Die weltweite Zunahme der Prävalenz von Übergewicht und Adipositas und den damit verbundenen medizinischen und sozioökonomischen Herausforderungen stellt eine der wesentlichen Herausforderungen der modernen medizinischen Versorgung dar. Im Mittelpunkt stehen dabei insbesondere die Auswirkungen von Übergewicht und Adipositas auf das kardiovaskuläre System und den damit verbundenen funktionellen und strukturellen Veränderungen der kardiovaskulären Funktion. Als Mediatoren dieser funktionellen und strukturellen Veränderungen stehen dabei zunehmend Adipozytokine im Interesse wissenschaftlicher Arbeiten. Unter Adipozytokinen versteht man in diesem Zusammenhang einen Sammelbegriff für von Adipozyten und anderen Fettgewebszellen sezernierten autokrin-, endokrin- und parakrin wirkenden bioaktiven Molekülen. Insbesondere bei Übergewicht und Adipositas kommt es zu einer charakteristischen Veränderung im Sekretionsmuster dieser Adipozytokine. Die Wirkung einzelner Adipozytokine auf die kardiovaskuläre Funktion wurde in den letzten Jahren intensiv untersucht, über die Wirkung ganzer Adipozytokinprofile ist bisher jedoch nur wenig bekannt. Ziel der vorliegenden Arbeit war es zu klären, welchen Einfluss eine 24-stündige Behandlung von neonatalen ventrikulären Kardiomyozyten mit einem physiologischen Adipozytokin-Profil auf Hypertrophie-assoziierte Signalwege und Zellproteine hat.

Die weltweite Zunahme der Prävalenz von Übergewicht und Adipositas und den damit verbundenen medizinischen und sozioökonomischen Herausforderungen stellt eine der wesentlichen Herausforderungen der modernen medizinischen Versorgung dar. Im Mittelpunkt stehen dabei insbesondere die Auswirkungen von Übergewicht und Adipositas auf das kardiovaskuläre System und den damit verbundenen funktionellen und strukturellen Veränderungen der kardiovaskulären Funktion. Als Mediatoren dieser funktionellen und strukturellen Veränderungen stehen dabei zunehmend Adipozytokine im Interesse wissenschaftlicher Arbeiten. Unter Adipozytokinen versteht man in diesem Zusammenhang einen Sammelbegriff für von Adipozyten und anderen Fettgewebszellen sezernierten autokrin-, endokrin- und parakrin wirkenden bioaktiven Molekülen. Insbesondere bei Übergewicht und Adipositas kommt es zu einer charakteristischen Veränderung im Sekretionsmuster dieser Adipozytokine. Die Wirkung einzelner Adipozytokine auf die kardiovaskuläre Funktion wurde in den letzten Jahren intensiv untersucht, über die Wirkung ganzer Adipozytokinprofile ist bisher jedoch nur wenig bekannt. Ziel der vorliegenden Arbeit war es zu klären, welchen Einfluss eine 24-stündige Behandlung von neonatalen ventrikulären Kardiomyozyten mit einem physiologischen Adipozytokin-Profil auf Hypertrophie-assoziierte Signalwege und Zellproteine hat.

Background As a major cause of morbidity and mortality treatment of venous thromboembolism is important, with the correct use of anticoagulants it is possible to greatly reduce both mortality and morbidity. Warfarin is among the most widely used anticoagulants being effective in treatment and prevention of venous thromboembolism with few negative side effects other than bleeding complications. With a narrow therapeutic window warfarin treatment requires constant monitoring and adjustments to stay effective without an increased bleeding risk. The aim of this thesis was to study the efficacy and safety of warfarin treatment in venous thromboembolic disease. Methods Using AuriculA, the Swedish national quality register for atrial fibrillation and anticoagulation, a cohort was created of patients registered with warfarin treatment during the study time January 1st 2006 to December 31th 2011, including all different indications for anticoagulation. In all four studies the study design was retrospective with information added to the cohort from the Swedish national patient register about background data and endpoints in form of bleeding complications in all studies and thromboembolic events in study 1 and 2. In study 3 and 4 information was added from the cause of death register about occurrence of death and in study 3 cause of death. In study 3, information from the prescribed drugs register about retrieved prescriptions of acetylsalicylic acid was added. Results In study 1 the mean TTR was found to be high both among patients managed at primary healthcare centres and specialised anticoagulation clinics at 79.6% and 75.7%. There was no significant difference in rate of bleeding between the two types of managing centres being 2.22 and 2.26 per 100 treatment years. In study 2 no reduction in complication rate with increasing centre TTR was seen for patients with atrial fibrillation with few centres having centre TTR below 70% (2.9%), in contrast to previous findings by Wan et al(1). For those with warfarin due to VTE where a larger proportion of the centres had centre TTR below 70% (9.1%) there was a reduction in complication rate with increasing centre TTR. Among the 13859 patients with treatment for VTE in study 3 age (HR 1.02, CI 95% 1.01-1.03), hypertension (HR 1.29, CI 95%1.02-1.64), Cardiac failure (HR 1.55, CI 95% 1.13-2.11), chronic obstructive pulmonary disease (HR 1.43, CI 95% 1.04- 1.96), alcohol abuse (HR 3.35, CI 95% 1.97-5.71), anaemia (HR 1.77, CI 95% 1.29-2.44) and a history of major bleeding (HR 1.75, CI 95% 1.27-2.42) increased the risk of bleeding during warfarin treatment. In study 4 both those with high iTTR and those with low INR variability had a low rate of bleedings at 1.27 (1.14-1.41) or 1.20 (0.94-1.21) per 100 treatment years compared to those with low iTTR and high INR variability having a rate of bleeding at 2.91 (2.61-3.21) or 2.61 (2.36-2.86) respectively. Those with the combination of both low iTTR and high INR variability had an increased risk of bleeding, hazard ratio HR 3.47 (CI 95 % 2.89-4.17). The quartile with both the lowest iTTR and the highest INR variability had an increased risk of bleeding with a hazard ratio 4.03 (3.20-5.08) and 3.80 (CI 95%, 3.01-4.79) compared to the quartile with the highest iTTR and lowest INR variability. Conclusion It is possible to achieve a safe warfarin treatment both in specialised anticoagulation centres and in primary health care. At initiation of treatment some of the patients at high risk of bleeding can be identified using knowledge about their background. With the use of quality indicators as TTR and INR variability during treatment those at high risk of complications can be identified and analysing treatment quality on centre level gives an opportunity to identify improvement areas among managing centres. With the addition of new treatment options warfarin can still be the most suitable option for some patients, being safe and effective when well managed.

The field of cardiac electrophysiological imaging has advanced tremendously in the past three decades with developments in fluorescent dyes, photodetectors, optical filters, illumination sources, computers and electronics. This thesis describes several scalable multi-parametric imaging systems and their application to cardiac tissue preparations at various levels of complexity. Using off-the-shelf components, single-camera multi-parametric optical mapping systems are described for various fluorescent dye combinations and single-element photodiode-based fibre-optic detection systems are described for drug-testing applications. The instruments described take advantage of modern voltage-sensitive dyes, multi-band optical filters and powerful light-emitting-diodes, from the ultraviolet to the red. The two electrophysiological parameters focused on were transmembrane voltage and the intracellular calcium concentration. Several voltage and calcium dye combinations were established, which produce no signal cross-talk. Furthermore, second- and third-generation voltage dyes were characterized in cardiac tissue, in vitro and in vivo. The developed systems were then applied to isolated Langendorff-perfused whole-hearts, in vivo whole-hearts, thin ventricular tissue-slices and human induced pluripotent stem cell-derived cardiac tissue. The interventions applied include accurately-timed electrical and mechanical local stimulation of the whole-heart to generate ectopic beats, cardiotoxic drugs and flash-photolysis of caged-compounds. With the high-throughput demands of drug discovery and testing, further development of scalable optical electrophysiological systems may prove critical in reducing attrition and costs. And for in vivo optical mapping, development of minimally-invasive and clinically-relevant optical systems will be essential in validating existing theories based on in vitro experiments and exploring cardiac function and behaviour with the heart intact in the organism.

This study determined whether pre-operative exercise and education (PREHAB) improves the frailty status and physical activity behaviour of older adults undergoing elective cardiac surgery, more than standard care (StanC). Using a subset of patients from a multi-centre trial (NCT02219815), twenty-six patients over the age of sixty were randomized to receive StanC (n=12) or PREHAB (n=14). Blinded research assistants collected data at baseline prior to randomization and one week pre-operatively. Changes in frailty were assessed using a 30-item functional frailty index (FFI); whereas, changes in physical activity behaviour were assessed using accelerometers. Baseline data was not different between groups. Frailty status improved by 17%, 5% and 35% amongst StanC, PREHAB “non-completers” and PREHAB “completers”, respectively. No changes in moderate to vigorous physical activity were found pre-operatively. These data suggest that the PREHAB intervention is feasible to implement and may result in improved frailty status amongst frail older adults awaiting elective cardiac surgery. / October 2016

Background: Heart transplantation remains the gold standard for end-stage heart failure, with current ex vivo organ storage times limited to 4 to 6 h before critical tissue damage occurs. Many preservation solutions exist in an attempt to limit both ischemic and reperfusion damage. In order to compare the effects of various storage solutions, mitochondrial function can be used to provide a sensitive analysis of cellular metabolic function. Methods: Experimental plates were seeded with cardiac myoblasts and kept in suspended animation for either 4 or 8 h at either 4(o) or 21 degrees C, in Celsior (R), Perfadex (R), or Somah storage solutions. Cells were then reanimated for 1 h at 37 degrees C to simulate a reperfusion or clinical transplant scenario. Cellular bioenergetics were measured immediately thereafter to examine biochemical differences between preservation solutions and their effectiveness on preserving metabolic function. Results: The oxygen consumption rates of Somah solution were significantly higher than Celsior (R) and Perfadex (R) at 4 degrees C, with the exception of Perfadex (R) at 4(o) for 4 h. This effect was sustained up to 8 h. At 21 degrees C, oxygen consumption rates of Somah solution are significantly higher than Celsior (R) and Perfadex (R) at basal conditions after 4 h, but this effect is not sustained after 8 h. Conclusions: The purpose of this experiment was to study the efficacy of various preservation solutions on a mitochondrial level. The significantly higher oxygen consumption rates of Somah at 4 degrees C suggests that Somah solution may have the ability to protect cellular mitochondrial integrity, improve transplanted organ function by reducing ischemic-reperfusion injury, and thereby improve transplant outcomes. Given that Somah offers benefits over Celsior (R) and Perfadex (R) at 4 degrees C, it should be a target in future organ preservation solution research.

OBJECTIVES The aim of this study was to test the hypothesis that hypothermia and early reperfusion are synergistic for limiting infarct size when an acutely occluded coronary is associated with cardiac arrest. BACKGROUND Cohort studies have shown that 1 in 4 post-cardiac arrest patients without ST-segment elevation has an acutely occluded coronary artery. However, many interventional cardiologists remain unconvinced that immediate coronary angiography is needed in these patients. METHODS Thirty-two swine (mean weight 35 +/- 5 kg) were randomly assigned to 1 of the following 4 treatment groups: group A, hypothermia and reperfusion; group B, hypothermia and no reperfusion; group C, no hypothermia and reperfusion; and group D, no hypothermia and no reperfusion. The left anterior descending coronary artery was occluded with an intracoronary balloon, and ventricular fibrillation was electrically induced. Cardiopulmonary resuscitation was begun after 4 min of cardiac arrest. Defibrillation was attempted after 2 min of cardiopulmonary resuscitation. Resuscitated animals randomized to hypothermia were rapidly cooled to 34 degrees C, whereas those randomized to reperfusion had such after 45 min of left anterior descending coronary artery occlusion. RESULTS At 4 h, myocardial infarct size was calculated. Group A had the smallest infarct size at 16.1 +/- 19.6% (p < 0.05). Group C had an intermediate infarct size at 29.5 +/- 20.2%, whereas groups B and D had the largest infarct sizes at 41.5 +/- 15.5% and 41.1 +/- 15.0%, respectively. CONCLUSIONS Acute coronary occlusion is often associated with cardiac arrest, so treatment of resuscitated patients should include early coronary angiography for potential emergent reperfusion, while providing hypothermia for both brain and myocardial protection. Providing only early hypothermia, while delaying coronary angiography, is not optimal. (J Am Coll Cardiol Intv 2016; 9: 2403-12)

The myocardium is known to release CPK, LDH1 , and GOT in response to ischemia as a result of myocardial infarction. This study was designed to induce the release of cardiac enzymes without adversely effecting the myocardium by perfusion hypothermia, thereby suggesting that these enzymes are not as specific in the diagnosis of myocardial infarction as once thought. Hypothermia was by in vivo perfusion of the left anterior descending coronary artery. Enzyme activity was measured from sera samples spectrophotometrically and electrophoretically. Significant CPK and LDH1 increases were observed in animals perfused between 25 and 19 C. These results indicate that, while heart function remained unchanged, an alteration occurred in the membrane integrity of the myocardial cells.

Cardiac hypertrophy leading to heart failure remains a leading cause of morbidity and mortality in the 21st century despite major therapeutic advances. Improved understanding of novel molecular and cellular processes contributing to cardiac hypertrophy therefore continues to be important. Cyclin-dependent Kinase 9 (CDK9), part of a family of proteins controlling cell cycle and growth, has emerged as one such potential candidate over the last 5 years. CDK9 is the catalytic subunit of the CDK9/CyclinT complex and acts by phosphorylating the carboxy-terminal domain of RNA polymerase II. Hypertrophic signals, such as Endothelin-1 (ET-1) and phenylephrine, have been shown to cause CDK9 activation leading to a hypertrophic response in cultured mouse cardiomyocytes associated with reactivation of the foetal gene program. CDK9 also forms a complex with GATA4 to play a role in differentiation of mouse ES cells into cardiomyocytes. These findings suggest a specific role for CDK9 in controlling growth and differentiation of cardiomyocytes and merits further study in models where cardiomyocyte differentiation and proliferation are key contributors. In contrast to mammals, zebrafish retain a high cardiomyocyte proliferative capacity throughout their life span and can readily repair following injury. I have examined the role of CDK9 on global and cardiac development in the zebrafish embryo. I have also assessed the impact of CDK9 manipulation on response to ventricle injury using a laser-induced injury model developed and validated as part of my thesis. My findings confirm that normal growth of the embryonic ventricle is associated with a rapid increase in cardiomyocyte number, that was of 50% in the period 96-120 hpf, accompanied by increasing chamber trabeculation. This is also characterized by an increase in the gene expression of most of cardiac development relevant transcription factors, i.e. GATA4, 5 and 6, and MEF2c. The significant reduced cardiovascular function (14% of Ejection Fraction compared to 20% in controls) at 2 h post laser injury in the zebrafish embryonic heart promptly recovers at 24 hour post-laser, accompanied by acceleration of cardiomyocyte proliferation, that increased of 49% in injured ventricles compared to 20% in controls in the period 2-24 h post-laser. Pharmacological and genetic inhibition of CDK9 activity also significantly reduced cardiac growth, cardiomyocyte number, ventricle function and impairs functional recovery following laser injury. Conversely, genetic inhibition of LARP7, a CDK9 repressor, resulted in increased cardiomyocyte number and was associated with full functional and cellular recovery following laser-injury. In conclusion, I have provided evidence, in the zebrafish embryonic heart, that CDK9 plays an important role in cardiac growth and development and impacts significantly on cardiomyocyte proliferation. I have also shown that CDK9 manipulation significantly affects cellular and functional recovery following laser-induced injury. Further studies are required to further define the role of CDK9 and LARP7 in the heart and develop therapeutic strategies using this pathway that could contribute to cellular repair mechanisms in the adult mammalian heart.

Master of Science / Department of Clinical Sciences / Matt Miesner / Minimal research is available pertaining to the suspected acute cardiac injury of cattle experiencing the early signs of respiratory disease. One of the limitations of cardiac disease diagnosis in cattle is the lack of accurate measurement of cardiac disease. Blood biomoarkers such as cardiac troponin I could be used. Cardiac troponin I is a serum biomarker for cardiac injury in humans and many veterinary species. The goal of this thesis is to evaluate biophysical changes including cardiac injury that holstien calves experience during acute pneumonia. The first objective of this research was to evaluate a point of care cardiac troponin I assay for use in the bovine. Purified bovine cardiac troponin I was used to validate the accuracy of the assay over a wide range of concentrations in an in vitro experiment. This point of care assay was capable of accurately identifying bovine cardiac troponin I. An in vivo experiment was conducted to evaluate concentrations of cardiac troponin I in healthy Holstein calves. Concentrations evaluated with the point of care assay were similar to concentrations of a previously validated immunoassay. The second objective was to evaluate biophysical changes including serum biochemistry, complete blood count, cardiac troponin I, and high resolution digital thermography in Holstein calves during the first fourteen days after induction of pneumonia. Fibrinogen concentration increased with lung disease severity. The changes observed were considered clinically significant. Cardiac troponin I increased as pneumonia progressed during the study in this population.