BACKGROUND We tested the hypothesis that hibernating myocardium represents an incomplete adaptation to a reduced myocardial oxygen supply. METHODS AND RESULTS In 38 patients, areas of hibernating myocardium were identified by angiography, multigated radionuclide ventriculography, thallium scintigraphy with reinjection, and low-dose dobutamine echocardiography. Biopsies removed at cardiac surgery showed structural degeneration characterized by a reduced protein and mRNA expression and disorganization of the contractile and cytoskeletal proteins myosin, actin, desmin, titin, alpha-actinin, and vinculin by electron microscopy, immunohistochemistry, and in situ hybridization. Additionally, an increased amount of extracellular matrix proteins resulting in a significant degree of reparative fibrosis was present. Dedifferentiation, ie, expression of fetal proteins, was absent. Apoptosis indicating suicidal cell death was found by the terminal deoxynucleotidyl transferase end-labeling method and electron microscopy. Radionuclide ventriculography showed improvement of regional function at 3 months postoperatively compared with preoperative values (mean values, 23.5% and 48%, respectively), and the echocardiographic wall-motion score index decreased from 3.4 to 1.8. The degree of severity of the morphological changes (three stages) correlated well with the extent of postoperative functional recovery: more advanced clinical improvement was observed in patients with slight and moderate morphological degeneration (stages 1 and 2), but recovery was only partial in severe degeneration (stage 3). CONCLUSIONS Cellular degeneration rather than adaptation is present in hibernating myocardium. The consequence is progressive diminution of the chance for complete structural and functional recovery after restoration of blood flow. The practical consequence from this study should be early revascularization in patients showing areas of hibernating myocardium.

Our own previous studies of the composition of the extracellular matrix of human failing hearts showed that collagen VI seems to play a major role in the origin of cardiac fibrosis. Therefore, collagen VI was investigated in more detail in tissue samples taken from clinically normal left ventricle and from myocardium failing because of dilated cardiomyopathy. Tissue sections prepared with collagen VI antibodies were examined by fluorescence microscopy using conventional or confocal laser scanning microscopy. In normal myocardium, collagen VI was located in both, endomysium and perimysium, in blood vessels it surrounded closely individual myocytes. Failing myocardium showed enlargement of the extracellular space and collagen VI was abundant. The localisation was perivascular as well as interstitial in fine or thick bundles enclosing the myocytes completely. In hearts with far progressed failure areas of replacement fibrosis containing increased amounts of collagen VI were evident. Double-staining for vimentin and collagen VI revealed a close interaction with fibroblasts. Although the function of collagen VI is not yet entirely clear it seems obvious that collagen VI plays an important role in the development of fibrosis in the failing heart.

Background. Recently, our group showed that in human hearts proteins are extremely sensitive to ischemic injury. The purpose of this investigation was to evaluate the effects of ischemia on contractile and cytoskeletal proteins in rabbit and pig hearts and to compare these findings with those obtained in humans.Methods. Rabbit hearts were arrested by perfusion with Euro-Collins solution at different temperatures. Hearts perfused with buffer served as controls. Tissue samples were incubated for varying time intervals and processed for immunohistochemistry and electron microscopy. Porcine hearts were treated in the same manner. Changes in the localization of myosin, desmin, and tropomyosin antibodies were evaluated and the degree of ischemic injury was determined by electron microscopy.Results. Healthy animal hearts tolerate ischemia better than human hearts. Cardiac proteins are more sensitive to ischemia than the ultrastructural cellular organelles. Temperatures as low as O degrees C produce more cell damage than 4 degrees C and should therefore be avoided. The Euro-Collins solution protects the myocardium better than buffer.Conclusions. We conclude that healthy animal hearts are more resistant to ischemia than diseased human hearts and that results from experimental studies should be interpreted with caution with regard to the human situation.

OBJECTIVE:Previous observations have shown that myocardium activates many adaptive processes after brief ischaemia. The aim of this study was to determine whether insulin-like growth factors (IGF) as well as their receptors and binding proteins (IGFBP), which control the activity of the IGF, may play an important role during these processes.METHODS:Ischaemia was induced in anaesthetised open chest pigs by two 10 min occlusions of the left anterior descending coronary artery, separated by 30 min of reperfusion, and followed by reperfusion up to 210 min. Tissue from the ischaemic area and from a non-ischaemic control region of the same heart was examined by means of northern blot, slot blot, and in situ hybridisation.RESULTS:IGF-I, IGF-II, the type I receptor, the insulin receptor, and IGFBP-2-6 are constitutively expressed in porcine myocardium. In situ hybridisation showed that IGF-I and IGF-II are mainly transcribed by myocytes. Ischaemia/reperfusion led to an early and significant increase in IGF-II mRNA compared to non-sham controls but not in comparison with sham operated animals, which already showed a (not significantly) enhanced IGF-II expression. In each case the IGF-II mRNA levels are equal in the control and the experimental region of the same heart. Whereas IGF-II expression was already increased by experimental stress, IGFBP-5 mRNA was enhanced only by ischaemia/reperfusion. The expression of IGF-I, the receptors, and IGFBP-2, 3, 4, and 6 remained unchanged during the experimental protocol. IGFBP-1 was neither expressed nor induced in our model.CONCLUSIONS:IGF-II acts like a stress-response gene activated by the experimental conditions (surgery, anaesthesia) and remains induced during following episodes of ischaemia/reperfusion. A possible interaction of IGFBP-5 with other components of the IGF system may contribute to the preconditioning response.

Objective: Angiogenesis in the porcine heart can be induced by myocardial ischaemia following vascular occlusions. This process is characterised by increased numbers of monocytes/macrophages, known to be potent producers of various mitogens such as insulin-like growth factors (IGF) and interleukins (IL). The aim of the study was to examine gene expression of these factors by means of northern blot hybridisation, slot blot analysis, and in situ hybridisation in a porcine model of coronary angiogenesis. Methods: Experimental ischaemia and subsequent focal necroses were induced by selective injection of 25 mu m microspheres into the left circumflex artery. The hearts were excised after 3-168 h of microembolisation, and tissue was collected from a non-ischaemic control area and the circumflex region of the same heart for further analysis. Results: IGF-I was constitutively transcribed in normal porcine myocardium mainly by myocytes. Following microembolisation, IGF-I mRNA expression was significantly increased in the experimental region (1.8-fold) after 72 h and to a lesser extent after 168 h. In the ischaemic region, characterised by capillary sprouting, numerous mononuclear cells contained IGF-I mRNA. In contrast, IGF-II mRNA levels, constitutively produced by porcine myocytes, were not altered by microembolisation. IL-1 alpha, IL-1 beta, and IL-4 mRNA expression was undetectable in our animal model, whereas IL-6 was constitutively transcribed in normal and ischaemic heart and remained insensitive to microembolisation and focal necrosis. Conclusion: After microembolisation, increased IGF-I mRNA expression occurred by infiltrating monocytes in areas of microsphere induced focal necrosis, where capillary sprouting can be detected, suggesting that IGF-I is involved in inflammation linked angiogenic processes.

Numerous morphological changes can be observed in human mycardium failing because of dilated cardiomyopathy. These can be observed by electron microscopy and by immunofluorescence microscopy using monoclonal antibodies. These changes include: 1) the occurrence of hypertrophied and atrophied myocytes as well as cells of normal size, 2) degenerative changes in myocytes; these consist of nuclei of varying size and shape, lack of contractile material, disorganization of the cytoskeleton, and sequestration of cellular particles into the extracellular space and 3) an enlarged extracellular space, that is, fibrosis, which contains increased amounts of the different matrix proteins such as fibronectin and laminin, the various collagens, and chondroitin sulfate, in addition to cellular debris and numerous macrophages and fibroblasts. On the basis of these findings it is hypothetized that there exists an interaction between myocytes and the extracellular matrix. The cells of the latter may be stimulated to higher rates of proteins synthesis by the presence of cellular debris. This process, in turn, may be harmful for the structural integrity of myocytes which consequently sequester more cellular particles. In this manner, a vicious circle may be started that leads to further structural and functional deterioration of the myocardium, finally resulting in failure.

Numerous morphological changes can be observed in human myocardium failing because of dilated cardiomyopathy. These can be observed by electron microscopy and by immunofluorescence microscopy using monoclonal antibodies. These changes include: 1) the occurrence of hypertrophied and atrophied myocytes as well as cells of normal size, 2) degenerative changes in myocytes; these consist of nuclei of varying size and shape, lack of contractile material, disorganization of the cytoskeleton, and sequestration of cellular particles into the extracellular space and 3) an enlarged extracellular space, that is, fibrosis, which contains increased amounts of the different matrix proteins such as fibronectin and laminin, the various collagens, and chondroitin sulfate, in addition to cellular debris and numerous macrophages and fibroblasts. On the basis of these findings it is hypothetized that there exists an interaction between myocytes and the extracellular matrix. The cells of the latter may be stimulated to higher rates of proteins synthesis by the presence of cellular debris. This process, in turn, may be harmful for the structural integrity of myocytes which consequently sequester more cellular particles. In this manner, a vicious circle may be started that leads to further structural and functional deterioration of the myocardium, finally resulting in failure.

Hypertension induced in rats by suprarenal banding has a blood pressure elevating effect that is accompanied by the occurrence of cardiac hypertrophy and fibrosis. This phenomenon is already present at 2 weeks after banding and persists up to 1.5 years. The increase in cardiac weight is mostly due to the development of fibrosis, since myocytes are only slightly increased in size. The fibrotic tissue consists mainly of fibronectin and collagen and contains numerous cellular elements. The occurrence of fibrosis can be completely inhibited by the administration of the specific ACE inhibiting drug, ramipril, which indicated that angiotensin II may directly stimulate fibroblasts to produce fibronectin and collagen. The antifibrotic effect of ramipril was also present in a low dosage that did not lower blood pressure, confirming the hypothesis that angiotensin II has a direct effect on connective tissue cells and their ability to produce extracellular matrix proteins. The direct effect of the renin-angiotensin system on the activity of interstitial cells was further proven by molecular biology techniques showing an upregulation of transcription for collagen I and III which is prevented by ACE inhibition.