) received hypothermic crystalloid cardioplegic solution, and were harvested and stored at 4 degrees C in balanced electrolyte solution for six hours prior to transplantation. Group 2 (N = 9) received identical treatment with the addition of 30,000 units of superoxide dismutase to the cardioplegic solution and the administration of 60,000 units of superoxide dismutase coincident with reperfusion. All animals were weaned from cardiopulmonary bypass. Preischemic and postischemic LV function was determined using sonomicrometry and a micromanometer-tipped LV catheter. Coronary blood flow was determined using standard microsphere techniques, and platelet deposition was assayed with autologous platelets labeled with indium 111. Lipid peroxidation products were measured using thiobarbituric acid assay. LV performance was significantly better (p less than .05) in Group 2 hearts when assessed by the slope of the end-systolic pressure-volume relationship and the stroke work versus end-diastolic volume relationship. There was better preservation of endocardial blood flow in the group receiving superoxide dismutase compared with controls (p less than .05). Platelet deposition, as determined by the tissue to blood ratio of scintigraphic counts, was greater (p less than .05) in controls compared with the group receiving superoxide dismutase. In addition, thiobarbituric acid reactive species were significantly less (p less than .05) in Group 2 versus Group 1 hearts.(ABSTRACT TRUNCATED AT 250 WORDS)     

Myocardial protection of neonatal heart by cardioplegic solution with recombinant human superoxide dismutase.

The effectiveness of high-potassium cardioplegic solution in the neonatal heart remains controversial. Our previous study indicated that the protection afforded by a cardioplegic solution was inadequate in the neonatal heart. On the hypothesis that oxyradicals were responsible for the ineffectiveness of cardioplegic solution in neonatal heart, the effects of a cardioplegic solution (a modified St. Thomas' Hospital cardioplegic solution) with recombinant human superoxide dismutase on the isolated perfused neonatal guinea pig hearts (within 2 days after delivery, body weight of 60 to 120 g) were studied in comparison with those on the adult hearts (6 to 8 weeks after delivery, body weight of 300 to 500 g). After arrest induced by modified St. Thomas' Hospital cardioplegic solution, hearts were subjected to 120 min of ischemia at 20 degrees C, during which time the cardioplegic solution was injected every 30 minutes. Then the heart was reperfused for 60 minutes at 37 degrees C. Under this condition, the left ventricular developed pressure recovered to 84.4% +/- 4.0% of the preischemic value in the adult heart, whereas the recovery was only 68.1% +/- 3.1% in the neonatal heart. Thiobarbituric acid-reactive substance level, a parameter of lipid peroxidation by oxyradicals, significantly increased during ischemic arrest both in the adult and neonatal heart. However, the increase was much greater in the neonatal heart than in the adult. Cardioplegia with recombinant human superoxide dismutase (300 and 1,000 U/mL) significantly inhibited this accumulation of thiobarbituric acid-reactive substance in the neonatal heart; at 1,000 U/mL, the myocardial function of the reperfused neonatal heart recovered to the level of the adult heart.(ABSTRACT TRUNCATED AT 250 WORDS)     

Studies of controlled reperfusion after ischemia. XXI. Reperfusate composition: superiority of blood cardioplegia over crystalloid cardioplegia in limiting reperfusion damage--importance of endogenous oxygen free radical scavengers in red blood cells

Postischemic damage is caused partially by oxygen free radical-mediated injury. This study will show that (1) crystalloid cardioplegia with room air oxygen is deleterious because it is devoid of free radical scavengers and (2) blood cardioplegia limits damage because it contains endogenous free radical scavengers in red blood cells. METHODS: Thirty-two dogs underwent 2 hours of ligation of the left anterior descending coronary artery followed by 20 minutes of regional blood cardioplegic reperfusion on bypass. Ten dogs received only the blood cardioplegic solution (containing its endogenous free radical scavengers); five received initial blood cardioplegia (5 minutes) with endogenous free radical scavengers (catalase and glutathione peroxidase) blocked by aminotriazole and N-ethylmaleimide, respectively; 12 received initial crystalloid cardioplegic solution oxygenated by room air (oxygen tension = 150 mm Hg); seven without and five with exogenous free radical scavengers (superoxide dismutase, catalase, coenzyme Q10); five received initial deoxygenated crystalloid cardioplegic solution (oxygen tension = 6 mm Hg); and five received deoxygenated crystalloid cardioplegic solution. RESULTS: Blood cardioplegia with endogenous free radical scavengers produced the best recovery of systolic shortening (69% systolic shortening) and resulted in the least histochemical damage (11% triphenyltetrazolium chloride nonstaining). The worst recovery and most damage occurred if blood cardioplegia was preceded by oxygenated crystalloid cardioplegia (3% systolic shortening, 48% triphenyltetrazolium chloride nonstaining; p less than 0.05 versus blood cardioplegia) or if free radical scavengers were blocked in the initial period of blood cardioplegia (3% systolic shortening, 41% triphenyltetrazolium chloride nonstaining; p less than 0.05 versus blood cardioplegia). Conversely, deoxygenation or supplementation of oxygenated crystalloid cardioplegic solution with exogenous free radical scavengers restored 60% systolic shortening (p less than 0.05 versus oxygenated crystalloid cardioplegia) and 54% systolic shortening (p less than 0.05 versus oxygenated crystalloid cardioplegia) and reduced damage to 34% and 21% (both p less than 0.05 versus oxygenated crystalloid cardioplegia). CONCLUSION: Blood cardioplegic solutions containing their own endogenous free radical scavengers are superior to crystalloid cardioplegic solutions, because they limit oxygen-mediated perfusion damage and restore contractile function. Initial crystalloid cardioplegic washout negates the salutary effect of blood cardioplegia. Exogenous free radical scavenger supplementation or deoxygenation of the cardioplegic reperfusate is necessary only if crystalloid cardioplegia is used.     

The effect of amino acids on the ischemic heart. Improvement of oxygenated crystalloid cardioplegic solution by an enriched branched chain amino acid formulation

This study was designed to test the effect of glucose and a formulation enriched with branched chain amino acids as additives to oxygenated crystalloid cardioplegic solution in the ischemic heart. Energy-depleted isolated working rat hearts were subjected to 68 minutes of normothermic global ischemia during which oxygenated cardioplegic solution was used to protect them. The hearts were then reperfused in the nonworking mode for 10 minutes and for a further 30 minutes in the working mode. The hearts were randomly divided into three groups, in which various oxygenated cardioplegic solutions were perfused. Group 1 (control) was subjected to modified St. Thomas' Hospital cardioplegic solution and groups 2 and 3 to the same solution with the addition of glucose (11.1 mmol/L) and glucose (11.1 mmol/L) and branched chain amino acids, respectively. Recovery of aortic flow, coronary flow, cardiac output, aortic pressure, adenosine triphosphate, creatine phosphate, and oxygen consumption was significantly better in group 2 than in group 1. In addition, recovery of aortic flow, coronary flow, cardiac output, aortic pressure, stroke volume, minute work, adenosine triphosphate, and creatine phosphate was found to be significantly enhanced in group 3. Release of adenine catabolites and lactic dehydrogenase from these hearts during postischemic reperfusion was significantly decreased. Thus, during global ischemia in the energy-depleted heart, the presence of glucose and branched chain amino acids in oxygenated crystalloid cardioplegic solution enhanced myocardial protection.