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We have developed a model for the analysis of the forward creatine kinase reaction in muscle as measured by the nuclear magnetic resonance (NMR) technique of magnetization transfer. The model, accounting for the double-exponential behavior observed in some NMR magnetization transfer data, allows for the existence of two ATP pools, one that is NMR-visible (NMR-VIS) and another that is NMR-invisible (NMR-INVIS). We have applied the model to experimental data for the forward creatine kinase reaction in skeletal and cardiac muscles to study the dependence of the creatine kinase rate constants and fluxes on workload and to account for the differences between heart and skeletal muscle. The results suggest that an NMR-distinct ATP pool exists in both heart and skeletal muscles, and that phosphate exchange with this pool catalyzed by creatine kinase increases with increased workload. The results also agree with previously published estimates of the rates of mitochondrial translocase and net ATP synthesis obtained by traditional biochemical methods.

Successful transcatheter closure of a calcified patent ductus arteriosus was performed in a symptomatic 78 year old man. Cardiac catheterization revealed a left to right shunt across the patent ductus arteriosus with a pulmonary to systemic flow ratio of 2.8:1. Calcification of the ductus and severe lung disease increased the risk of surgical patent ductus arteriosus closure. A 17 mm Rashkind double umbrella was positioned in the ductus percutaneously by way of the femoral vein. After closure of the ductus there was marked hemodynamic improvement and the patient was discharged with improved exercise tolerance. Transcatheter closure of patent ductus arteriosus may be a viable option for the elderly patient too sick to withstand cardiovascular surgery.

Recovery of postischemic function may be limited by energy synthesis by mitochondria, energy transfer via the creatine kinase reaction, or energy utilization at myofibrils. To identify the limiting step, we defined the relations among oxygen consumption, creatine kinase reaction velocity and cardiac performance in myocardium reperfused following mild, moderate, and severe ischemia. Isolated isovolumic ferret hearts were perfused with Krebs-Henseleit buffer at 37 degrees C. After 30 minutes of control, hearts were made ischemic for 20, 40, or 60 minutes and reperfused for 40 minutes. During preischemia, cardiac performance (estimated as the rate-pressure product), was 14.8 x 10(3) mm Hg/min, oxygen consumption was 16.7 mumol/min/g dry weight, and creatine kinase reaction velocity measured by 31P-nuclear magnetic resonance saturation transfer was 12.7 mM/sec. For hearts reperfused after 20, 40, or 60 minutes of ischemia, rate-pressure product was 11.5, 6.5, and 1.1 x 10(3) mm Hg/min; oxygen consumption was 13.5, 14.2, and 6.9 mumol/min/g dry weight; and creatine kinase reaction velocity was 9.6, 5.0, and 2.0 mM/sec, respectively. Thus, with increasing severity of insult, creatine kinase reaction velocity decreased monotonically with performance (r = 0.99). Changes in creatine kinase reaction velocity were predicted from the creatine kinase rate equation (r = 0.99; predicted vs. measured velocity) and can therefore be explained by changes in substrate concentration. Oxygen consumption did not correlate with performance or creatine kinase velocity, consistent with abnormalities in mitochondrial energy production. In all cases, creatine kinase reaction velocity was an order of magnitude faster than the maximal rate of ATP synthesis estimated by oxygen consumption. We conclude that, in postischemic myocardium, creatine kinase reaction velocity decreases in proportion to performance, but high-energy phosphate transfer does not limit availability of high-energy phosphate for contraction.

Previous studies have suggested that flux through the creatine kinase reaction is coupled to cardiac performance and to the rate of adenosine triphosphate synthesis in the intact, beating heart. To define the effect of passive myocardial stretch on creatine kinase kinetics, we measured the rate constants and chemical fluxes for both directions of the creatine kinase reaction with the 31P-nuclear magnetic resonance technique of magnetization transfer in isolated, arrested rat hearts at four levels of left ventricular pressure and volume. Adenosine triphosphate synthesis was estimated from oxygen consumption measurements. As left ventricular pressure rose from 0 to 24 mm Hg and oxygen consumption increased by 20%, we observed a twofold increase in the rate constants and fluxes (mean +/- SD, n = 4-7) for the creatine kinase reaction. The forward rate constant increased from 0.33 +/- 0.03 to 0.80 +/- 0.08, and the reverse rate increased from 0.34 +/- 0.11 to 0.74 +/- 0.32/sec. The forward and reverse fluxes for the creatine kinase reaction increased from 12.0 +/- 3.4 to 26.5 +/- 5.8 and from 9.1 +/- 3.4 to 19.1 +/- 3.4 mumol/g dry weight per sec, respectively. At each level of left ventricular pressure, the forward and reverse rate constants were the same. However, as left ventricular pressure increased, the ratio of the forward to the apparent reverse fluxes for the creatine kinase reaction increased. The relationships between the rate constant or flux through the creatine kinase reaction vs. left ventricular pressure were linear. In addition to providing further support for the coupling between creatine kinase and mitochondrial adenosine triphosphate synthesis, these results suggest that flux through the creatine kinase reaction and adenosine triphosphate synthesis increases with myocardial stretch in the intact, noncontracting heart.

Cusp entrapment is a previously unreported mechanism of aortic insufficiency after balloon aortic valvuloplasty. In a patient who developed severe acute aortic insufficiency and expired after balloon aortic valvuloplasty, pathologic evaluation revealed a large, solitary, fractured, calcific nodule in the noncoronary cusp in which the malaligned, irregular fracture surfaces of the nodule had entrapped the leaflet in an open position. The ease with which the entrapped leaflet was reduced by manipulation on postmortem examination suggests that further manipulation of the cusp might restore valve competence in some cases when aortic insufficiency occurs after balloon valvuloplasty in calcific aortic stenosis.

Peak left ventricular pressure during balloon inflation was measured in 20 patients who underwent balloon valvuloplasty for severe aortic stenosis to define the determinants of ventricular pressure development in response to increased loading conditions. The peak left ventricular pressure ranged from 150 +/- 5 to 386 +/- 22 mm Hg (mean +/- SD), was reproducible in each patient with each balloon inflation (mean coefficient of variation 7.8%) and correlated with concurrent echocardiographic measurements of ejection fraction (r = 0.89, p = 0.0001) and mass/volume ratio in systole (r = 0.91, p = 0.0001) or diastole (r = 0.88, p = 0.0001). Thirteen patients with class II or more severe congestive heart failure had lower values for peak left ventricular pressure than did those without failure (225 +/- 46 versus 305 +/- 45 mm Hg, p = 0.002), whereas no difference in rest left ventricular systolic pressure was seen between the two groups. The measurement of peak left ventricular pressure was inversely related to rest mean circumferential end-systolic wall stress (r = 0.52, p = 0.046). Thus, peak left ventricular systolic pressure measured during aortic valvuloplasty in humans correlates closely with traditional measures of left ventricular function. This measurement, which previously has been obtained only in experimental animal studies, is a simple and reproducible hemodynamic index that may provide new insights in studies of ventricular function and congestive heart failure in aortic stenosis.

It is now appreciated that mitochondrial creatine kinase (CKm) may play an important role in heart high-energy phosphate metabolism and that this isozyme is solubilized in vitro by dilute solutions of Pi. Since an increase in cellular Pi is known to occur with even brief periods of myocardial ischemia, we investigated the relationship between CKm activity and myocardial performance in rabbit hearts subjected to total global ischemia. CKm activity is expressed as a ratio to mitochondrial malate dehydrogenase (MDHm), a stable marker enzyme. A significant decline in this ratio was observed after only 10 min of ischemia, a time prior to changes in total homogenate creatine kinase activity. After 60 min of ischemia, the CKm/MDHm ratio was depressed by more than 70%. Since there was no restoration of activity following 30 min of reperfusion, we correlated changes in enzyme activity to contractile dysfunction following variable periods of total ischemia. The data showed a close correlation between the decline in the CKm/MDHm ratio and the reduction in performance, measured as left ventricular developed pressure. No correlation was observed between State 3 respiratory rates and performance. Using KCl arrest at 27 degrees C or hyperthermic ischemia at 40 degrees C, the CKm/MDHm ratio consistently correlated to the degree of postischemic functional depression, independent of the duration of ischemia. Isoenzyme electrophoresis failed to detect soluble CKm activity in the postischemic supernatant. Therefore, CKm activity appears to be altered rapidly and irreversibly by ischemia. The implications of these observations on the integration of myocardial high-energy phosphate metabolism are discussed.

Using 31P-nuclear magnetic resonance, we studied the relationship between myocardial high-energy phosphate content and flux values for the creatine kinase reaction in the living rat under inotropic states achieved during norepinephrine infusion and halothane anesthesia. Under 2% halothane anesthesia (n = 4), 1% halothane anesthesia (n = 5) and norepinephrine infusion (n = 4), rats developed rate-pressure products of 19.5 +/- 1.6, 32.0 +/- 3.5, and 48.5 +/- 2.0 X 1,000 mmHg/min, respectively. Adenosine triphosphate content was not affected by inotropic state, ranging from 24.3 +/- 1.1 to 25.6 +/- 1.1 mumol/g dry weight, but creatine phosphate content varied inversely and reversibly with cardiac performance from 45.6 +/- 6.0 under 2% halothane to 26.0 +/- 6.5 mumol/g dry weight during norepinephrine infusion. The flux values for the creatine kinase reaction were 15.4 +/- 4.6, 20.5 +/- 2.0, and 30.1 +/- 7.9 mumol/g dry weight per s under 2% halothane, 1% halothane, and 1% halothane with norepinephrine, respectively. These results suggest that the turnover of myocardial high-energy phosphate compounds, not their tissue contents, matches cardiac performance during inotropic stimulation.