Table Of ContentP1
Regulation of Mitochondrial Signaling and Intracellular Ca2+ by β2-Adrenergic Receptors in Doxorubicin Cardiomyopathy
Giovanni Fajardo, Mingming Zhao, Gerald Berry, Daniel Bernstein, Stanford Univ, Stanford, CA
Beta adrenergic receptor (β-AR) subtypes regulate both cardiac function and remodeling through crosstalk with multiple signaling
pathways. We have previously shown that β1-ARs mediate cardiotoxicity and β2-ARs cardioprotection after acute exposure to the
anthracycline doxorubicin. One of the mechanisms of doxorubicin toxicity involves a Ca2+-dependent opening of the mitochondrial
permeability transition pore (MPT) and subsequent cell death, however the upstream signaling linking cell surface receptors and the
MPT is not clear. In this study we assessed the crosstalk between β2-ARs and mitochondrial cell death signaling in doxorubicin
cardiomyopathy. Doxorubicin 10 mg/kg was administered to β2-/- and WT mice. Whereas there was no mortality in WT, 85% of β2-/-
mice died within 30 min (n=20). LV myocardium from β2-/- mice treated with doxorubicin exhibited increased variation in
mitochondrial size and shape and marked vacuolization of the cristae compared to controls. At baseline, complex I activity was
increased in β2-/- mice vs. WT (4956±579 vs 4228±88 nmoles/min/mg, respectively), however after doxorubicin, in β2-/- mice
complex I activity dropped (2929±752 nmoles/min/mg) and was now lower than WT (3928±648 nmoles/min/mg). Ca2+ transients
were assessed using fura-2 fluorescence. Baseline rate of Ca2+ release was increased 85% and peak [Ca2+]ratio 17% in β2-/- compared
i
to WT. Pretreament with cyclosporine 10 mg/kg, a blocker of both MPT and calcineurin, reduced doxorubicin mortality to 50%
(n=16). In contrast, pretreatment with FK506 0.5 mg/kg, a blocker of calcineurin but not the MPT, did not reduce doxorubicin
mortality (81%, n=16). These findings suggest that β2-ARs play a role in the regulation of mitochondrial cell death signaling in
Doxorubicin cardiomyopathy. We propose that absence of β2-ARs enhances doxorubicin toxicity via modulation of intracellular Ca2+,
sensitizing mitochondria to opening of the MPT.
Author Disclosure Block:
G. Fajardo, None; M. Zhao, None; G. Berry, None; D. Bernstein, None.
P2
Depressed Force Frequency Relationship in Ventricular Tissue from Children with Hypoplastic Left Heart Syndrome
Mary B Wagner, Rob F Wiegerinck, Anca Cojoc, Carlo M Zeidenweber, Guoliang Ding, Kirk R Kanter, Paul M Kirshbom, Brian E
Kogon, Ronald W Joyner, Emory Univ, Atlanta, GA
Little is known about the time course of postnatal development of excitation-contraction coupling and its regulation in human
ventricle. We compared contractile properties of ventricular muscle strips from hypoplastic left heart syndrome (HLHS) patients (<1
wk, n=5) and tetralogy of Fallot (TOF) patients (3-12 mo, n=7). Methods: Isometric developed force (DF) was measured at 3 cycle
lengths (CLs) to determine the force frequency relationship (FFR). RT-PCR, western blot and immunostaining were used to quantify
changes in protein expression. Results: At CL 2000 ms, DF in HLHS strips was 1.0±0.4 mN/mm2, not significantly different from
TOF strips (0.9±0.4 mN/mm2). In the TOF group, decreasing CL increased DF to 131±8% (CL 1000 ms) and 157±18% (CL 500 ms,
p<0.05 vs. CL 2000 and 1000) demonstrating a robust positive FFR. In contrast, the HLHS group showed no difference in DF
between CL 2000 ms and either CL 1000 ms (111±4%) or CL 500 ms (99±6%). The percent increase in the TOF group at CL 500 ms
was significantly larger than in the HLHS group (p<0.001). Sodium-calcium exchange (NCX) mRNA levels were significantly larger
in the HLHS compared to the TOF group (0.94±0.07, n=6 vs. 0.59±0.05, n=5, p=0.003). SR calcium atpase (SERCA) mRNA levels
were unchanged but phospholamban (PLB) was smaller in the HLHS group (0.89±0.11, n=6 vs. 1.39±0.09, n=5, p=0.007) as was the
PLB/SERCA ratio (0.96±0.16, n=6 vs. 1.43±0.08, n=5, p=0.034). Similarly, NCX protein levels were significantly larger in the HLHS
group vs. the TOF group (6245±767 a.u., n=6 vs. 2897±465, n=6, p=0.004) and SERCA protein levels were not different between the
two groups. Immunostaining of HLHS cells for NCX showed peripheral bright staining whereas in TOF cells, NCX was also found in
T-tubules, consistent with the earlier developmental stage of HLHS group. SERCA staining was regular and striated in both groups.
Conclusion: RV tissue from HLHS patients has a flat FFR, higher levels of NCX and lower levels of PLB and PLB/SERCA ratio
compared to TOF patients. Thus, diminished calcium load in the sarcoplasmic reticulum due to greater calcium extrusion via NCX
may contribute to the HLHS flat FFR. This suggests that treatment in these patients must consider both the stage of development as
well as the underlying pathology.
Author Disclosure Block:
M.B. Wagner, AHA Grant in Aid, Significant, B. Research Grant (includes principal investigator, collaborator, or consultant and
pending grants as well as grants already received); NIH R01, Significant, B. Research Grant (includes principal investigator,
collaborator, or consultant and pending grants as well as grants already received); R.F. Wiegerinck, None; A. Cojoc, None; C.M.
Zeidenweber, None; G. Ding, None; K.R. Kanter, None; P.M. Kirshbom, NIH R01, Modest, B. Research Grant (includes principal
investigator, collaborator, or consultant and pending grants as well as grants already received); B.E. Kogon, None; R.W. Joyner, NIH
R01, Modest, B. Research Grant (includes principal investigator, collaborator, or consultant and pending grants as well as grants
already received).
P3
Glucose Transport and Insulin Resistance in a Murine Model of Dilated Cardiomyopathy
Kai Chien Yang, Qingyun Yan, Paul W Hruz, Patrick Y Jay, Washington Univ Sch of Med, Saint Louis, MO
INTRODUCTION. The normal heart relies mostly upon fatty acids to generate ATP, whereas the failing heart shifts toward glucose
even in the presence of myocardial insulin resistance. Whether such changes are adaptive or not is unknown. Using a transgenic
mouse strain, TG9, which develops dilated cardiomyopathy and premature death from congestive heart failure, we demonstrate the
pathophysiologic significance of glucose transport and insulin resistance.
METHODS. TG9 and nontransgenic mice were studied by serum glucose measurement, glucose tolerance test, western analysis of
Glut1 and 4, the predominant cardiac glucose transporters, and myocardial 2-deoxyglucose uptake. We administered the HIV protease
inhibitors ritonavir and lopinavir, which acutely block glucose transport via Glut4, and atazanvir, which does not, to assess their affect
on survival and cardiac function. Finally, we treated the animals with rosiglitazone or exenatide to assess the affect of insulin
sensitization on survival.
RESULTS. TG9 animals develop fasting hyperglycemia during the progression of dilated cardiomyopathy. In glucose tolerance tests
mice with severe heart failure have double the peak glucose level and a prolonged clearance phase compared to the nontransgenics.
Glut1 protein is twice the normal level in the failing heart; Glut4 is unchanged. Despite the upregulation of Glut1, myocardial glucose
uptake is less than half normal, consistent with insulin resistance in the failing heart. Acute pharmacologic blockade of Glut4 causes
acute cardiac decompensation and pulmonary edema in TG9 mice as well as an acute decrease in left ventricular end-diastolic
diameter with apparently preserved shortening fraction. Glut4 blockade had no effect in nontransgenic mice. Treatment of insulin
resistance by either of two drugs that act at different targets in TG9 animals significantly prolonged survival.
CONCLUSIONS. The failing heart has a critical requirement for glucose particularly in diastolic relaxation. Upregulation of Glut1
may thus represent an adaptive response to preserve cardiac lusitropy. In contrast, the development of insulin resistance appears to be
maladaptive, as its treatment in the mouse model has beneficial effects on symptoms and survival.
Author Disclosure Block:
K. Yang, None; Q. Yan, None; P.W. Hruz, None; P.Y. Jay, None.
P4
Cardiac Cardiolipin Profile in Pediatric Dilated Cardiomyopathy
Ilina R Datkhaeva, Univ of Colorado, Boulder, CO; Shelley D Miyamoto, Johan Van Hove, Univ of Colorado Denver Health Sciences
Ctr and The Children’s Hosp, Aurora, CO; Genevieve C Sparagna, Univ of Colorado, Boulder, CO
Barth Syndrome is an X-linked recessive disease caused by a mutation in the tafazzin gene. Boys with Barth Syndrome suffer from
skeletal myopathy, growth delays, neutropenia and dilated cardiomyopathy (DCM). Heart failure is the most common cause of death
in the first months of life in these patients. The cardiac effects of the mutation causing Barth Syndrome are related to alterations in
cardiolipin, an essential phospholipid surrounding and conferring activity to many metabolic proteins in the mitochondria. Tafazzin is
a cardiolipin remodeling enzyme and its mutation renders cardiolipin unable to be remodeled into its linoleic acid rich form.
Cardiolipin expression is altered in explanted hearts from adults with idiopathic DCM. These alterations in cardiolipin from adults
include a decrease in its active form, tetralinoleyl cardiolipin (containing 4 linoleic acid side chains), and an increase in other
cardiolipin species containing alternate fatty acyl chains. We therefore hypothesize that children with DCM may also express an
abnormal cardiolipin profile. To test our hypothesis, left ventricular tissue from the explanted hearts of children ages 1 week to 18
years undergoing transplant for idiopathic DCM (n= 38) and non-failing control hearts was obtained with IRB approval from our
institution. Lipids were isolated from ventricular tissue and cardiolipin molecular species analysis was performed using electrospray
ionization mass spectrometry. Using standard methods, mRNA and cDNA were isolated to test alterations in the tafazzin gene.
Cardiolipin levels varied widely in these children, but the variation did not correlate with age. A subset of patients had decreased
levels of tetralinoleyl cardiolipin and higher than normal levels of monolyso cardiolipin indicating a similarity to those with Barth
Syndrome. In conclusion, alterations in the level of cardiac tetralinoleyl cardiolipin in children with DCM may contribute to altered
mitochondrial metabolism and represent a common pathway in the development of heart failure. Further studies are ongoing to
determine the relationship between changes in cardiolipin, the tafazzin gene, and the treatment profiles of these patients.
Author Disclosure Block:
I.R. Datkhaeva, None; S.D. Miyamoto, None; J. Van Hove, None; G.C. Sparagna, None.
P5
Excitation-Contraction Coupling Alterations During Cardiac Glutathione Depletion: Relation to Myocyte Reactive Nitrogen
Species and NOS2 Induction
Bing Han, Hong Huang, Mandar S Joshi, Brandon L Schanbacher, John A Bauer, Nationwide Children's Hosp & Res Inst, Columbus,
OH
Increased myocyte inflammation and redox stress has been linked to the pathogenesis of ischemic heart disease, but their roles in non-
ischemic settings are less established. Recycling of glutathione (GSH) with its disulfide product (GSSG) is a major component of
intracellular redox regulation but its contribution to normal EC coupling is not well defined. We tested the hypothesis that in vivo
cardiac GSH depletion in normal mice causes increased myocyte oxidative stress and modulates cardiac electrophysiological and
contractile performance, at rest and under moderate cardiovascular stress. Mice were pretreated with buthionine sulfoximine (BSO,
888mg/kg, glutathione biosynthesis inhibitor); comprehensive cardiovascular performance measures were made at 24hr using 4-lead
ECGs and echocardiography at rest and following acute isoproterenol dosing (ISO, 2.5mg/kg ip). LV tissues were isolated for GSH
and GSSG determination followed by NOS2 and protein 3-nitrotyrosine (marker of reactive nitrogen species) prevalence and
distributions by immunohistochemistry. BSO caused significant reductions of cardiac GSH and GSH/GSSG at 24hr, returning to
control levels by 7d. At rest, GSH depletion caused elongation of QTc, decreased LV diastolic performance, and increased LV stroke
volume (p<0.05), with no change in HR or vascular resistance. Acute ISO caused increases in QTc, provoked increased arrhythmic
episodes, and increased RR variability in animals pretreated with BSO (p<0.05). GSH depletion was also associated with increased
prevalence of cardiac myocyte NOS2 and protein 3-NT, in the absence of ischemia. Tissue GSSG and GSH/GSSG were correlated to
increases in NOS2 and protein 3NT, as well as QTc (p<0.01). These data demonstrate intracellular redox status modulates myocardial
excitation-contraction coupling. Acute depletion of cardiac GSH, in the absence of ischemia can perturb normal myocardial
performance, elongate QTc and promote arrhythmia in vivo; this is further enhanced during acute increases in cardiac demand and
may be mediated by myocyte NOS2 induction, reactive nitrogen species formation and/or direct nitration of cellular constituents.
Author Disclosure Block:
B. Han, None; H. Huang, None; M.S. Joshi, None; B.L. Schanbacher, None; J.A. Bauer, None.
P6
Disparate Effect of Isoproterenol on Contractility and Calcium Current in Ventricle from Hypoplastic Left Heart Syndrome
Patients
Ronald W Joyner, Rob F Wiegerinck, Guoliang Ding, Carlo M Zeidenweber, Lavanya Parachuru, Kirk R Kanter, Paul M Kirshbom,
Brian E Kogon, Mary B Wagner, Emory Univ, Atlanta, GA
We compared effects of sympathetic stimulation on contraction of right ventricular muscle strips and L-type calcium current (I ) of
Ca
isolated right ventricular cells from hypoplastic left heart syndrome (HLHS, < 1 wk old) and Tetralogy of Fallot (TOF, 3-12 mo old)
patients. Methods: Isometric developed force (DF) was measured in control and in response to 100 nM isoproterenol (ISO) at cycle
length 2000 ms. I was recorded by voltage clamp in isolated ventricular cells. To facilitate comparison, ISO responses are shown as
Ca
percent change from control. Results: The ISO response of DF in the HLHS group (53±6% increase, n=5) was significantly smaller
than in the TOF group (177±43% increase, n=7, p=0.04). To determine if this differential response of DF to ISO was due to
differences in the response of I , we measured I in isolated ventricular cells from both patient groups. In the TOF group, basal I
Ca Ca Ca
(3.0±0.6 pA/pF, n=5) was significantly increased (by 172±38%) to 7.4±1.0 pA/pF (p=0.002) by ISO. In the HLHS group, basal I
Ca
(2.8±0.4 pA/pF, n=5) was also significantly increased (by 159±20%) to 7.5±1.3 pA/pF (p=0.009) by ISO. There were no differences
in the amplitude of I in control, amplitude of I in ISO or the ISO-induced percent increase of I between the HLHS and the TOF
Ca Ca Ca
group. This is in contrast to the differential response of the DF to ISO. In rabbit, there is a developmental change in dependence on I
Ca
for the contraction (vs. sodium-calcium exchange) that correlates with a switch in splice variants of the calcium channel (the ratio of
the A/B variant decreases) and corresponds to the development of T-tubules. We examined these splice variants in humans using RT-
PCR and found that the B isoform was not different between the HLHS and TOF groups but that the A isoform level and the A/B ratio
was significantly higher in the HLHS group. Furthermore, immunostaining with di8ANEPPs shows no T-tubules in the HLHS group
but significant T-tubule development in the TOF group. Conclusions: The diminished response to ISO of the contraction in the HLHS
group is not matched by a decreased response of I to ISO in this group. Developmental changes similar to the rabbit suggest that
Ca
HLHS patients may be less dependent on calcium entry via I for the contraction.
Ca
Author Disclosure Block:
R.W. Joyner, NIH R01, Modest, B. Research Grant (includes principal investigator, collaborator, or consultant and pending grants
as well as grants already received); R.F. Wiegerinck, None; G. Ding, None; C.M. Zeidenweber, None; L. Parachuru, None; K.R.
Kanter, None; P.M. Kirshbom, NIH R01, Modest, B. Research Grant (includes principal investigator, collaborator, or consultant and
pending grants as well as grants already received); B.E. Kogon, None; M.B. Wagner, AHA Grant in Aid, Significant, B. Research
Grant (includes principal investigator, collaborator, or consultant and pending grants as well as grants already received); NIH R01,
Significant, B. Research Grant (includes principal investigator, collaborator, or consultant and pending grants as well as grants already
received).
P7
Role of Inflammation and Oxidants in Chronic Heart Failure Progression: Reversal by Cardiac Resynchronization Therapy
Mandar S Joshi, Lindsay M Arnott, Nationwide Children's Hosp & Res Inst, Columbus, OH; David S Feldman, The Ohio State Univ
Coll of Med, Columbus, OH; John A Bauer, Nationwide Children's Hosp & Res Inst, Columbus, OH
Chronic heart failure (CHF) is a major medical problem associated with high mortality, frequent hospitalizations, and high health care
costs. Although Cardiac resynchronization therapy (CRT) is highly effective in end stage HF, especially in non-ischemic settings, but
the mechanistic aspects are not completely understood. Via a collaborative research project with OSU investigators, we tested the
hypothesis that HF progression is associated with myocardial inflammatory signaling and that CRT modulates this process. We used
our recently established canine model of non-ischemic dilated cardiomyopathy and HF via RV tachypacing. Animals were
randomized to receive either continued RV pacing or CRT by biventricular pacing for an additional 9 months. At the conclusion of the
study, animals were sacrificed and cardiac tissues were rapidly collected for tissue studies. An additional 4 dogs were also included as
controls, these dogs were studied in vivo and sacrificed in parallel. Microarray analyses were used to investigate the gene expression.
Formalin fixed and paraffin embedded tissues were used for immunohistochemical analyses.We observed that RV tachypacing causes
functional impairments in the animals that resemble clinical observation in humans during HF. Myocardial tissue C-reactive protein
(CRP) and Xanthine oxidase (XO) gene expression levels were higher in HF. Myocardial tissue CRP (OD: 0.03[[Unsupported
Character - Codename ­]]±0.006; 0.21±0.01, CTRL; HF, p<0.05) and XO (OD: 0.02±0.004; 0.10±0.01, CTRL; HF, p<0.05)
levels were significantly higher in the HF group. Interestingly, CRT increased the exercise tolerance in the treated animals and caused
a significant reduction in inflammatory/oxidant gene expression and protein levels in the myocardium in comparison to HF group
(p<0.05).These findings demonstrate that inflammation and oxidants participate in the pathophysiology of HF progression and that
CRT modulates these changes, apparently eliciting an ‘anti-inflammatory’ effect at the level of cardiac myocytes.
Author Disclosure Block:
M.S. Joshi, None; L.M. Arnott, None; D.S. Feldman, None; J.A. Bauer, None.
P8
Interaction of Innate Immunity and Calcium Handling Pathways in Endotoxin-Induced Cardiac Failure
Wendy Luce, Hong Huang, Mandar S Joshi, Yusen Liu, John Anthony Bauer, Nationwide Children's Hosp & Res Inst, Columbus, OH
Cardiovascular compromise is central to the development of septic shock in children. Activation of mitogen-activated protein kinase
(MAPK) pathways and reactive nitrogen species (RNS) have both been implicated, but their interactions are not defined. MKP-1 is a
negative regulator of inflammatory signaling and regulates phosphorylation of phospholamban (PLB) and intracellular calcium
handling in cardiac myocytes. We’ve shown that MKP-1 plays a role in suppressing endotoxic shock; its role in sepsis-related cardiac
dysfunction is not established. We tested the hypothesis that MKP-1 null mice have enhanced cardiac dysfunction after endotoxin
exposure, which is related to RNS formation and/or perturbations in cardiac myocyte calcium handling. Cardiovascular status was
evaluated in 5 week-old wild type (WT) and MKP-1(-/-) mice at 0,4,24 h after LPS(1.5mg/kg i.p.). Cardiac tissues were collected at
24h and evaluated for myocardial protein nitration (3-NT), fibrosis and left ventricular(LV) morphology. Western blotting was used to
determine phosphorylated PLB content. LPS in WT mice decresed BP(p<0.05) at 4h, which returned to baseline at 24h, with no
significant change in LV fractional shortening (FS%) or cardiac output(CO). In contrast, the MKP-1-/- mice showed significant
decrease in CO(p<0.05), which returned to baseline at 24h, and decreases in systemic vascular resistance(p<0.05), BP(p<0.05) and
FS%(p<0.001) at 4h and 24h. There was no difference in myocardial fibrosis between groups. MKP-1(-/-) mice showed evidence of
LV dilation (p<0.001) 24h after LPS but a lesser myocardial 3-NT(p<0.001) than the WT. In response the LPS, there was a 60-fold
increase in P-PLB in MKP-1(-/-) vs. an 80% decrease in WT. MKP-1 deficiency leads to an enhanced impairment in cardiac function
after endotoxin exposure that is not related to RNS formation but is associated with acute LV dilation and increased P-PLB. These
findings demonstrate that there is significant interaction of innate immunity signaling and calcium handling in cardiomyocytes in
cardiac failure. This novel concept deserves further investigation in order to develop successful therapeutics for sepsis-related cardiac
dysfunction, especially for our most vulnerable patients such as neonates.
Author Disclosure Block:
W. Luce, None; H. Huang, None; M.S. Joshi, None; Y. Liu, None; J.A. Bauer, None.
P9
A High-Fat Diet Enhances Innate Immunity Pathways and LPS-Induced Vasculopathy
Hong Huang, Nationwide Children's Hosp & Res Inst, Columbus, OH; Dale G Hoyt, The Ohio State Univ Coll of Pharmacy,
Columbus, OH; John A Bauer, Nationwide Children's Hosp & Res Inst, Columbus, OH
Vasculopathy and cardiovascular collapse are major contributors to sepsis outcomes and are apparently related to activation of innate
immunity pathways leading to systemic inflammation and oxidative injury. A key contributor for gram-negative pathogens is the Toll-
like receptor-4 (TLR4) signaling pathway. Recent studies have suggested that chronic intake of a high-fat diet (HFD) promotes a state
of low level inflammation in humans and animals, which may contribute to cardiovascular disease risk and/or progression. We
therefore tested the hypothesis that chronic high fat diet would enhance the systemic and/or vascular response to a low dose LPS
challenge in mice. C57BL/6J mice were fed with HFD (16% saturated fat, 1.25% cholesterol) or isocaloric control diet (CD, 5%
saturated fat, 0.03% cholesterol) for 4 weeks, followed by a single sub-lethal dose of LPS (0.5 mg/kg, ip,) or saline control and
sacrificed at 0.5, 2, 4, 12, or 24 h post treatment (n=5 per group). Plasma lipid levels, cytokines (IL6, TNFα, IFNγ) and serum amyloid
A (SAA) were measured. Isolated vascular function was assessed at 24 post-LPS using thoracic aortic segments. TLR4 mRNA and
protein levels were detected with RT-PCR and immunohistochemistry, respectively. HFD induced hypercholesterolemia (total
cholesterol: 343.5 vs.158.1 mg/dL; LDL cholesterol: 217.5 vs. 113.0 mg/dL, p<0.05) and increased levels of plasma SAA (144.3 vs
1.49 μg/mL, p<0.01), but not cytokines, prior to LPS. Hepatic TLR4 mRNA (3.14-fold, p<0.05) was also induced in HFD mice, as
were markers of hepatic injury. LPS induced cytokine responses, SAA induction, and TLR4 expression were enhanced in HFD mice
(2- to 4-fold increase relative to control responses). Specific deficits in endothelial vascular responses were also observed in LPS
treated HFD tissues, whereas no change was observed for either LPS or HFD alone (acetylcholine vasorelaxant response: 79.1%,
82.4%, 75.6%, and 60.8* for CD, LPS, HFD, LPS+HFD, respectively, *p<0.05). These data demonstrate that HFD induced low-grade
inflammatory state can amplify responses to LPS and promote cardiovascular toxicities. This apparent synergy of innate immunity
pathway amplification may contribute to the heterogeneous outcomes observed in clinical sepsis.
Author Disclosure Block:
H. Huang, None; D.G. Hoyt, None; J.A. Bauer, None.
P10
Intracellular Remodeling in Chronic Heart Failure: Spatial Mapping of the Intermediate Filament Desmin in a Large Animal
Model of Microinfarction
Mark A Gerhardt, Gretel Monreal, The Ohio State Univ Medical Ctr, Columbus, OH; Angela C Cook, Brandon L Schanbacher, Bing
Han, John A Bauer, Nationwide Children's Hosp & Res Inst, Columbus, OH
Unlike extracellular fibrosis, upregulation of intracellular elements (cytoskeleton) may enhance contractility while worsening
myocyte compliance in CHF. This intracellular remodeling (“intracellular fibrosis”) would most likely occur in the endocardium,
which is subjected to greater wall stresses. Using an ovine model of microinfarction, we test the hypothesis that the intermediate
filament desmin undergoes spatial alterations and correlates to impaired diastolic relaxation in CHF. CHF was induced in sheep via
LCx microembolization and time dependent LV function was determined by conductance catheter. LV posterior (PW), anterior
septum (AS), and RV free wall (RV) myocardium was collected from control (n=9), early CHF (4 months, n=7) and late CHF sheep
(>12 months, n=5). Regional prevalence of fibrosis and desmin expression was determined by immunohistochemistry and digital
image analysis; *p<0.05 was considered significant. LV diastolic and systolic performance was progressively impaired and region-
specific distributions of interstitial fibrosis were observed. Myocyte desmin expression temporally and regionally changed during CHF
progression. RV desmin did not increase. In PW, extracellular fibrosis increased (early, 325%*; late, 852%*) and myocyte desmin
increased with CHF duration (early, 255%*; late, 352%*), correlating to extracellular fibrosis (r=0.83*). PW spatial mapping showed
increased desmin in endo- (313%*), meso- (222%*), and epicardium (241%*) in early CHF. Endocardial PW desmin continued to
increase with CHF progression (504%* vs control; p<0.01 vs early CHF). AS (non-infarcted region) fibrosis did not change, while
desmin increased (early, 85%*; late, 195%*) and correlated to increased LV relaxation time (r=0.90*). This ovine microinfarction
model recapitulates human cardiac remodeling events, with time and region specific changes in LV function, interstitial fibrosis, and
hypertrophy. Increased myocyte desmin was also observed and was spatially and temporally changed, with the most pronounced
increases in ischemic regions and endocardium. This intracellular adaptive change may enhance regional contractility in the remaining
viable myocytes but decrease LV compliance.
Author Disclosure Block:
M.A. Gerhardt, None; G. Monreal, None; A.C. Cook, None; B.L. Schanbacher, None; B. Han, None; J.A. Bauer, None.
P11
Signaling Mechanisms of Dyslipidemia-Induced Cardiomyocyte Dysfunction
Jianjing Xue, Loren Wold, Nationwide Children's Hosp & Res Inst, Columbus, OH
Cardiovascular disease (CVD) is a leading cause of death in diabetic patients and it’s prevalence in children is increasing. There is
growing evidence that dyslipidemia associated with diabetes contributes to the pathogenesis of diabetic cardiomyopathy, potentially
through activation of protein kinase C (PKC) and/or angiotensin II (AngII). Our goal in this study was to determine the effect of
culturing with fatty acid (oleic acid; OA) on cardiomyocyte function and the role of PKC and AngII signaling in this process.
Ventricular myocytes were isolated from rats and cultured overnight in normal medium ± OA (0.2mM), and/or the non-specific PKC
inhibitor bisindolylmaleimide (1μM) or the ACE inhibitor captopril (0.1μM). We used the highest concentration possible that did not
adversely affect normal cells. Isolated cardiomyocytes were field stimulated at 0.5 Hz in physiological saline, maintained at 31±1ºC
and mechanical function was assessed using the IonOptix video-based edge detection system. H9C2 cells were cultured in 0.2mM OA
and real-time RT-PCR was used to assess PKC isoform changes. Overnight culture in OA caused a significant prolongation in area
under the relaxation phase normalized to peak of the contracting myocyte when compared to control (85 ± 2ms vs. 106 ± 3ms in
control and OA groups, respectively; n=164-186 from 8-9 hearts). This index was normalized when OA was co-cultured with either
inhibitor. H9C2 cells cultured in 0.2mM OA for 24 hours caused an increase in mRNA of PKC α and ζ, and decrease in δ and ε. Our
data show that OA induces cardiomyocyte dysfunction, which is preventable by PKC or ACE inhibition, and mRNA for PKC
isoforms is altered after OA culture. These data suggest that OA elicits direct effects on cardiac myocyte signaling pathways,
potentially through PKC and/or AngII involvement, and may play a critical role in the development of diabetes-related CVD.
Author Disclosure Block:
J. Xue, None; L. Wold, None.
P12
Folate Rescues Inhibitory Effects of Wnt/β-Catenin Signaling During Heart Development
Maria C Serrano, Mingda Han, James C Huhta, Rosana Lastra, Shyam Manisastry, Kersti K Linask, Univ of South Florida, St
Petersburg, FL
Lithium (Li), a mood stabilizing drug, mimics the Wnt/β-Catenin signaling pathway by inactivating glycogen synthase kinase-3β
(GSK-3). During cardiac specification, Li, Wnt 3A, and GSK-3 inhibitor SB415286 adversely affects cardiogenesis with severity of
anomalies based on timing of exposure. In the mouse, Li exposure (6.25 mg/ml) on ED 5.5 to 6.5 resulted in embryonic lethality; later
exposure at ED 6.75 to 7.25 produced valve defects, including Ebstein’s anomaly that in human pregnancy also occurs at higher
incidence with Li exposure. Folate (FA) deficiency leads to elevated homocysteine (HCys) and pregnant mice exposed to 11.6 µg/ml
HCys on ED 6.75 resulted in similar valve defects as with Li exposure. An intersection between HCys/FA metabolism and Wnt/β-
Catenin transduction was hypothesized. Folate supplementation overrides Li/ Wnt/β-Catenin/Wnt 3A and HCys inhibition of heart
development and gene expression in chick embryonic heart fields. To initiate cardiogenesis, Wnt antagonists act on the endoderm to
up-regulate Hex, an inducer of cardiogenesis. Exposure of stage 4 chick embryos to Li or HCys inhibited Hex expression in the
cardiogenic crescent, thus augmenting inhibitory Wnt/β signaling. FA, known to protect against HCys and neural tube defects, was
tested to protective effects during cardiogenesis. With FA addition, the cardiac inducer Hex is reexpressed in the chick heart fields and
in the mouse no valve defects were detected in HCys exposed embryos. Regimen of FA supplementation to rescue Li adverse effects
is currently being tested. In conclusion, folate supplementation potentiates the repression of Wnt/β-Catenin signaling and can rescue
heart and valve defects.
Author Disclosure Block:
M.C. Serrano, None; M. Han, None; J.C. Huhta, None; R. Lastra, None; S. Manisastry, None; K.K. Linask, None.
P13
Myocardial Gene Expression in Children with Dilated Cardiomyopathy
Shelley D Miyamoto, The Children's Hosp, Denver, CO; Paul Lampe, Fred Hutchinson Cancer Res Ctr, Seattle, WA; Rebecca D
Sobus, Univ of Colorado Denver Health Sciences Ctr, Denver, CO; Jane E Nydam, The Children's Hosp, Denver, CO; Brian L
Stauffer, Univ of Colorado Denver Health Sciences Ctr, Denver, CO
Dilated cardiomyopathy (DCM) is an important cause of heart failure and sudden death in children. Adult failing myocardium is
characterized by a reversion to a fetal gene profile consisting of higher levels of atrial natriuretic peptide (ANP), β-Myosin heavy
chain (MyHC) and lower expression of α-MyHC and both amount and phosphorylation of the major gap junction protein Connexin 43
(Cx43). These maladaptive changes contribute to arrhythmias and contractility abnormalities. Myocardial gene expression and the
contribution to pathophysiologic adaptation in children with DCM is largely unexplored. We hypothesize that children with heart
failure would express an altered myocardial expression pattern similar to that observed in adults indicative of myocardial remodeling.
Left ventricular tissue from the explanted hearts of children undergoing transplant for DCM (n=9) and non-failing control hearts (NF,
n=6) was obtained with IRB approval from our institution. Protein and mRNA were isolated using standard methods. The expression
of ANP, α and β-MyHC and Cx43 genes was measured by Realtime quantitative PCR. Cx43 protein was measured using standard
Western blotting techniques. As expected, α-MHC expression and the α-/β-MHC ratio were each 10-fold higher in the NF tissue
(p<0.01). DCM samples expressed more ANP (4.8-fold), β-MHC (1.9-fold) and Cx43 (2.7-fold, p<0.01) than NF controls. However,
there was no difference in Cx43 protein expression or phosphorylation (Serine 365) between DCM and NF samples. Interestingly a
sex difference in Cx43 phosphorylation was demonstrated (Female > Male). In conclusion, the hearts from children with DCM
demonstrate many similarities to the expression profiles to adults with heart failure. Additional investigation is necessary to
understand how these changes influence protein expression as well as disease progression and response to therapy.
Author Disclosure Block:
S.D. Miyamoto, None; P. Lampe, None; R.D. Sobus, None; J.E. Nydam, None; B.L. Stauffer, None.
P14
Prenatal Imprinting of Adult Cardiac Dysfunction: Impact of Maternal High-Fat Diet in Mice
Hongyan Zhang, Hong Huang, Brandon Schanbacher, John Anthony Bauer, Peter Giannone, Nationwide Children's Hosp & Res Inst,
Columbus, OH
An adverse environmental exposure leads to irreversible adaptations in the structure and function of organs that may predispose the
individual to the later onset of chronic disease, recognized as “the fetal origins hypothesis”. The relationship between maternal
nutritional uptake and fetal metabolic status/cardiovascular performance has not been defined. High-fat diet (HFD) and hyperlipidemia
are associated with increased inflammation and oxidative stress, which play mechanistic roles in many cardiovascular disorders in
adults. Here, we tested the hypothesis that prenatal HFD alters normal cardiovascular development, affects innate immunity
mechanisms, and thereby predisposes the offspring to cardiovascular disease in adulthood. Female C57BL/6 mice were fed with either
control diet (CD) or HFD while breeding and 3 weeks after delivery. Offspring were fed with a regular mouse chow after weaning
(21-day). Cardiac profiles were assessed in offspring at 5-week with echocardiogram and electrocardiogram, at basal condition and
under cardiac stress (isoproteronol, 2.5 mg/kg, ip). Fasting blood was collected retro-orbitally for lipid measurements. Offspring were
then given a single dose of bacterial endotoxin (LPS, 1mg/kg, ip). Blood samples were taken at 0, 2h, and 24h after treatment. Plasma
serum amyloid A (SAA) levels were measured with ELISA. There were no significant differences on total cholesterol, LDL
cholesterol, and triglycerides between control and prenatal HFD offspring. While basal heart rate, cardiac output, and LV fractional
shortening (FS) showed no difference, offspring exposed to prenatal HFD had significant less isoproteronol (2.5 mg/kg, ip) induced
increases of fractional shortening (p<0.05), indicating a reduced cardiac reserve capacity. An elevation of plasma SAA level was
detected at 24h after LPS treatment (p<0.001). Mice with prenatal HFD exposure had significant higher SAA levels compared with
the control mice (p<0.001), suggesting an increased sensitivity to LPS. We have shown, in this mouse model, that even though
maternal HFD does not affect lipid profiles significantly in offspring, it causes permanent cardiac function changes especially under
stress. It also causes an increase in LPS sensitivity.
Author Disclosure Block:
H. Zhang, None; H. Huang, None; B. Schanbacher, None; J.A. Bauer, None; P. Giannone, None.
P15
Alterations in β1-Integrin and Connexin-43 in Restrictive Ventricular Septal Defect
Gretel Monreal, The Ohio State Univ, Columbus, OH; Alistair B Phillips, Nationwide Children's Hosp, Columbus, OH; Loren E
Wold, John Anthony Bauer, The Res Inst at Nationwide Children's Hosp, Columbus, OH; Mark A Gerhardt, The Ohio State Univ,
Columbus, OH
Background: Restrictive ventricular septal defect (rVSD) is a common congenital cardiac defect characterized by a left-to-right shunt
and is not surgically repaired due to the lack of hemodynamic involvement. We reported marked remodeling of the RV cytoskeleton
in rVSD in the absence of hemodynamic alterations. β1-integrin links the cytoskeleton to the extracellular matrix and with the gap
junction protein connexin-43 (Cx43) participates in intercellular electrical coupling. rVSD is commonly associated with arrhythmias,
however electrical remodeling of rVSD myocardium has not been studied. Alterations in β1-integrin and Cx43 may contribute to
arrhythmias in rVSD. Using a porcine model of rVSD, we measure myocardial β1-integrin and Cx43 levels to gain insights into
differential electrical remodeling.
Methods: A mid-muscular rVSD was created in 3 pigs. Hemodynamics were measured at baseline and 1 week post-rVSD and
compared to controls. Western blot (WB) with densitometry was performed on LV and RV myocardium using β1-integrin and Cx43
antisera. WB data was normalized to actin. *p<0.05.
Results: There was no change in pressures (mmHg) from LV (37±2 vs 36±5), RV (17±1 vs 15±0.7), Ao (58±4 vs 54±5), or PA
(19±0.9 vs 18±0.7) in baseline vs VSD animals. O saturations were unchanged (Ao 100% pre and post, PA 85.8±2.7% vs
2
85.0±6.7%). VSD myocardium demonstrated acute alterations in electrical signaling proteins. Cx43 increased 571%* and 393%* in
the LV and RV, respectively, of VSD myocardium. In contrast, β1-integrin content increased only in the RV of rVSD myocardium
(65%*).
Conclusions: rVSD is associated with significant alterations in signal transduction proteins. Cx43 was globally upregulated whereas
β1-integrin upregulation occurred only in RV myocardium. Alterations in β1-integrin and gap junction protein expression suggest that
electrical remodeling is taking place and may foreshadow future arrhythmias in rVSD patients. Interventions which target intracellular
remodeling at the molecular level may represent novel therapeutic strategies or diagnostic modalities for rVSD. These findings may
lead to a fundamental change in the clinical management of pediatric rVSD by providing evidence for early repair of the VSD based
on molecular remodeling.
Author Disclosure Block:
G. Monreal, None; A.B. Phillips, None; L.E. Wold, None; J.A. Bauer, None; M.A. Gerhardt, None.
P16
Death Among Children Hospitalized with Acute Heart Failure Syndromes
Jack Price, David P Nelson, Texas Children's Hosp, Houston, TX
Background: Large national surveys and registries have provided important insight into the clinical features and outcomes of acute
heart failure syndromes (AHFS) in adults. However, few data have been collected for AHFS in children. We sought to characterize the
etiology, manner and frequency of death in children hospitalized with AHFS.
Methods: We performed a retrospective medical record review of patients who were hospitalized with AHFS from 1/2003 to 1/2007.
AHFS was defined as “the gradual or rapid deterioration in heart failure signs and symptoms resulting in a need for urgent therapy.”
Exclusion criteria: pts >21 years of age; pts whose HF symptoms were attributable to left-to-right intracardiac shunting or left-sided
obstructive lesions.
Results: Data were available in 134 pt hospitalizations for AHFS. Median age was 6.8 years (range 0.1 to 20.5 years). Etiology of HF
included idiopathic dilated cardiomyopathy (DCM) (n=78), congenital heart disease (n=23), ischemic cardiomyopathy (n=10), acute
myocarditis (n=9), acute graft rejection (n=9) and restrictive cardiomyopathy (n=3). Sixty-nine (51%) had pre-existing HF symptoms.
There were 22 deaths (16%) in this cohort. Median age among non-survivors was 11.1 years (range 1.1 to 20.3 years). Cause of death
included pump failure (n=10), multi-system organ failure (n=7), sudden death (n=4) and sepsis (n=1). Fourteen (64%) non-survivors
(NS) had a history of heart failure prior to hospitalization. VT was documented in 14 NS during their hospitalization and occurred
immediately preceding death in 6 NS. Among the NS, CPR was performed in 15 and a DNR order was present for 8. Seventeen
patients died in an intensive care unit, 3 in the emergency department and 2 in the general cardiology ward. Four pts received
mechanical circulatory support prior to or at the time of their death.
Conclusions: These data provide important insight into the cause and frequency of death in children hospitalized with AHFS. Sudden
death was an uncommon manner of death in children with AHFS and in-hospital mortality for pediatric AHFS was higher than
mortality rates reported in adults. Future data gathering in this critically ill population will yield risk factors for outcome and aid in
future algorithm and treatment trial design.
Author Disclosure Block:
J. Price, None; D.P. Nelson, None.
P17
Heart Failure Symptoms and B-Type Natriuretic Peptide Concentrations in Children with Hypertrophic Cardiomyopathy
Jack F Price, Ricardo Pignatelli, John L Jefferies, Jeffrey J Kim, William J Dreyer, Susan W Denfield, Jeffrey A Towbin, Texas
Children's Hosp, Houston, TX
Objective: Plasma B-type natriuretic peptide (BNP) concentrations are associated with heart failure (HF) symptoms in adults with
hypertrophic cardiomyopathy (HCM) and correlate with echocardiographic measurements. The purpose of this study was to determine
the range of BNP levels in children with HCM and whether BNP levels are associated with HF symptomatology and
echocardiographic measurements.
Methods: We prospectively measured whole blood BNP concentrations in 42 consecutive pts with HCM and 16 healthy controls.
BNP levels were measured using the Biosite Triage Assay. We required a maximum thickness of the left ventricular (LV) free wall or
septum of >2 Z-scores. Exclusion criteria: age greater than 21 years, left ventricular ejection fraction <50%, aortic valve stenosis,
hospitalization in the previous 3 months. An echocardiogram, physical examination and medical history were performed for each
patient at the time of enrollment. Symptoms included fatigue, decreased activity, dyspnea or increased work of breathing with
exertion. Left ventricular outflow tract obstruction (LVOTO) was defined as an estimated peak pressure gradient by Doppler
interrogation of the LVOT of at least 25 mmHg. Echocardiographers and clinicians were blinded to BNP results.
Results: Median age of study patients was 15.4 years (interquartile range [IQR], 10.2 to 17.2 years). BNP concentrations were
elevated in children with HCM compared with healthy controls (median, 43 pg/mL, [IQR, 7 to 205 pg/mL] versus median, 7 pg/mL
[IQR, 5 to 11 pg/mL]; p<0.001). Symptomatic pts had greater BNP concentrations than asymptomatic pts (median, 504 pg/mL [IQR,
174 to 673 pg/mL] versus median, 18 pg/mL [IQR, 5 to 48 pg/mL]; p<0.001). BNP correlated with maximal LV thickness z-score
(r=0.54; p<0.001) and LV mass z-score (r=0.46; p=0.004). There was no difference in BNP levels between pts with LVOTO (n=8)
and pts without LVOTO (n=34), (median, 85 pg/mL [IQR 50 to 265 pg/mL] versus median, 26 pg/mL [IQR 7 to 202 pg/mL], p=0.8).
Conclusions: Whole blood BNP concentrations are elevated in children with HCM and are associated with HF symptomatology and
echocardiographic measurements. Further studies should examine the role of BNP in risk stratification of pts with HCM.
Author Disclosure Block:
J.F. Price, None; R. Pignatelli, None; J.L. Jefferies, None; J.J. Kim, None; W.J. Dreyer, None; S.W. Denfield, None; J.A. Towbin,
None.
P18
Comparison of Brain Natriuretic Peptide and N-Terminal Pro-Brain Natriuretic Peptide in a Pediatric Population
Dhaval R Parekh, Catherine Bendel, Philippe R Gaillard, Michael Tsai, Univ of Minnesota, Minneapolis, MN; Priscilla Borman, Univ
of Minnesota Medical Ctr, Fairview, Minneapolis, MN; Elizabeth Braunlin, Univ of Minnesota, Minneapolis, MN
Introduction: Pro Brain Natriuretic Peptide is a neurohormonal substance mainly secreted by cardiac myocytes in response to left
ventricular stress and strain from volume overload. It is cleaved to give both Brain Natriuretic Peptide (BNP) and N-Terminal Pro-
Brain Natriuretic peptide (NT-ProBNP). Currently, the bulk of our experience with natriuretic peptides is with BNP. Testing for NT-
ProBNP instead of BNP has been proposed given NT-ProBNP s improved stability, automation and reduced sample volume. To date
there is limited evaluation of simultaneous BNP and NT-ProBNP measurements in the pediatric population.
Objective: To compare BNP and NT-ProBNP values in the pediatric population and to determine the extent of relationship between
the two measurements.
Methods: A total of 246 simultaneous BNP and NT-ProBNP samples from 126 (70 males) pediatric subjects (mean age=7.2 yrs;
SD=6.7) from both inpatient and outpatient settings were evaluated. BNP levels were measured using a Triage BNP Test Kit (Biosite
Inc.) and NT-ProBNP using a Vitros NT-ProBNP Immunodiagnostic assay (Ortho-Clinical Diagnostics Inc.). Simple linear regression
analysis (SAS ver. 9.1) and a Bland-Altman method for assessing agreement (Analyze-It ver. 2.04) were performed.
Results: BNP and NT-ProBNP plasma levels for the total cohort were correlated with an r-value of 0.77 and log transformations
yielded an r-value of 0.87. The Bland-Altman analysis revealed wide 95% limits of agreement for the total cohort ( 818.3). Grouping
by pediatric ages shows that the correlations did not substantially improve with age, however, there was a substantial improvement in
the 95% limits of agreement after age 13 ( 321.4). For the total cohort, adjusting BNP and NT-ProBNP for creatinine did not improve
the correlation (r=0.79) or the 95% limits of agreement ( 807.2) significantly.
Conclusions: Our results show that BNP and NT-ProBNP are correlated in the pediatric population. However, high prediction
intervals and wide limits of agreement make clinical conversion from BNP to only NT-ProBNP challenging in evaluating pediatric
heart disease states, especially in those younger than 13 years. Finally, adjusting for creatinine did not significantly influence our
correlations or limits of agreement.
Author Disclosure Block:
D.R. Parekh, None; C. Bendel, None; P.R. Gaillard, None; M. Tsai, None; P. Borman, None; E. Braunlin, None.
P19
Prevalence of ECG Abnormalities in Very Young Duchenne Muscular Dystrophy Patients
Jeanne James, Cincinnati Children's Hosp, Cincinnati, OH; Larry Markham, Monroe Carell Jr Children's Hosp at Vanderbilt Univ,
Nashville, TN; Kathleen Kinnett, Woody Benson, Robert Spicer, Linda Cripe, Cincinnati Children's Hosp, Cincinnati, OH
As DMD patients develop clinical manifestations of cardiac involvement, they display characteristic ECG findings of tall R waves in
the right precordial leads and deep inferolateral Q waves, the latter a result of posterobasal left ventricular fibrosis. We sought to
determine the prevalence of ECG abnormalities in very young DMD patients who presented for evaluation at the Cincinnati
Children’s Hospital Comprehensive Neuromuscular Care Center. Between 1991 and 2008 we performed cardiac evaluations on 58
boys aged 0.9 - 4 yrs (mean 3.2 ± 0.9 yrs) with confirmed mutations in the dystrophin gene. The ECGs of three patients already on
corticosteroid therapy at the time of evaluation were excluded from analysis. Of the 55 remaining ECGs, 61.8% (34 of 55) were
abnormal. The most common findings were left ventricular hypertrophy (29.1%, 16 of 55), biventricular hypertrophy (20.0%, 11 of
55), prominent mid-precordial voltages (9.1%, 5 of 55) and non-specific ST segment and T wave changes (9.1%, 5 of 55). Right axis
deviation, left axis deviation, right ventricular hypertrophy and ventricular pre-excitation were each found in single patients. One
patient exhibited sinus bradycardia (70 bpm in a 2.6 year old), with the remainder having a normal heart rate for age (range 84 - 157,
mean 112 ± 14 bpm). A single patient demonstrated deep inferolateral Q waves. In contrast to the ECG abnormalities, all patients
were without cardiac symptoms and all but one had normal left ventricular shortening fraction by echocardiography. We conclude that
ECG abnormalities are common in young (≤4 years) DMD patients, occur prior to other clinical manifestations of cardiac disease and
differ from the reported classic DMD ECG. Early evidence of cardiac involvement is not entirely surprising since the disease
pathogenesis associated with dystrophin deficiency that leads to necrosis, inflammation and fibrosis is ongoing even in the primary
stages of disease.
Author Disclosure Block:
J. James, None; L. Markham, None; K. Kinnett, None; W. Benson, None; R. Spicer, None; L. Cripe, None.
P20
Left Ventricular Dimension at Presentation Is Associated with Poor Outcome in Pediatric Dilated Cardiomyopathy
Jean L Cavanaugh, Biagio A Pietra, Shelley D Miyamoto, The Children's Hosp, Denver, CO
Dilated cardiomyopathy (DCM) is a major cause of heart failure in children and can result in sudden cardiac death or need for a heart
transplant. This retrospective study tests the hypothesis that predictors of outcome could be identified at initial presentation of DCM in
children. Our Cardiomyopathy database was reviewed and 29 consecutive children who presented to our institution with new onset
idiopathic DCM were studied. Age, hospital course and echocardiogram findings at presentation and long term outcome are described.
The median age at presentation was 6 months (birth-16 years). At presentation, 83% (24/29) of patients were admitted to the hospital.
Of those hospitalized, 21% (5/24) required intubation. Inotropic support was used in 66% (19/29)- 52% (15) were on milrinone, 31%
(9) were on dopamine, 21% (6) were on dobutamine. Of the 19 patients on inotropes, 9 (47%) required 1 inotrope, 9 required 2
inotropes and 1 patient was on 3 inotropes. Of patients hospitalized at presentation, 21 of the 24 (88%) were discharged home on
medical therapy, while 3 could not be weaned off inotropes and were transplanted prior to discharge. Overall, 41% (12) have survived
without needing a transplant (L), 48% (14) have been transplanted (T), 2 died suddenly (SCD) and 1 patient died while listed for
transplant. Median time from presentation to transplant was 8 months (18 days-5.6 years). There was no association between number
of or days on inotropes at initial presentation and outcome. There was no significant (ns) difference in age or body surface area at
presentation between groups. LV end-diastolic dimension (LVEDd) was significantly greater for the T and SCD groups compared to
the L group (p<0.01). The LVEDd z-score was significantly larger in SCD patients compared to the L or T group (p<0.01). Fractional
shortening at presentation was 15.8±8% for L, 13.9±7% for T and 7.3±3.2% for SCD (ns). In conclusion, the majority of children with
new onset DCM require hospitalization with 2/3 requiring inotropic support. In our series, nearly 50% of patients presenting with new
onset DCM have required a heart transplant. A smaller LVEDd at presentation is associated with survival without need for transplant,
while a larger LVEDd z-score at presentation is associated with higher risk of SCD.
Author Disclosure Block:
J.L. Cavanaugh, None; B.A. Pietra, None; S.D. Miyamoto, None.
P21
Variations of Coronary Origin, a Case of Bland White Garland Syndrome via 64-Slice Cardiac CT Angiography
Shah Azmoon, NYMC, White Plains, NY; Matthew Budoff, David Atkinson, Harbor UCLA, Torrance, CA
Background: Anomalies of the coronary arteries have been described as early as the 1800s. In 1933 Drs. Bland, White and Garland
described the clinical syndrome of heart failure seen in infants with anomalous origin of the left coronary artery arising from the
pulmonary artery. Mortality rates have been reported to be greater than 90% within the first year of life if left untreated. Two
dimensional echocardiography with doppler color flow mapping has been frequently used for initial diagnosis where conventional
coronary angiography remains the gold standard.
Case Presentation: Here we present a case of Bland White Garland syndrome in which the left coronary arteries arise from the
pulmonary artery in a symptomatic young child. Diagnosis was promptly made using 64 slice Cardiac CT Angiography after failed
attempts in diagnosis using other modalities and the patient was sent for surgical correction. Using low dose protocols, the estimated
radiation dose to the infant was 1 milliseivert.
Conclusion: The high spatial and temporal resolution of 64 slice cardiac CT angiography may provide an alternate imaging modality
in the diagnosis of congenital coronary anomalies avoiding invasive risks of conventional coronary angiography.
Description:Mary B Wagner, Rob F Wiegerinck, Anca Cojoc, Carlo M Zeidenweber, Guoliang . Ilina R Datkhaeva, Univ of Colorado, Boulder, CO; Shelley D Miyamoto, .. AHFS was defined as “the gradual or rapid deterioration in heart failure
