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BACKGROUND: The Telectronics Accufix pacing leads were recalled in November 1994 after 2 deaths and 2 nonfatal injuries were reported. This multicenter clinical study (MCS) of patients with Accufix leads was designed to determine the rate of spontaneous injury related to the J retention wire and results of lead extraction. METHODS AND RESULTS: The MCS included 2589 patients with Accufix atrial pacing leads that were implanted at or who were followed up at 12 medical centers. Patients underwent cinefluoroscopic imaging of their lead every 6 months. The risk of J retention wire fracture was approximately 5.6%/y at 5 years and 4.7%/y at 10 years after implantation. The annual risk of protrusion was 1.5%. A total of 40 spontaneous injuries were reported to a worldwide registry (WWR) that included data from 34 672 patients (34 892 Accufix leads), including pericardial tamponade (n=19), pericardial effusion (n=5), atrial perforation (n=3), J retention wire embolization (n=4), and death (n=6). The risk of injury was 0.02%/y (95% CI, 0.0025 to 0. 072) in the MCS and 0.048%/y (95% CI, 0.035 to 0.067) in the WWR. A total of 5299 leads (13%) have been extracted worldwide. After recall in the WWR, fatal extraction complications occurred in 0.4% of intravascular procedures (16 of 4023), with life-threatening complications in 0.5% (n=21). Extraction complications increased with implant duration, female sex, and J retention wire protrusion. CONCLUSIONS: Accufix pacing leads pose a low, ongoing risk of injury. Extraction is associated with substantially higher risks, and a conservative management approach is indicated for most patients.

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OBJECTIVE: The aims were (1) to measure simultaneously and on a beat to beat basis intracellular calcium concentration ([Ca2+]i) transients and force transients in isolated ferret cardiac trabeculae; (2) to obtain and compare independent estimates of the recirculating fraction of Ca2+ using the [Ca2+]i data and the force data (recirculating fraction is the fraction of activator Ca2+ taken up by the sarcoplasmic reticulum in each beat and, in the steady state twitch, the fraction of activator Ca2+ released by the sarcoplasmic reticulum); and (3) to estimate the amount of Ca2+ that returns to the sarcoplasmic reticulum and the amount that, during steady state contractions, enters the cytosol, presumably from the extracellular compartment, with each beat. METHODS: Eight trabeculae were mounted in the myograph. The servo-controlled muscle length was 98% of the length at which developed force was maximal. A modified technique was used for chemical loading of aequorin, and a new method for computer controlled low level photon counting, storage, calibration, and analysis. [Ca2+]i transients and force transients were simultaneously recorded during potentiated beats, together with their respective decays toward control steady state [Ca2+]i transients and force transients. A modified test of postextrasystolic potentiation achieved with a brief train of rapid pacing followed by a pause was used to evoke the potentiated beats. RESULTS: At 2.0 mM extracellular Ca2+ ([Ca2+]o), resting [Ca2+]i was 283(SD 77) nM. The resting tension was 1.6(0.3) g.mm-2. The steady state [Ca2+]i transient and the peak potentiated [Ca2+]i transient averaged 992(165) and 1290(154) nM respectively. The corresponding tensions were 4.0(1.9) and 8.7(3.1) g.mm-2 respectively. The recirculating fraction of Ca2+ calculated from the dissipation of the potentiated [Ca2+]i transient averaged 45(4)%. This recirculating fraction was indistinguishable from the one calculated with another method from the decay of the force potentiation. CONCLUSIONS: This is the first study to estimate the recirculating fraction of activator Ca2+ using measurements of [Ca2+]i. The results indicate that over a wide range of [Ca2+]i and tensions the Ca(2+)-force relationship is well approximated by a straight line. At 2.0 mM [Ca2+]o it appears that some 450 nM of Ca2+ recirculates and that a similar amount per steady state beat enters the cytosol, probably from the extracellular compartment.

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This communication reports the development of a modified procedure for chemical loading of aequorin in small multicellular cardiac preparations, with special emphasis directed toward the implementation of a new method for computer-controlled low-photon counting and digital processing and analysis of the data to obtain intracellular Ca2+ concentration ([Ca2+]i). In eight ferret right ventricular trabeculae, we measured the mechanical performance and found that, at 1.25 mM extracellular Ca2+ concentration ([Ca2+]o), resting tension, developed tension, and time to peak tension were unchanged by the loading procedure. Estimated resting and peak systolic [Ca2+]i were 299 +/- 65 and 766 +/- 131 nM, respectively. Thirty minutes after raising the [Ca2+]o to 5 mM, there was a robust increase in mechanical performance, with peak systolic [Ca2+]i averaging 1,218 +/- 222 nM. The diastolic [Ca2+]i remained unchanged. In four other trabeculae, exposure to a low-Na(+)-containing superfusate demonstrated a remarkable beat-to-beat correspondence of increases in diastolic [Ca2+]i and resting tensions. The same beat-to-beat concordance was also observed between the rapidly changing amplitudes of peak [Ca2+]i and developed tension. In additional experiments, simultaneous recordings of [Ca2+]i and force transients were obtained during rapid pace pause maneuvers. These studies showed distinct and quantifiable fluctuations of [Ca2+]i in a 1:1 relation to the mechanical record to a frequency of at approximately 300 beats/min. These results demonstrate that beat-to-beat measurements of [Ca2+]i and tension transients can be obtained with good resolution in multicellular cardiac preparations.

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Abnormal cardiac energy metabolism has been postulated as a mechanism for adriamycin induced cardiotoxicity. This study was designed to determine high energy phosphate stores at rest and with hemodynamic stress in perfused rat hearts after animals had been chronically exposed to adriamycin (2 mg/kg weekly for 14 weeks). Morphologic and hemodynamic changes were mild in this model. Phosphorus-31 NMR determined intracellular pH and levels of inorganic phosphate (Pi) and ATP were comparable in treated and control hearts. Phosphocreatine (PCr) levels were markedly decreased in treated hearts (0.89 +/- 0.07 units/g versus 1.7 +/- 0.13 units/g, p less than 0.001). The PCr/Pi ratio decreased in both groups during hemodynamic stress. It recovered earlier in controls and there was a marked over-shoot after cessation of rapid pacing in this group which was not present in adriamycin treated hearts. These results suggest that metabolic regulation in response to hemodynamic stress is impaired after chronic adriamycin exposure. PCr depletion and delayed metabolic recovery after hemodynamic stress appear to be potentially useful markers for the effect of adriamycin on the heart.

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Potentiated contractions were evoked with rapid pace pause maneuver in 14 length-clamped ferret papillary muscles paced 12 times/min at 25 degrees C. At 1.25 mM [Ca2+]o the average steady-state force was 2.94 +/- 1.08 g/mm2 and the potentiated contraction averaged 10.96 +/- 1.61 g/mm2. At 5.0 mM [Ca2+]o the steady-state force increased to 6.18 +/- 1.23 g/mm2 and the potentiated contraction averaged 12.08 +/- 1.15 g/mm2. Under the conditions of these experiments the potentiated contraction obtained at 5.0 mM [Ca2+]o is equal to the maximum twitch tension (Fmax) these muscles can generate. We have previously shown that Fmax is an equivalent of maximal calcium activated force. Since there is a beat to beat nearly exponential decay of the evoked potentiation, the fraction (= fraction x) of the potentiation that is not dissipated with each beat is nearly constant. Using an excitation-contraction coupling model we have previously found that x reflects a measure of the recirculating fraction of activator calcium. Because the tension-calcium relationship is better characterized by a sigmoidal curve, we have now incorporated the Hill equation in the model. To account for the inverse relationship between [Ca2+]i and the magnitude of the slow inward current, a term for negative feedback (h) was also included. We have determined the quantity (x-h) because x and h could not be determined separately. The quantity (x-h) was denoted as x'. The average values of x' at 1.25 and 5.0 mM [Ca2+]o were significantly different (p less than 0.0001), approximately 20% at the lower [Ca2+]o and about 50% at the higher [Ca2+]o.(ABSTRACT TRUNCATED AT 250 WORDS)

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Proton (1H) nuclear magnetic resonance (NMR) imaging has been used to define zones of myocardial infarction (MI), which appear as areas of relatively increased signal intensity (SI). However, zones of decreased SI have been observed within the areas of infarction and have been postulated to result from intramyocardial hemorrhage. To explore this phenomenon further, ex vivo spin-echo 1H NMR imaging at 1.5 Tesla was performed in 17 dogs after 24 hr (n = 9) and after 72 hr (n = 8) of coronary artery occlusion. In all dogs, a zone of increased SI (118 +/- 9% compared with normal myocardium) was observed in the distribution of the occluded coronary artery. In 12 of the 17 dogs, zones of decreased SI (92 +/- 8% compared with normal) were seen within or around the central zone of increased SI. Gross inspection and histological assessment of sliced myocardium usually disclosed hemorrhage in the regions of decreased SI. In three of the five dogs with no apparent zones of decreased SI on NMR, the infarct was small, and only minor hemorrhage was observed by gross inspection, whereas in the remaining two dogs no hemorrhage was seen. Myocardial flow in the hemorrhagic regions was significantly higher than in the necrotic core (59 +/- 29% vs. 31 +/- 24% compared with control, P less than 0.05). Image-derived calculation of T2 relaxation times in the different infarcted regions revealed a significant shortening of T2 in the infarcted hemorrhagic zones with decreased SI compared with the infarct zones with increased SI (49 +/- 8 msec vs. 66 +/- 8 msec, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

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Anticoagulant therapy is frequently used after thrombolytic agents in the treatment of acute myocardial infarction (AMI) although it is unclear that such therapy will prevent subsequent infarct vessel reocclusion. The role of duration of heparin therapy in maintaining infarct artery patency was studied retrospectively in 53 consecutive AMI patients who received streptokinase therapy and underwent coronary angiography acutely and at 14 +/- 1 days. Of the 39 patients with initial infarct vessel patency, patency at follow-up angiography was observed in 100% (22 of 22) of those who received greater than or equal to 4 days of intravenous heparin but in only 59% (10 of 17) of those patients who received less than 4 days of heparin (p less than 0.05). Of the 14 patients not initially recanalized after streptokinase, patent infarct-related arteries at follow-up angiography were found in 3 of 8 (38%) treated with greater than or equal to 4 days of heparin therapy but in none of the 6 patients treated for less than 4 days (difference not significant). No significant difference in hemorrhagic complications was noted between the short- and long-term heparin treatment groups. Thus, greater than or equal to 4 days of intravenous heparin therapy after successful streptokinase therapy in AMI is more effective in maintaining short-term infarct vessel patency than a shorter duration of therapy and it may maintain the short-term patency of the infarct vessel in those patients who later spontaneously recanalize.

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Extent, time course, and underlying mechanisms of the negative inotropic effect of ryanodine were examined in 22 length-clamped ferret right ventricular papillary muscles paced 12/min at 25 degrees C. After 60 minutes of exposure to 5 microM ryanodine a new steady state was attained with developed forces averaging 10-15% of maximum twitch force. Ryanodine does not pharmacologically excise the sarcoplasmic reticulum (SR) in this preparation. Ryanodine does not appreciably inhibit the ability of the SR to take up Ca2+ as evidenced by the potentiated beats obtained after a short pause that are nearly as large after ryanodine as before. On comparing equipotent beats before and after ryanodine, we found that ryanodine actually increases the rate at which Ca2+ is released during the twitch if the SR Ca2+ stores are equal or similar. The evidence for this conclusion is a larger maximum rate of tension rise and briefer time to peak tension after ryanodine. Since ryanodine increases the time that SR Ca2+ release channels are open and decreases their conductivity, it must follow that the former effect predominates over the latter in our experiments. Ryanodine increases the leakiness of the SR during diastole probably by inhibiting closure of SR Ca2+ release channels. The evidence for this conclusion is as follows: the early peak of the restitution curves after ryanodine, the brevity of the time required for a rested state contraction after ryanodine, and the small amplitude of the steady-state contraction at a rate of 12/min. The SR leaks even in the absence of ryanodine, but if external Ca2+ is so high that Ca2+ loss from the cell is slowed or a Ca2+ leak into the cell through the sarcolemma cancels the SR leak, then the effects of the SR leak are minimized. The evidence for this conclusion is the time required for rested-state contraction to occur or the slope of the descending limb of restitution curve; however, in presence of ryanodine even high external Ca2+ cannot prevent rapid depletion of SR Ca2+ stores. Even though we have presented evidence for a mechanism whereby ryanodine increases the number of open SR Ca2+ release channels in both systole and diastole, we do not mean to imply that most of them stay open in diastole; the SR would leak too fast to accumulate any Ca2+ for the potentiated beat. Thus, probably most channels close after being open a certain length of time, even in the presence of ryanodine.

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A classic case of Swan-Ganz catheter-induced pulmonary infection was studied with both conventional chest radiography and computed tomography (CT). Chest radiography initially showed a fan-shaped opacity in the right middle lobe which later became somewhat rounded with no discernible cavitation. However, a cavitary lung lesion with a bulls-eye appearance was clearly demonstrated by CT. We speculate that such a cavitary lung lesion might be quite common in catheter-induced pulmonary infarction when CT is widely applied to such cases.

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Histopathologic studies have demonstrated accumulation of lipid droplets in myocardium subjected to greater than or equal to 6 h of ischemic insult. Proton nuclear magnetic resonance (NMR) spectroscopy can provide a noninvasive means to evaluate changes in tissue lipid and, potentially, to characterize the ischemic insult. To determine whether lipids accumulate with a brief ischemic insult, myocardial lipid content was evaluated by 1H NMR spectroscopy of ex-vivo samples from seven dogs in a model of postischemic dysfunction created by 15 min of left anterior descending coronary artery occlusion followed by 3 h of reperfusion. Regional myocardial function was assessed by measuring segment length shortening with use of a pair of ultrasonic crystals placed in the ischemic zone and in the control zone. During the occlusion, all dogs had significant ischemia of the occlusion zone as measured by radiolabeled microspheres (0.08 +/- 0.08 versus 0.88 +/- 0.09 ml/g per min for the control zone), and all dogs developed systolic stretching of the ischemic zone segment. Myocardial lipid content was significantly elevated in the samples from the coronary occlusion zone (p less than 0.02). The increase in lipid signal may result from the ischemia-induced decrease in beta oxidation and resultant accumulation of fatty acyl esters (for example, fatty acids, triglycerides and acylcarnitines). In conclusion, this study shows that myocardium subjected to a brief (approximately 15 min) coronary occlusion followed by 3 h of reperfusion demonstrates a significant increase in NMR-detectable lipid content.

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Proton (1H) nuclear magnetic resonance (NMR) imaging is thought to depict zones of recent myocardial infarction in contrast to noninfarcted myocardium. This is related to T2 increases in infarct zones that have been verified previously by relaxometry measurements in excised myocardial samples. Accordingly the present study was undertaken to evaluate a 1H NMR imaging method to optimize T2 contrast and measure infarct size in a high-field imaging system (1.5 T). To accomplish this, NMR images were acquired every other R wave with echo times of 30 and 100 msec. The first echo image was used for myocardial border definition and the second echo image, which highlighted the myocardial infarction, for infarct border definition. This T2-weighted approach yielded a significant correlation between infarct size by NMR and pathologic methods. However, NMR imaging tended to overestimate infarct size, and the NMR image depicted abnormal signal well beyond the extent of the pathology-determined infarct. There was a significant relationship between NMR-imaged infarct size and myocardial mass with microsphere-determined reduction in blood flow of 25% or more. These data suggest that T2-weighted NMR imaging depicts not only infarct but also some reversibly injured myocardium.

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A rare case of solitary neurofibroma of the vagus nerve in the aortopulmonary window masquerading as a developmental cyst is reported. Its computed tomographic characteristics and magnetic resonance imaging are described and correlated with pathologic findings. Although the features of such imaging modalities are quite characteristic for a neurofibroma, its differentiation from "atypical" developmental cysts may be difficult.

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Contrast produced by differences in regional proton relaxation times (T1 and T2) provides the potential to assess the extent of myocardial infarction using nuclear magnetic resonance (NMR) imaging. Previous laboratory studies have shown that longitudinal (T1) and transverse (T2) relaxation times are prolonged in acute myocardial infarction, and these prolongations have been attributed entirely to increases in tissue water content. The present study seeks to evaluate the relation between both T1 and T2 and regional myocardial perfusion and water content throughout a wide range of blood flow reduction. The left anterior descending coronary artery and collateral vessels supplying a region of the anterior wall of the left ventricle were ligated in 10 dogs for 4 hours until they were killed. Both water proton and bulk proton relaxation times of myocardial samples from ischemic and control zones were measured at 200 and 20 MHz, respectively. Regions of severe ischemia (flow less than 5% of control) demonstrated no significant alteration in T1 compared with nonischemic myocardium. Greatest T1 and T2 elevations were observed in moderately ischemic myocardium (flow = 5 to 50% of control). The water relaxation behavior differed with the severity of the flow reduction and was not totally dependent on changes in water content. These data suggest that relaxation time alterations are more complex than previously reported in myocardial ischemic insult. In the future, using T1 weighted imaging methods, myocardial ischemic insults associated with severe reductions in blood flow would be anticipated to demonstrate a doughnut pattern with an area of abnormal intensity in the peripheral zone surrounding a central ischemic zone with normal intensity.

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Proton NMR methods can monitor mobile lipids (e.g., fatty acids and glycerides) in intact tissue. Lipids play a major role in cardiac energy production, and elevated levels of myocardial lipids have been reported following an ischemic insult. The present study examines the potential of high-resolution 1H NMR spectroscopy to monitor lipid alterations 24 h following coronary occlusion in dogs, and to correlate these finds with regional myocardial blood flow (RMBF) measured by radiolabeled microspheres. The dogs were killed, and samples of excised myocardium were studied by high-resolution 1H NMR spectroscopic analysis using solvent suppression in combination with the Hahn spin-echo pulse sequence. Mobile lipids levels in myocardium with moderate blood flow reduction (28.6 +/- 7, integral values, arbitrary units; flow 5-50% of control) were significantly elevated compared to the mobile lipid levels in control myocardium (5.3 +/- 8, P less than 0.001) and in myocardium with severe flow reduction (7.2 +/- 10, P less than 0.001; flow less than 5% of control). The mobile lipids in myocardium with severe flow reduction were not elevated significantly relative to control tissue. As anticipated, depression in the level of creatine paralleled the microsphere determined degree of ischemia, i.e., compared to control (9.0 +/- 3); creatine levels were moderately decreased with flows 5-50% of control (5.5 +/- 4, P less than 0.001) and markedly decreased with flows less than 5% of control (1.0 +/- 2, P less than 0.001). This study suggests that high-resolution 1H NMR spectroscopy may be used to evaluate alterations in myocardial lipid levels following an ischemic insult.(ABSTRACT TRUNCATED AT 250 WORDS)

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Monitoring human cardiac allograft rejection is currently accomplished by endomyocardial biopsy. Available noninvasive methods for identifying rejection have lacked the necessary sensitivity or specificity, or both, for routine clinical application. In vivo phosphorus-31 (P-31) nuclear magnetic resonance (NMR) spectroscopy has been used for monitoring phosphorus metabolism in both animal models and humans. In the present study this technique was employed as a noninvasive means to assess the bioenergetic processes that occur during cardiac allograft rejection in a rat model. Brown Norway rat hearts were transplanted subcutaneously into the anterior region of the neck of Lewis rat recipients (allografts). Control isografts employed Lewis donors and recipients. Phosphocreatine to inorganic phosphate (PCr/Pi), phosphocreatine to beta-adenosine triphosphate (PCr/ATP beta), beta-adenosine triphosphate to inorganic phosphate (ATP beta/Pi) ratios and pH of the transplanted hearts were monitored using surface coil P-31 NMR spectroscopy (at 4.7 tesla) daily for 7 days. To allow recovery from the compromise induced by the surgical procedure, the measurements obtained on day 2 were taken as a baseline. PCr/Pi was unchanged or increased in the isografts but decreased continually in allografts, with the difference becoming significant by day 4 when compared with levels in day 2 allografts (p less than 0.005) and by day 3 when compared with levels in the isograft group (p less than 0.05). PCr/ATP beta in isografts did not change throughout the study; however, allografts demonstrated a significant decrease as early as day 3 (p less than 0.01), although a significant difference between isografts and allografts did not become manifest until day 4 (p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

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The current status and some of the future possibilities for nuclear magnetic resonance imaging of the cardiovascular system have been described. With many of these possibilities there is overlap with existing techniques. For example, functional analysis of the left ventricle can be obtained using either echocardiography or radionuclide techniques. With current instrumentation and current costs, these conventional techniques could frequently provide a more cost-effective approach for morphologic and functional assessment of the cardiovascular system. Nevertheless, because of the excellent resolution, the inherent contrast, the sensitivity to blood motion, the three-dimensional nature, and the lack of ionizing radiation, the cardiovascular morphologic imaging capabilities of NMR may provide justification for such applications. However, for NMR to achieve its most important status as a cardiovascular imaging technique, some of its unique possibilities will need to be developed. These include the ability to reproducibly depict the proximal coronary arteries, to define regional myocardial blood flow distribution, to evaluate regional high energy phosphate or other metabolic activity; and to characterize myocardial disease using proton T1 and T2 alterations.

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The current status and suggestions of the future potential for nuclear magnetic resonance imaging of the cardiovascular system are described. With many of the potential applications, there is overlap with existing methods. For example, imaging of the left ventricle can be accomplished with either echocardiography or radionuclide techniques with adequate evaluation of the left ventricular function. At current costs these conventional techniques may provide a more cost-effective approach for morphologic and functional assessment of the cardiovascular system. For this type of imaging, the advantages of NMR include its excellent resolution, the inherent tissue contrast, the sensitivity to blood motion, the 3-dimensional measure, and the lack of ionizing radiation. Because of these, NMR could provide an important adjunct for evaluation of the cardiovascular system. However for NMR to achieve its full promise as a cardiovascular imaging technique, some of its unique potentials need to be developed. These include: the ability to reliably image at least the proximal coronary arteries, the ability to delineate regional myocardial blood flow distribution, the ability to evaluate regional metabolic activity such as high-energy phosphate metabolites, and the ability to characterize myocardial disease using proton T1 and T2 alterations.

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