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Mitral Regurgitation Augments
Post-Myocardial Infarction Remodeling
Failure of Hypertrophic Compensation
Ronen Beeri, MD,* Chaim Yosefy, MD,* J. Luis Guerrero, BS,* Francesca Nesta, MD,*
Suzan Abedat, MSC,§ Miguel Chaput, MD,* Federica del Monte, MD, PHD,†
Mark D. Handschumacher, BS,* Robert Stroud, MS,? Suzanne Sullivan, BS,* Thea Pugatsch, PHD,§
Dan Gilon, MD, FACC,§ Gus J. Vlahakes, MD, FACC,‡ Francis G. Spinale, MD, FACC,?
Roger J. Hajjar, MD, FACC,† Robert A. Levine, MD, FACC*
Boston, Massachusetts; Jerusalem, Israel; and Charleston, South Carolina
We examined whether mitral regurgitation (MR) augments post-myocardial infarction (MI) remodeling.
MR doubles mortality after MI, but its additive contribution to left ventricular (LV) remodeling is debated and has
not been addressed in a controlled fashion.
Apical MIs were created in 12 sheep, and 6 had an LV-to-left atrial shunt implanted, consistently producing re-
gurgitant fractions of ?30%. The groups were compared at baseline, 1, and 3 months.
Left ventricular end-systolic volume progressively increased by 190% with MR versus 90% without MR (p ?
0.02). Pre-load–recruitable stroke work declined by 82 ? 13% versus 25 ? 16% (p ? 0.01) with MR, with de-
creased remote-zone sarcoplasmic reticulum Ca2?-ATPase levels (0.56 ? 0.03 vs. 0.76 ? 0.02, p ? 0.001), and
decreased isolated myocyte contractility. In remote zones, pro-hypertrophic Akt and gp130 were upregulated in
both groups at 1 month, but significantly lower and below baseline in the MR group at 3 months. Pro-apoptotic
caspase 3 remained high in both groups. Matrix metalloproteinase (MMP)-13 and membrane-type MMP-1 were
increased in remote zones of MR versus infarct-only animals at 1 month, then fell below baseline. The MMP
tissue inhibitors rose from baseline to 3 months in all animals, rising higher in the MI ? MR–group border
In this controlled model, moderate MR worsens post-MI remodeling, with reduced contractility. Pro-hypertrophic
pathways are initially upregulated but subsequently fall below infarct-only levels and baseline; with sustained
caspase 3 elevation, transformation to a failure phenotype occurs. Extracellular matrix turnover increases in MR
animals. Therefore, MR can precipitate an earlier onset of dilated heart failure.
476–86) © 2008 by the American College of Cardiology Foundation
(J Am Coll Cardiol 2008;51:
Expansion of infarcted tissue begins acutely after myocardial
infarction (MI). A more gradual remodeling process, how-
ever, also involves the noninfarcted areas (1,2); initially
compensatory, this process subsequently becomes mal-
adaptive, generating a larger, more spherical, and poorly
contracting ventricle (3–7), associated with reduced sur-
vival (2,8,9).
See page 487
Myocardial infarction can also cause mitral regurgitation
(MR) by altering ventricular geometry and function (10–
12). Such ischemic MR doubles the risk of death after MI
(13,14). Severe nonischemic MR has been shown to pro-
mote left ventricular (LV) remodeling and reduce survival
(15–19). However, whether more typically moderate isch-
emic MR does so remains controversial. A recent paper
maintained that "ischemic MR is a consequence, not a
cause, of post-infarction remodeling," because remodeling
persisted despite annuloplasty with apparent MR reduction
From the *Cardiac Ultrasound Laboratory, †Cardiovascular Research Center, and
‡Cardiac Surgery Department, Massachusetts General Hospital and Harvard Medical
School, Boston, Massachusetts; §Heart Institute and Cardiovascular Research Lab-
oratory, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; and the
?Cardiothoracic Surgery Department, Medical University of South Carolina,
Charleston, South Carolina. Supported, in part, by a Grant-in-Aid (0350422N)
of the American Heart Association; grants R01HL38176, R01HL72265, and
K24HL67434 from the NIH/NHLBI; and a grant from the USA-Israel Binational
Science Foundation (no. 2001037).
Manuscript received May 3, 2007; revised manuscript received July 9, 2007,
accepted July 16, 2007.
Journal of the American College of Cardiology
© 2008 by the American College of Cardiology Foundation
Published by Elsevier Inc.
Vol. 51, No. 4, 2008
Page 2
(20). Practically, "MR might not represent a target for
therapy if indeed it is not the major culprit" (21), adding to
the uncertainty regarding the risk versus benefit of repairing
ischemic MR (22).
In patients, ischemic myocardial changes and regurgita-
tion develop concurrently, precluding the ability to separate
their effects and analyze their interaction directly (23). This
requires a model in which MR can be varied independently
in the presence of MI, but without interventions such as
infarct patching (24–27) that might themselves influence
remodeling. Most experimental studies of post-MI remod-
eling have used an infero-posterior MI model (27,28); this
has the disadvantage of linking the MI-induced remodeling
to the development of MR. We therefore tested the
incremental contribution of MR in a controlled manner
using a model in which the MI by itself does not cause MR,
and the MR can be created in a standardized and fixed
fashion (29,30).
In such a study, it must be recalled that remodeling is a
complex process, involving changes not only in ventricular
geometry (3) and in global and regional myocardial function
(31), but also in calcium handling, molecular signals pro-
moting hypertrophy, cardiomyocyte viability (32–34), and
extracellular matrix turnover (35). Intracellular pathways
that promote compensatory hypertrophy also tend, if chron-
ically activated, to drive cells down pathways to cell death by
apoptosis and thus to loss of contractile elements, with
further deterioration of cardiac function (Fig. 1). Accord-
ingly, it is important to correlate evidence of remodeling at
the molecular, cellular, and whole-heart levels (36). We
therefore tested the hypothesis that MR accompanying MI
produces greater remodeling than a comparable infarct
alone, and may be associated with a different progression of
molecular events, with transition from signals promoting
hypertrophy to those inducing failure.
MR model. A modification of
the chronic MR sheep model of
Rankin et al. (29) was imple-
mented in conjunction with Luis
Guerrero, a surgeon experienced
in physiological modeling, using
an 8-cm long, 8-mm diameter
reinforced Teflon (PTFE) graft
(Edwards Lifesciences, Irvine,
California) (cross-sectional area
of 0.50 cm2) implanted under
sterile conditions into the LV
base and left atrial (LA) append-
age with intramuscular portions
stiffened with epoxy resin (Fig.
2). The regurgitant flow was
confirmed during each thoracot-
omy (see the following text) us-
ing a transonic flow probe and
color Doppler echocardiography imaging. The standardized
shunt diameter and length have produced consistent levels
of MR (regurgitant fractions of approximately 30%, corre-
sponding to moderate MR [37]). Animals were treated with
heparin (3 days) and then oral aspirin.
Animal studies. A total of 12 Dorsett hybrid sheep (20 to
30 kg) were loaded for 3 days with amiodarone (200 mg
orally twice a day) then anesthetized with thiopentothal
sodium (0.5 ml/kg), intubated, and ventilated at 15 ml/kg
with a 2% isoflurane-oxygen mixture. All received glyco-
pyrrolate (0.4 mg intravenously) and prophylactic vancomy-
cin (0.5 g intravenously) and amiodarone (150 mg intrave-
nous drip over the course of the operation). Surface
electrocardiogram (ECG) was monitored, and a sterile left
thoracotomy performed with pericardial incision and cre-
ation of a cradle. A high-fidelity micromanometer-tipped
catheter (Millar Instruments Inc., Houston, Texas) was
placed into the LV. After baseline 2-dimensional (2D) and
3-dimensional (3D) echocardiography imaging, an antero-
apical MI was produced by ligating the mid- to distal left
anterior descending coronary artery, known to produce a
substantial MI without MR (38). An immediate 2D echo-
cardiography apical image was performed to confirm that
septal wall motion abnormality extended approximately
one-third of the way from LV apex to base for standard-
ization. Mitral regurgitation equivalent volume overload
was created for 90 days in 6 sheep with an open LV-to-LA
shunt (referred to as the infarct ? MR group); in the other
6, the shunt was closed (infarct-only group). In addition to
analgesia, propranolol, 1 mg intravenously in 2 divided
doses, was given for evident stress and sinus tachycardia
(?150) upon extubation. Antibiotics (cephapirin, 0.5 g
intravenously) and analgesics (buprenorphine, 0.3 mg
twice a day) were administered for the next 5 days, and
oral amiodarone (200 mg twice a day) for the next 3.
Figure 1 The Vicious Cycle of Remodeling
EC ? extracellular; LV ? left ventricle; MR ? mitral regurgitation.
and Acronyms
EF ? ejection fraction
LA ? left atrium/atrial
LV ? left
MI ? myocardial infarction
MMP ? matrix
MR ? mitral regurgitation
MT-MMP ? membrane-type
matrix metalloproteinase
SERCA2a ? sarcoplasmic
reticulum Ca2?-ATPase
TIMP ? tissue inhibitor of
matrix metalloproteinase
2D ? 2-dimensional
3D ? 3-dimensional
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86
Beeri et al.
MR Augments Post-MI Remodeling
Page 3
During repeat sterile thoracotomy at day 30, 3D echo-
cardiography was performed to evaluate LV remodeling and
function, with directed biopsies of the noninfarcted myo-
cardium near and remote from the border zone using a
TruCut needle (Cook, Winston-Salem, North Carolina).
At day 90, 3D echocardiography and blood sampling were
repeated at thoracotomy, followed by euthanasia and whole-
heart pathological and myocyte size and contractility studies
that require considerable tissue. The animal studies con-
formed to National Institutes of Health Guidelines for
Animal Research (Guide for the Care and Use of Labora-
tory Animals, National Research Council, Washington,
DC, 1996) and were approved by the institutional animal
care committee.
3D echocardiography and LV function. Three-
dimensional quantitation is necessary because LV shape
changes with chronic MR, as well as MI (39). Rotated
apical images were obtained at 10° intervals with an epicar-
dial 5-MHz transesophageal echocardiography probe (So-
nos 7500, Philips Medical Systems, Andover, Massachu-
setts), rotated by software and gated to ECG and
respiration. Digital images were analyzed on a workstation
with custom programs (40). Endocardial surfaces were
traced to calculate LV volumes and ejection fraction (EF),
and coded for wall motion abnormality to produce a
quantitative 3D wall motion map validated against a 36-
crystal sonomicrometer array (41). Remodeling was quan-
tified in terms of increasing LV volumes (42). Regurgitant
fraction was calculated as transonic MR-equivalent flow
divided by LV ejection volume, with cross-correlation by
pulsed Doppler time–velocity integral of shunt flow multi-
plied by shunt cross-sectional area. At thoracotomy, the
initial and final pressure–volume loops were obtained using
Millar catheters and 4 sterile subendocardial crystals (Sono-
metrics Corp., London, Ontario, Canada), with an inferior
vena cava occlusion to obtain the end-systolic pressure–
volume relation for contractility (43) and pre-load–
recruitable stroke work (44). Crystals were located at the LV
apex and base (between aorta and mitral annulus) and
anteriorly and posteriorly along a midventricular short-axis.
Crystals were not placed at day 30 to maximize sterility and
survival. dP/dt was obtained by the high-fidelity Millar
catheter (Millar Instruments, Houston, Texas).
Myocyte size and contraction. Small (5 to 10 g) areas of
tissue were removed at euthanasia from the noninfarcted
LV and perfused via the corresponding coronary artery for 5
min with low-magnesium Krebs-Henseleit (KH) cardiople-
gia solution. Myocardial cells were isolated using a well-
established method (45,46). The LV sections were perfused
with Ca2?-free KH containing collagenase (Worthington
Biochem Corp., Lakewood, New Jersey) and hyaluronidase
(Sigma, St. Louis, Missouri). Ventricular muscle tissue was
minced into small pieces and placed in enzyme buffer I
(Sigma) in the presence of trypsin and deoxy-ribonuclease.
The tissue was washed in a 3:1 mixture of Ca2?-free KH in
Dulbecco's phosphate-buffered saline (GIBCO, Gaithers-
burg, Maryland). Cells were loaded with the Ca2?fluores-
cent indicator Fura-2 for 15 min in a light-sealed chamber
mounted on an inverted microscope. Myocyte length and
width were measured offline on 50 consecutive cells using
commercial image analysis software to establish proportions
of normal short cells versus elongated cells characteristic of
eccentric hypertrophy in the failing phenotype. The cells
were excited to contract using platinum electrodes in the
bath, and a dual excitation spectrofluorometer recorded
fluorescence emissions (505 nm from exciting wavelengths
340 mm and 380 mm) to calculate intracellular calcium
concentrations. Cell motion was measured by a video-edge
motion detector (Crescent Electronics, Sandy, Utah) (45).
Molecular assays. We measured levels of several molecular
species that determine cell contractility, that modulate cell
hypertrophy and death, and that are responsible for extra-
cellular matrix turnover. All protein assays were performed
and specimens pooled from the same treatment group and
Calcium cycling proteins: sarcoplasmic reticulum Ca2?-
ATPase (SERCA2a) and phospholamban. Sarcoplasmic
reticulum membranes were obtained from the myocardial
biopsy specimens using a sucrose gradient centrifugation
method (47). Myocardium was homogenized and centri-
fuged at 7,700 g for 20 min, and the supernatant filtered and
centrifuged at 136,000 g for 60 min. The pellets, resus-
pended and rehomogenized in 10% sucrose buffer, were
centrifuged at 55,000 g in a 10% to 40% sucrose gradient,
and the bands between 30% and 40% enriched in sarcoplas-
mic reticulum were collected, centrifuged at 136,000 g for
60 min, and the pellet resuspended in freezing buffer.
Protein was determined by a modified Bradford procedure
(using bovine serum albumin for the standard curve).
Proteins were separated from the sarcoplasmic reticulum
vesicle preparation from tissue frozen in liquid nitrogen, and
an immunoblot using monoclonal anti-SERCA2 and phos-
pholamban performed. Proteins levels were normalized
against total myocardial protein.
Pro-hypertrophic and anti-apoptotic cascades. We mea-
sured levels of Akt (protein kinase B) and gp130, which are
Figure 2
Schematic and 2D Echocardiographic
Image of the LA-LV Shunt Creating MR
Single arrows indicate flow direction; paired arrows indicate shunt exit from
the LV. LA ? left atrial; MI ? myocardial infarction; 2D ? 2-dimensional; other
abbreviations as in Figure 1.
478Beeri et al.
MR Augments Post-MI Remodeling
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86
Page 4
both at their respective levels (cytosol and membrane)
important crossroads in pro-hypertrophic signaling; and
caspase 3, the final common pathway for intracellular
signaling of apoptosis. Western blot analysis was performed
on cell lysates from biopsies at baseline and days 30 and 90.
Antibodies binding for anti-gp130, anti-phospho Akt, and
antiactivated caspase 3 (48) were detected with a
peroxidase-conjugated antimouse IgG and chemilumines-
cence. ?-Actin was used as a housekeeping control. Densi-
tometry of the blots was assessed using commercially avail-
able software (Photoshop 5, Adobe Systems Inc., San Jose,
Modulators of extracellular matrix turnover: matrix met-
alloproteinases (MMPs). Assays were performed for
membrane-type matrix metalloproteinase-1 (MT1-MMP),
MMP-13, tissue inhibitor of matrix metalloproteinase
(TIMP)-1, and TIMP-4 by immunoblotting using methods
previously described (35). Left ventricular myocardial sam-
ples were homogenized and concentrated to prevent MMP
proteolytic activation and degradation. Trypsin (2.5 ?M; 5
min) was used to cleave nascent MMPs to fully activate
enzyme moieties and/or facilitate the removal of endoge-
nous inhibitors. Relative TIMP-1, TIMP-4, MT1-MMP,
and MMP-13 levels were then measured by immunoblot-
ting. A positive control was included in all immunoblots
(MMP-13: CC068; MT1-MMP: CC1042) (Chemicon,
Temecula, California).
Statistics. Statistical analysis was performed using a Stu-
dent t test for continuous variables and a chi-square test for
categorical variables (Stat View 5, SAS Institute Inc., Cary,
North Carolina). A value of p ? 0.05 was considered
significant. Multiple comparisons were performed using
analysis of variance (for repeated measurement where
needed) and a Student-Neumann Keuls post-hoc test.
Interobserver and intraobserver variability for 3D echo-
measured LV volumes and EF in our laboratory is 3.5%.
Remodeling: LV volumes. Left ventricular end-diastolic
volume relative to the acute post-MI value increased by an
average of 26% in the infarct-only group versus 130% in
those with volume overload (p ? 0.02). Left ventricular
end-systolic volume progressively increased by 190% with
MR-type volume overload versus 90% with MI only (p ?
0.02) (Figs. 3 and 4).
Remodeling: LV function. Pre-load–recruitable stroke
work from pressure-volume loops declined more in the
infarct ? MR group by 82 ? 13% versus 25 ? 16% of
baseline in the infarct-only group (p ? 0.01). Left ventric-
ular dP/dt also declined progressively in the MR group to 52
? 9% of baseline, but only by 22 ? 12% in the shams (p ?
0.04) (Fig. 4). These results were corroborated by reduced
contractility of isolated cells with reduced calcium transients
and increased diastolic intracellular calcium concentration
(Tables 1 and 2). The diastolic relaxation constant tau was
more prolonged in the infarct ? MR group (78 ? 23 ms vs.
44 ? 13 ms, p ? 0.01).
Calcium cycling proteins. As shown in Figure 5,
SERCA2a abundance was downregulated in the infarct
region and border zone compared with the remote region in
both infarct ? MR and infarct-only sheep LVs. There was
a lower level of SERCA2a in the remote zone of infarct ?
MR than of infarct-only sheep. Phospholamban was un-
changed in all regions. These changes are typical for
remodeling myocardium.
Intracellular signaling pathways. Akt, a pro-hypertrophic
enzyme (49), was upregulated in the remote zones of infarct
? MR and infarct-only animals at 1 month, but was lower
in animals with than without MR at 3 months (Fig. 6). In
the infarct ? MR group at 3 months, Akt also fell below
baseline of the same group. The same pattern was observed
for the interleukin-6-family receptor subunit gp130 (50).
Expression of activated caspase 3 (32–34,51), the final
common pathway of apoptosis, remained elevated in all
regions of both groups at both 1 and 3 months.
Cell morphology. Myocytes in the MR group were elon-
gated, characteristic of myocardial failure (45), compared
with cells from the MI-only animals (Fig. 7).
Extracellular matrix and MMPs. In the remote myocar-
dium of infarct ? MR sheep, at initial follow-up, there was
a significant increase in MMP-13 and MT1-MMP, fol-
lowed by a decrease at the time of sacrifice (Fig. 8, "shunt
remote" bars): MMP-13 increased to 238 ? 29% of baseline
at follow-up, and then fell to 79 ? 13% of baseline at 3
months sacrifice; MT1-MMP increased to 165 ? 23% of
baseline at follow-up, and then fell to 85 ? 16% of baseline
at sacrifice. In the remote myocardium of infarct-only
sheep, the rise and fall of MMP-13 did not reach statistical
Figure 3
Echocardiographic 3D Reconstructions
of the Endocardial Surface of the LV
Echocardiographic 3-dimensional (3D) reconstructions of the endocardial sur-
face of infarct (MI) only (A and B) and infarct ? MR (C and D) animals at dias-
tole (top) and systole (bottom). Note the enlarged and spherical infarct ? MR
ventricles. Abbreviations as in Figures 1 and 2.
JACC Vol. 51, No. 4, 2008
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Beeri et al.
MR Augments Post-MI Remodeling
Page 5
significance (170 ? 85% of baseline at initial follow-up; 75
? 22% at sacrifice), and MT1-MMP did not significantly
increase at 1 month (Fig. 8, "sham remote" bars). In the
border zones of the infarct-only sheep, there was a signifi-
cant decrease in MT1-MMP at sacrifice (to 60 ? 8% of
baseline), with levels maintained in the infarct ? MR
group. In contrast, TIMP-4 showed progressive rises from
baseline to initial follow-up and then to sacrifice in the
border and remote zones of both groups, with significantly
higher levels at sacrifice in the infarct ? MR group border
zone (207 ? 9% vs. 152 ? 10% of baseline, p ? 0.05).
Tissue inhibitor of matrix metalloproteinase-1 showed a
similar pattern of progressive increases in the infarct ? MR
group remote zone, with a significant late rise at sacrifice.
Myocardial infarction, with loss of contracting myocytes,
leads to a sequence of events aimed at preserving cardiac
output, including increased LV end-diastolic volume to
augment pre-load. Cells in noninfarcted areas hypertrophy
by addition of contractile elements in series, creating eccen-
tric hypertrophy without increased wall thickness. This
allows the LV to dilate, a process that is also promoted by
altered MMP activation with extracellular matrix degrada-
tion (52), and acceleration of cell death by apoptosis (32,53).
This process eventually culminates in systolic enlargement,
extensive fibrosis, and LV failure, the extent of which
predicts further cardiac events (2,9). Volume and pressure
overload increase wall stress, which can aggravate remodel-
ing (54) and promote eccentric hypertrophy through in-
creased fiber stretch (Fig. 1). Conversely, hemodynamically
unloading the LV reverses the functional and cellular
stigmata of cardiac failure as well as the remodeling process
(55,56). Neurohumoral activation and activation of inflam-
matory mediators and cytokines initially compensate for
reduced cardiac output but, in the long term, mediate
increased load, cell death, and cardiac fibrosis (50,57–59).
Increased wall stress also up-regulates the production and
Figure 4Measurement of LV Volumes and Function
End-diastolic volume (EDV) (A) and end-systolic volume (ESV) (B) of infarct-only
(yellow bars) and infarct ? MR (red bars) sheep at baseline (pre), 1 month
follow-up (f/u), and 3 months sacrifice. (C and D) dP/dt and pre-load–recruit-
able stroke work (PRSW) of infarct-only (broken lines) and infarct ? MR (solid
lines) sheep at pre, f/u, and 3 months sacrifice. *p ? 0.05. Abbreviations as
in Figure 1.
Isolated Cardiomyocyte Contractility in the Different Groups
Isolated Cardiomyocyte
Contractility in the Different Groups
Table 1
Control SheepInfarct ? MR Infarct Only
Cell shortening (%)5.7 ? 0.4 2.6 ? 0.7*3.5 ? 0.3*†
t90% (ms) 390 ? 82676 ? 68*510 ? 59*†
*p ? 0.01 compared with normal control sheep; †p ? 0.01 compared with infarct ? mitral
regurgitation (MR) group.
t90% ? time to 90% relaxation.
Intracellular CalciumMeasurements in the Different Groups
Intracellular Calcium
Measurements in the Different Groups
Table 2
Diastolic (Ca2?) (nM)
Systolic (Ca2?) (nM)
Control Sheep Infarct ? MRInfarct Only
230 ? 41320 ? 21*275 ? 22*†
796 ? 24 535 ? 44* 714 ? 43*‡
t90% (ms)361 ? 34 542 ? 38*455 ? 43*†
*p ? 0.01 compared with normal control sheep; †p ? 0.03 compared with infarct ? mitral
regurgitation (MR) group; ‡p ? 0.005 compared with infarct ? MR group.
t90% ? time to 90% relaxation of the calcium signal.
480Beeri et al.
MR Augments Post-MI Remodeling
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86
Page 6
release of MMPs, which are believed to be pivotal in
altering the extracellular matrix in ways that promote
ventricular dilatation (60). Their transgenic activation in-
duces congestive heart failure (61), and their inhibition
attenuates post-MI remodeling (62,63).
Mitral regurgitation, caused by alterations in ventricular
geometry and function after MI (10,12), can itself initiate
the remodeling cascade, and causes progressive deterioration
of ventricular function at a cellular and molecular level
(15–17). Mitral regurgitation considerably alters the load on
the LV. It increases diastolic wall stress, which can induce
eccentric LV hypertrophy and subsequent dilatation and
failure (18), and it thereby increases early systolic wall stress.
Although MR permits LV emptying during systole into the
lower-pressure LA, it has been shown actually to increase
end-systolic wall stress and, hence, afterload in patients with
chronic MR (64,65). Moreover, MR induces further LV
dilatation due to activation of neurohumoral and cytokine
components of the remodeling cascade (66–68). As MR is
both a cause and a result of LV remodeling, it can
potentially exacerbate the vicious cycle spiraling down to
cardiac failure unless the remodeling or the MR is reversed
Regarding clinical implications, knowing whether the
parallel occurrence of MR and MI causes more pronounced
remodeling is critical, because at least MR can be eliminated
by repairing or replacing the valve, and thus relieving the
volume overload induced by it. Separating these 2 dynamic
processes in an experimental model is a challenge, because
in most existing models they are linked. One recent study of
inferior MIs, in fact, concluded that prevention of ischemic
MR does not influence the outcome of remodeling (20),
despite benefits in nonischemic models (18) and concerns in
nonischemic patients (72). In our model, we therefore
implanted an LV-to-LA shunt, which created a moderate
and standardized MR-like regurgitant flow, independent of
a medium-sized antero-apical MI that by itself does not
cause MR.
In this controlled model, moderate MR worsened
post-MI remodeling. Specifically, it induced large diastolic
and systolic LV volumes reflecting volume overload and
reduced global function. Reduced contractility was also
apparent in less pre-load–dependent physiological measures
such as pre-load–recruitable stroke work. These changes
paralleled decreased single-cell contractility in the nonin-
farcted myocardium with reduced SERCA2a levels, which
directly correlate with cell contraction (46).
In contrast to progressive changes in the LV, several
mediators of the hypertrophic process underwent biphasic
changes in the noninfarcted myocardium of animals with
MR-type volume overload. These include gp130, a glyco-
protein that forms heterodimers to produce different recep-
tors, notably of the interleukin 6/CT1/LIF family. The
activation of these receptors has been linked to cardiomyo-
cyte hypertrophy (50,73), and their reduced abundance,
manifested by reduced gp130 levels, has been associated
with the transition from hypertrophy to failure (74,75). Akt,
or protein kinase B, is a serine-threonine kinase activated by
Figure 5SERCA2a and Phospholamban Quantification
(A) Quantification of sarcoplasmic reticulum Ca2?-ATPase (SERCA2a) activity in remote, border, and infarct regions of experimental and normal control sheep hearts. (B)
Immunoblots from different regions of the myocardium in different groups for SERCA2a and phospholamban. Note that in the infarct region, there was residual myocar-
dium that was homogenized and protein extracted. Abbreviations as in Figures 1 and 2.
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86
Beeri et al.
MR Augments Post-MI Remodeling
Page 7
several pro-survival and -hypertrophic factors, among others
cardiotrophin-1 (76), acting through the gp130-containing
receptor, or growth factor receptors activating
phosphoinositide-3 kinase (77).The constitutive activation
of Akt in a model of rat ischemia-reperfusion injury reduced
cell death and improved function (78). Like gp130, reduced
levels of Akt are related to increased apoptosis and a
transition from compensatory hypertrophy to a failure
phenotype (49). In our model, while both infarct ? MR and
infarct-only sheep had elevated expression of Akt and gp130
after 1 month, the MR sheep demonstrated a notable
reduction in these protein levels after 3 months, compared
with the no-MR animals and with baseline. The pro-
hypertrophic process, which begins in both groups at 1
month, continues in the animals without MR but is down-
regulated at 3 months in the MR group, in association with
continued adverse remodeling and LV dysfunction. This
decline may represent earlier termination of the hypertro-
phic process or transition to a failure phenotype specific to
the persistent-MR situation; either way, it represents failure
of the hypertrophic process. The ongoing drive to cell death,
with the suppressed pro-hypertrophic drive, further pro-
motes the transition to failure. These findings are consistent
with the emerging view of LV remodeling in general as a
failed attempt at compensation for initial stresses on the
myocardium—in this case, exacerbated by the MR volume
overload (7,74); in others, it reflects the transition from
hypertensive hypertrophy to failure (79,80).
There was also excessive activation of MMPs, notably
MMP-13 and MT-MMP1, in the noninfarcted remote
zone of the MR sheep. This could induce excess extracel-
lular matrix turnover and potentially exacerbate remodeling.
However, these same MMP levels fell at sacrifice, with the
fall in remote-zone MT-MMP1 being significantly greater
in the MR sheep, and the fall in MMP-13 being significant
only for the MR group. As this change parallels the
down-regulation of the pro-hypertrophic signaling process,
it could be also part of the failure of compensation by
limiting the adaptive geometrical changes in myocardial
hypertrophy. Matrix metalloproteinase inhibitors showed a
different pattern, with a progressive rise from baseline to
sacrifice that was significantly greater with MR. This
suggests a possible shift from matrix turnover to matrix
accumulation and stabilization over time, a response typical
of remodeling myocardium (81). However, it is clear that
neither the MMP nor the TIMP changes adequately
compensate for the remodeling process, as LV volume
progressively rose while systolic function fell.
This study has several limitations. Ischemic MR affecting
a native valve often progressively increases (28,69–71), but
is inherently linked to the underlying MI and is not
standardized. Based on the motivation for this study, it was
Figure 6Protein Levels of Akt, gp130, and Caspase 3
Protein expression of Akt, gp130, and activated caspase 3 from infarct-only
(broken lines) and infarct ? mitral regurgitation (solid lines) sheep at base-
line, 1 month follow-up (f/u), and 3 months sacrifice. Note the biphasic change
in infarct ? mitral regurgitation animals for gp130 and Akt expression at fol-
low-up (high) and sacrifice, while no significant change is noted in caspase 3
levels. Values are ? standard error of the mean, *p ? 0.01.
Figure 7 Photomicrographs of Separated Cardiomyocytes
Elongated myocytes from sheep with MI and MR shunt (A) versus more normal
cells from MI-only animals (B). Note the different scales used to accommodate
the elongated cells of the MI ? MR sheep within the field. Abbreviations as in
Figures 1 and 2.
482Beeri et al.
MR Augments Post-MI Remodeling
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86
Page 8
critical to separate the 2 processes of infarction and regur-
gitation to determine the incremental role of MR most
directly, and to do so with a standardized orifice, which
provided stable regurgitant fractions of ?30% throughout
the study. Although the LV also fills through this valveless
orifice, based on prior experience, this should not impor-
tantly alter LV filling (29).
We did not assess whether any one of the molecular
changes reported in the present study is causative. We
intended to test whether differences in remodeling based on
MR are associated with molecular changes described in the
remodeling process. Determining which factors are caus-
ative versus concomitants, and studying all possible factors,
is beyond the scope of this study. Nevertheless, we analyzed
pathways extensively linked to the pro-hypertrophic and
remodeling processes, and causally implicated through
transgenic and pharmacologic modification (61,74,78).
While the impact of isolated MR is important to explore,
the study specifically addresses the challenge posed by the
recent literature (20), which can be stated as an alternative
hypothesis that remodeling in ischemic MR is caused only or
predominantly by the underlying infarct, not the MR. This
required comparing infarct-only versus infarct ? MR
groups. The data do show important effects of the infarct
alone, with end-systolic volume nearly doubling, and in-
creases in gp130, Akt, and caspase. The changes with infarct
Figure 8MMP Abundance
Levels of membrane-type (MT) matrix metalloproteinase (MMP)1 and tissue inhibitor of matrix metalloproteinase (TIMP)-4 in the infarct-only ("sham", green bars) and
infarct ? mitral regurgitation (red bars) animals at first follow-up (T2) and sacrifice (T3) time points. *p ? 0.05 relative to baseline; #p ? 0.05 for myocardial infarction
? mitral regurgitation relative to myocardial infarction only animals for the same zone and stage; $p ? 0.05 for sacrifice relative to initial follow-up.
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86
Beeri et al.
MR Augments Post-MI Remodeling
Page 9
plus MR, however, were greater, with end-systolic volume
nearly tripling, and a different pattern of activation followed
by exhaustion of hypertrophic- and apoptotic-signaling
molecules gp130 and Akt. The findings, therefore, suggest
an additive rather than exclusive role of MR. This is sup-
ported by our data (unpublished results) from sheep with an
identical shunt and no MI, which did not cause significant
remodeling in the same 3-month time-frame in terms of
either volume or contractility changes.
Recently, contribution of MR to post-MI remodeling has
been challenged by Guy et al. (20) in an inferior MI model
in which either MR was reduced using an undersized
annuloplasty ring repair, or MI was restrained using a mesh.
The MR repair group remodeled more, leading to the
suggestion that the MR is not causative, but may be a
consequence of post-MI remodeling. The main caveat to
these conclusions is that undersized ring annuloplasty may
by itself alter LV mechanics, as recently shown (82), so as to
exacerbate remodeling. Thus, the excess remodeling ob-
served may have been caused, at least partially, by the repair
itself, which was performed 2 weeks before infarct creation.
The difficulty in eliminating MR as a potential contributor
to continued remodeling by annuloplasty has also been
reported (72). Another recent paper (83) has suggested that
repairing MR in a subgroup of patients with LV dysfunc-
tion has no survival benefit. While this is intriguing, the
patient population in that study had prominent LV dys-
function at baseline (?30% EF), and thus it is possible that
repair was performed too late for many to benefit in terms
of LV function or outcome. Based on their inclusion
criteria, the patients also had at least moderate-to-severe
MR—more severe than in our model. Further, unlike this
MI model, roughly 40% of the patients did not have
coronary artery disease as the basis for their LV dysfunction.
Thus, these clinical data cannot readily be compared with
our relatively mild MI model with normal baseline LV
function and moderate MR. There is definitely a need for a
randomized controlled study to clinically address the issue
of mitral valve repair in moderate ischemic MR.
This study demonstrates that MR accompanying MI pro-
duces greater ventricular remodeling than a comparable
infarction alone, with an earlier transition to a failure
phenotype. This is the case even for only moderate MR,
most typical of the ischemic situation, for which the greatest
uncertainty exists regarding impact on the heart and need
for intervention. The changes at the level of the whole heart
parallel cellular and molecular abnormalities in the nonin-
farcted myocardium that reflect the complex remodeling
process. These molecular events also progress differently
with MR than with comparable infarction alone, with an
initial rise in pro-hypertrophic and antiapoptotic signals,
followed by their exhaustion. Recognizing this pattern can
motivate a search for the responsible molecular "switch," so
that decompensation might be limited or reversed, averting
the earlier onset of dilated heart failure precipitated by MR
that may portend a worse prognosis.
Reprint requests and correspondence: Dr. Robert A. Levine,
Cardiac Ultrasound Laboratory YAW5, Massachusetts General
Hospital, 55 Fruit Street, Boston, Massachusetts 02114. E-mail:
1. Pfeffer MA, Braunwald E. Ventricular remodeling after myocardial
infarction: experimental observations and clinical implications. Circu-
lation 1990;81:1161–72.
2. Cohn JN, Ferrari R, Sharpe N. Cardiac remodeling—concepts and
clinical implications: a consensus paper from an international forum on
cardiac remodeling. J Am Coll Cardiol 2000;35:569–82.
3. Picard MH, Wilkins GT, Ray PA, Weyman AE. Progressive changes
in ventricular structure and function during the year after acute
myocardial infarction. Am Heart J 1992;124:24–31.
4. Pfeffer MA. Left ventricular remodeling after acute myocardial infarc-
tion. Annu Rev Med 1995;46:455–66.
5. Gianuzzi P, Temporelli PL, Bosimi E, et al., for the Gruppo Italiano
per lo Studio della Sopravvivenza nell'Infarto Miocardico-3 Echo
Substudy Investigators. Heterogeneity of left ventricular remodeling
after acute myocardial infarction: results of the Gruppo Italiano per lo
Studio della Sopravvivenza nell'Infarto Miocardico-3 echo substudy.
Am Heart J 2001;141:131–8.
6. Davidoff R, Picard MH, Force T, et al. Spatial and temporal variability
in the pattern of recovery of ventricular geometry and function after
acute occlusion and reperfusion. Am Heart J 1994;127:1231–41.
7. Mann DL, Bristow MR. Mechanisms and models in heart failure. The
biomechanical model and beyond. Circulation 2005;111:2837–49.
8. Lamas GA, Mitchell GF, Flaker GC, et al. Clinical significance of
mitral regurgitation after acute myocardial infarction. Circulation
9. White HD, Norris RM, Brown MA, Brandt PW, Whitlock RM,
Wild CJ. Left ventricular end-systolic volume as the major determi-
nant of survival after recovery from myocardial infarction. Circulation
10. Otsuji Y, Handschumacher MD, Schwammethal E, et al. Insights
from three-dimensional echocardiography into the mechanisms of
functional mitral regurgitation: direct in vivo demonstration of altered
leaflet geometry. Circulation 1997;96:1999–2008.
11. Cochran RP, Kunzelman KS. Effect of papillary muscle position on
mitral valve function: relationship to homografts. Ann Thorac Surg
12. Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of
ischemic mitral regurgitation: an experimental evaluation. Circulation
13. Lehmann KG, Francis CK, Dodge HT, the TIMI Study Group.
Mitral regurgitation in early myocardial infarction: incidence, clinical
detection and prognostic implications. Ann Intern Med 1992;117:
14. Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ.
Ischemic mitral regurgitation: long-term outcome and prognostic
implications with quantitative Doppler assessment. Circulation 2001;
15. Carabello BA, Nakano K, Corin W, Biederman R, Spann JF Jr. Left
ventricular function in experimental volume overload hypertrophy.
Am J Physiol 1989;256:H974–81.
16. Urabe Y, Mann DL, Kent RL, et al. Cellular and ventricular
contractile dysfunction in experimental canine mitral regurgitation.
Circ Res 1992;70:131–47.
17. Ishihara K, Zile MR, Kanazawa S, et al. Left ventricular mechanics
and myocyte function after correction of experimental chronic mitral
regurgitation by combined mitral valve replacement and preservation
of the native mitral valve apparatus. Circulation 1992;86:16–25.
18. Spinale FG, Ishihra K, Zile MR, DeFryte G, Crawford FA, Carabello
BA. Structural basis for changes in left ventricular function and
484Beeri et al.
MR Augments Post-MI Remodeling
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86
Page 10
geometry because of chronic mitral regurgitation and after correction
of volume overload. J Thorac Cardiovasc Surg 1993;106:1147–57.
19. Ling LH, Enriquez-Sarano M, Seward JB, et al. Clinical outcome
of mitral regurgitation due to flail leaflet. N Engl J Med 1996;335:
20. Guy TS, Moainie SL, Gorman JH, et al. Prevention of ischemic mitral
regurgitation does not influence the outcome of remodeling after
posterolateral myocardial infarction. J Am Coll Cardiol 2004;43:
21. Carabello BA. Ischemic mitral regurgitation and ventricular remodel-
ing. J Am Coll Cardiol 2004;43:384–5.
22. Trichon BH, Glower DD, Shaw LK, et al. Survival after coronary
revascularization, with and without mitral valve surgery, in patients
with ischemic mitral regurgitation. Circulation 2003;108 Suppl 1:
23. Neskovic AN, Marinkovic J, Bojic M, Popovic AD. Early mitral
regurgitation after acute myocardial infarction does not contribute to
subsequent left ventricular remodeling. Clin Cardiol 1999;22:91–4.
24. Oh JH, Badhwar V, Mott BD, Li CM, Chiu RC. The effects of
prosthetic cardiac binding and adynamic cardiomyoplasty in a model of
dilated cardiomyopathy. J Thorac Cardiovasc Surg 1998;116:148–53.
25. Kelley ST, Malekan R, Gorman JH III, et al. Restraining infarct
expansion preserves left ventricular geometry and function after acute
anteroapical infarction. Circulation 1999;99:135–42.
26. Hung J, Guerrero JL, Handschumacher MD, Supple G, Sullivan S,
Levine RA. Reverse ventricular remodeling reduces ischemic mitral
regurgitation: echo-guided device application in the beating heart.
Circulation 2002;106:2594–600.
27. Moainie SL, Guy TS, Gorman JH, et al. Infarct restraint attenuates
remodeling and reduces chronic ischemic mitral regurgitation after
postero-lateral infarction. Ann Thorac Surg 2002;74:444–9.
28. Llaneras MR, Nance ML, Streicher JT, et al. Large animal model of
ischemic mitral regurgitation. Ann Thorac Surg 1994;57:432–9.
29. Rankin JS, Nicholas LM, Kouchoukos NT. Experimental mitral
regurgitation: effects on left ventricular function before and after
elimination of chronic regurgitation in the dog. J Thorac Cardiovasc
Surg 1975;70:478–88.
30. Braunwald E, Welch GH Jr., Sarnoff SJ. Hemodynamic effects of
quantitatively varied experimental mitral regurgitation. Circ Res 1957;
31. Fisher JP, Picard MH, Mikan JS, et al. Quantitation of myocardial
dysfunction in ischemic heart disease by echocardiographic endocardial
surface mapping: correlation with hemodynamic status. Am Heart J
32. Cheng W, Kajstura J, Nitahara JA, et al. Programmed myocyte cell
death affects the viable myocardium after infarction in rats. Exp Cell
Res 1996;226:316–27.
33. Foo RS, Mani K, Kitsis RN. Death begets failure in the heart. J Clin
Invest 2005;115:565–71.
34. Wencker D, Chandra M, Nguyen K, et al. A mechanistic role for
cardiac myocyte apoptosis in heart failure. J Clin Invest 2003;111:
35. Spinale FG, Coker ML, Heung LJ, et al. A matrix metalloproteinase
induction/activation system exists in the human left ventricular myo-
cardium and is upregulated in heart failure. Circulation 2000;102:
36. Sabbah HN, Sharov VG, Gupta RC, et al. Reversal of chronic
molecular and cellular abnormalities due to heart failure by passive
mechanical ventricular containment. Circ Res 2003;93:1095–101.
37. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations
for evaluation of the severity of native valvular regurgitation with
two-dimensional and Doppler echocardiography. J Am Soc Echocar-
diogr 2003;16:777–82.
38. Gorman JH, Gorman RC, Plappert T, et al. Infarct size and location
determine development of mitral regurgitation in the sheep model.
J Thorac Cardiovasc Surg 1998;115:615–22.
39. Young AA, Orr R, Smaill BH, Dell'Italia LJ. Three-dimensional
changes in left and right ventricular geometry in chronic mitral
regurgitation. Am J Physiol 1996;271:H2689–700.
40. Handschumacher MD, Lethor J-P, Siu SC, et al. A new integrated
system for three-dimensional echocardiographic reconstruction: devel-
opment and validation for ventricular volume with application in
human subjects. J Am Coll Cardiol 1993;21:743–53.
41. Buck T, Handschumacher MD, Tanabe H, Guerrero JL, Levine RA.
A new method for automatic quantification and visualization of
regional left ventricular dysfunction by three-dimensional echocardi-
ography: direct in vivo validation against three-dimensional sonomi-
crometry (abstr). J Am Coll Cardiol 1999;33:440A.
42. Mitchell GF, Lamas GA, Vaughan DE, Pfeffer MA. Left ventricular
remodeling in the year after first anterior myocardial infarction: a
quantitative analysis of contractile segment lengths and ventricular
shape. J Am Coll Cardiol 1992;19:1136–44.
43. Nakano K, Swindle MM, Spinale FG, et al. Depressed contractile
function due to canine mitral regurgitation improves after correction of
the volume overload. J Clin Invest 1991;87:2153–61.
44. Glower DD, Spratt JA, Snow ND, et al. Linearity of the Frank-
Starling relationship in the intact heart: the concept of preload
recruitable stroke work. Circulation 1985;71:994–1009.
45. del Monte F, O'Gara P, Poole-Wilson PA, Yacoub M, Harding SE.
Cell geometry and contractile abnormalities of myocytes from failing
human left ventricle. Cardiovasc Res 1995;30:281–90.
46. del Monte F, Harding SE, Schmidt U, et al. Restoration of contractile
function in isolated cardiomyocytes from failing human hearts by gene
transfer of SERCA2a. Circulation 1999;100:2308–11.
47. Chu A, Dixon MC, Saito A, Seiler S, Fleischer S. Isolation of
sarcoplasmic reticulum fractions referable to longitudinal tubules and
junctional terminal cisternae from rabbit skeletal muscle. Methods
Enzymol 1988;157:36–46.
48. Molkentin JD, Dorn GW II. Cytoplasmic signaling pathways that
regulate cardiac hypertrophy. Annu Rev Physiol 2001;63:391–426.
49. Haq S, Choukroun G, Lim HW, et al. Differential activation of signal
transduction pathways in human hearts with hypertrophy versus
advanced heart failure. Circulation 2001;103:670–7.
50. Hirota H, Yoshida K, Kishimoto T, Taga T. Continuous activation of
gp130, a signal-transducing receptor component for interleukin
6-related cytokines, causes myocardial hypertrophy in mice. Proc Natl
Acad Sci U S A 1995;92:4862–6.
51. Communal C, Sumandea M, de Tombe P, Narula J, Solaro RJ, Hajjar
RJ. Functional consequences of caspase activation in cardiac myocytes.
Proc Natl Acad Sci U S A 2002;99:6252–6.
52. Spinale FG, Coker ML, Thomas CV, Walker JD, Mukherjee R,
Hebbar L. Time-dependent changes in matrix metalloproteinase
activity and expression during the progression of congestive heart
failure: relation to ventricular and myocyte function. Circ Res 1998;
53. Sam F, Sawyer DB, Chang DLF, et al. Progressive left ventricular
remodeling and apoptosis late after myocardial infarction in mouse
heart. Am J Physiol 2000;279:H422–8.
54. Rumberger JA. Ventricular dilatation and remodeling after myocardial
infarction. Mayo Clin Proc 1994;69:664–74.
55. Levin HR, Oz MC, Chen JM, Packer M, Rose EA, Burkhoff D.
Reversal of chronic ventricular dilation in patients with end-stage
cardiomyopathy by prolonged mechanical unloading. Circulation
56. Heerdt PM, Holmes JW, Cai B, et al. Chronic unloading by left
ventricular assist device reverses contractile dysfunction and alters gene
expression in end-stage heart failure. Circulation 2000;102:2713–9.
57. Ono K, Matsumori A, Shioi T, Furukawa Y, Sasayama S. Cytokine
gene expression after myocardial infarction in rat hearts: possible
implication in left ventricular remodeling. Circulation 1998;98:149–
58. Wollert KC, Taga T, Saito M, et al. Cardiotrophin-1 activates a
distinct form of cardiac muscle cell hypertrophy. J Biol Chem
59. Sivasubramanian N, Coker ML, Kurrelmeyer KM, et al. Left ventric-
ular remodeling in transgenic mice with cardiac restricted overexpres-
sion of tumor necrosis factor. Circulation 2001;104:826–31.
60. MacKenna D, Summerour SR, Villarreal FJ. Role of mechanical
factors in modulating cardiac fibroblast function and extracellular
matrix synthesis. Cardiovasc Res 2000;46:257–63.
61. Kim HE, Dalal SS, Young E, Legato MJ, Weisfeldt ML, D'Armiento
J. Disruption of the myocardial extracellular matrix leads to cardiac
dysfunction. J Clin Invest 2000;106:857–66.
62. Coker ML, Thomas CV, Clair MJ, et al. Myocardial matrix metallo-
proteinase activity and abundance with congestive heart failure. Am J
Physiol 1998;274:H1516–23.
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86
Beeri et al.
MR Augments Post-MI Remodeling
Page 11
63. Peterson JT, Hallak H, Johnson L, et al. Matrix metalloproteinase
inhibition attenuates left ventricular remodeling and dysfunction in a
rat model of progressive heart failure. Circulation 2001;103:2303–9.
64. Corin WJ, Monrad ES, Murakami T, Nonogi H, Hess OM, Kray-
enbuehl HP. The relationship of afterload to ejection performance in
chronic mitral regurgitation. Circulation 1987;76:59–67.
65. Zile MR, Gaasch WH, Levine HT. Left ventricular stress-dimension-
shortening relations before and after correction of chronic aortic and
mitral regurgitation. Am J Cardiol 1985;56:99.
66. Dell'Italia LJ, Meng QC, Balcells E, et al. Increased ACE and
chymase-like activity in cardiac tissue of dogs with chronic mitral
regurgitation. Am J Physiol 1995;269:H2065–73.
67. Kapadia SR, Yakoob K, Nader S, Thomas JD, Mann DL, Griffin BP.
Elevated circulating levels of serum tumor necrosis factor-alpha in
patients with hemodynamically significant pressure and volume over-
load. J Am Coll Cardiol 2000;36:208–12.
68. Talwar S, Squire IB, Davies JE, Ng LL. The effect of valvular
regurgitation on plasma cardiotrophin-1 in patients with normal left
ventricular systolic function. Eur J Heart Fail 2000;2:387–91.
69. Otsuji Y, Handschumacher MD, Liel-Cohen N, et al. Mechanism of
ischemic mitral regurgitation with segmental left ventricular dysfunction:
three-dimensional echocardiographic studies in models of acute and
chronic progressive regurgitation. J Am Coll Cardiol 2001;37:641–8.
70. Liel-Cohen N, Guerrero JL, Otsuji Y, et al. Design of a new surgical
approach for ventricular remodeling to relieve ischemic mitral regur-
gitation. Circulation 2000;101:2756–63.
71. Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent
ischemic mitral regurgitation post-annuloplasty: continued LV remod-
eling as a moving target. Circulation 2004;110:85–90.
72. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quan-
titative determinants of the outcome of asymptomatic mitral regurgi-
tation. N Engl J Med 2005;352:875–83.
73. Kunisada K, Tone E, Fujio Y, Matsui H, Yamauchi-Takihara K,
Kishimoto T. Activation of gp130 transduces hypertrophic signals via
STAT3 in cardiac myocytes. Circulation 1998;98:346–52.
74. Hirota H, Chen J, Betz UAK, et al. Loss of a gp130 cardiac muscle cell
survival pathway is a critical event in the onset of heart failure during
biomechanical stress. Cell 1999;97:189–98.
75. Zolk O, Ng LL, O'Brien RJ, Weyand M, Eschenhagen T. Aug-
mented expression of cardiotrophin-1 in failing human hearts is
accompanied by diminished glycoprotein 130 receptor protein abun-
dance. Circulation 2002;106:1430–2.
76. Craig R, Wagner M, McCardle T, Craig AG, Glembotski CC. The
cytoprotective effects of the glycoprotein 130 receptor-coupled cyto-
kine, cardiotrophin-1, require activation of NF-kappa B. J Biol Chem
77. Shioi T, Kang PM, Douglas PS, et al. The conserved phosphoinositide
3-kinase pathway determines heart size in mice. EMBO J 2000;19:
78. Matsui T, Tao J, del Monte F, et al. Akt activation preserves cardiac
function and prevents injury after transient cardiac ischemia in vivo.
Circulation 2001;104:330–5.
79. Rosen BD, Edvardsen T, Lai S, et al. Left ventricular concentric
remodeling is associated with decreased global and regional systolic
function. The Multi-Ethnic Study of Atherosclerosis. Circulation
80. Drazner MH. The transition from hypertrophy to failure: how certain
are we? Circulation 2005;112:936–8.
81. Spinale FG, Coker ML, Bond BR, Zellner JL. Myocardial matrix
degradation and metalloproteinase activation in the failing heart: a
potential therapeutic target. Cardiovasc Res 2000;46:225–38.
82. Cheng A, Nguyen TC, Malinowski M, et al. Effects of undersized
mitral annuloplasty on regional transmural left ventricular wall
strains and wall thickening mechanisms. Circulation 2006;114:
83. Wu AH, Aaronson KD, Bolling SF, Pagani FD, Welch K, Koelling
TM. Impact of mitral valve annuloplasty on mortality risk in patients
with mitral regurgitation and left ventricular systolic dysfunction. J Am
Coll Cardiol 2005;45:381–7.
486 Beeri et al.
MR Augments Post-MI Remodeling
JACC Vol. 51, No. 4, 2008
January 29, 2008:476–86


text:
Wednesday, October 1 2014
Batgirl Takes a Bow at Long Beach Comic-Con, Along With Lois
Tuesday, August 12 2014
In the Shadow of the Shadow of the Bat
It's common knowledge that the 'best' superhero is the one in cape and cowl. And that's true. It's just not the one you think.
Tuesday, June 21 2011
Where Have All the Snarky Girls Gone?: Batgirl #22
It's a fond farewell to one of DC's most consistently well-written titles in recent years. Good night sweet Stephanie "Dork Knight" Brown. You will be missed.

subset: commoncrawl


text:
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bachelor buttons
grspirit(Z4 KS)August 31, 2010
I understand bachelor buttons reseed. My ? is can I toss seed in my garden in Sept. or Oct. so that they will come up in my garden in the spring?
midnightsmum (Z4, ON)
If you are planting the annual Bachelors Buttons, then no, don't sow in the Fall. I wonder if they would start the same way as my poppies and larkspur. I sprinkle the seed in the winter - usually February, on the snow. You will need to remember where you want them!! lol. Hopefully, someone who has actually done this with BB's will chime in.
Here is a link that might be useful: Starting Bachelor Button's


text:
SVC Nursing Students Receive 100 Percent Pass Rate
September 4, 2008
The Southern Vermont College Nursing Division is pleased to announce a 100 percent pass rate on the National Licensing Exam for the 2008 graduates of the RN Nursing program.
The licensing examination is a national exam created by the National Council of State Boards of Nursing (NCSBN). Students who successfully complete this exam are eligible for licensure in any state of the United States. A pass rate of 100 percent is a great achievement and difficult to accomplish, due to the rigor of the examination process.
SVC Chair of the Nursing Division Patricia Wrightsman stated, "We are very proud of this class and their success. They gave 100 percent of themselves to achieve this goal, balancing family and work responsibilities with significant academic challenges. Each one enters the profession with a commitment to excellence. Congratulations to the class of 2008."
President Karen Gross stated, "I applaud our nursing students on their success. They will contribute to helping patients and families in time of need, and we are proud of them. Importantly, future nursing students can look to our program as a pathway to success in their chosen profession."
This level of success demonstrates the excellence of the SVC Nursing program and affirms the mission of Southern Vermont College. Founded in 1926, Southern Vermont College offers a career-enhancing, liberal arts education with 19 academic degree programs for approximately 500 students. Southern Vermont College recognizes the importance of educating students for the workplace of the twenty-first century and for lives as successful leaders in their communities. The College is accredited by the New England Association of Schools and Colleges.
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text:
Sorry for the dumb question, guys, but I was having no luck searching.
I'm getting ready to auto tune my PID. Do I just run tap water thru the RIMS tube and then set the PID to autotune and wait? Anything else to know?
That's what I did. I set the PID to autotune, and did a "dry run" with an entire brew volume of just plain water. Worked fine on the subsequent two real brews. Everything seems to be working like it's supposed to.
When I started auto tuning the SV or Set temperature value was on 800. I turned it down to 100. I'm not sure if this affects anything, but I didn't want the PID to try and tune itself to 800 degrees. 800 was what it was on when I turned it on.
Should I have left it alone? I set it to 100 as my water was at 85.
I think the RTD is giving an inaccurate reading. Auto tune has been running for about 45 minutes. I'm recirculating into my mash tun and the PID temp reads 102, but the mash temp thermometer only reads 80.
The RTD appears to be connected properly. Do I need to calibrate it?
Reset PID and tried auto tune again. PID and mash tun were much better aligned in temp, but now it seems to be drifting again. PID PV reads 111, mash tun 140.
Any help is appreciated.
Figured it out. Had to set the inty (sensor type) to p10. Now it's spot on. Just got her auto tuned and ready to go. Need to reorganize my brew space, though to accommodate my control box.
FYI, read the entire PID manual. I skipped some where it got technical, hysteresis band, etc., and it cost me 3 hours of confusion.


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You think you can name all Chris Young music? How many Chris Young songs can you guess? Prove it! Guess the song name and become a true Chris Young Fan. Take the challenge and try your hand at Chris Young music Quiz. You will hear fragments of Chris Young most popular music hits. Songs Included: You're Gonna Love Me - Flowers - Im Headed Your Way Jose - beer or Gasoline - Lay It On Me - Whos Gonna Take Me Home - Burn - Drinkin Me Lonely - Center of My World - Voices - Gettin You Home - The Shoebox - Rose In Paradise - That Makes Me - The Man I Want To be - The Dashboard - Rainy Night In Georgia - When Shes On - Shes Got This Thing about Her - You - Flashlight - Chris Young - Old Love Feels New - Tomorrow - Save Water Drink beer. We will be constantly adding new Chris Young songs! If you like quiz Games and music this app is perfect choice for you! Its one of the best apps!
Readers who want adventure and intrigue are recommended to read this book. It is packed with action, adventure and intrigue to draw attention from young readers. When the four of us: Bill, Laura Sam and I decide to take the new spooky coaster ride, action and adventure follows! We have to make quick decisions to escape the traps and exit the castle. But can we do it?


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All Purpose Tomato Sauce
Made This Recipe? Add Your Photo
Total Time
Prep15 mins
Cook30 mins
I have not tried this recipe. I got this recipe from Obesity Help. It was posted by Amy W.
Make and share this All Purpose Tomato Sauce recipe from Food.com.
- 1 cup fat-free chicken broth or 1 cup vegetable stock
- 1 -2 garlic clove, minced
- 1 small carrot, grated
- 1 cup chopped onion
- 1⁄4 cup chopped celery
- 1⁄2 cup low-sodium tomato paste (with no added salt)
- 1 bay leaf
- 3 cups coarsely chopped fresh tomatoes
- 1 -2 tablespoon fresh basil or 1⁄2 teaspoon dried basil
- fresh ground pepper
- 2 tablespoons chopped fresh parsley
- Heat 1/2 cup of stock in large pot.
- Cook onions, garlic, celery and carrot in the stock pot till tender.
- Add remaining ingredients, including remaining stock. Stir well.
- Bring to a boil; lower heat and simmer covered for 30 to 45 minutes.
- Remove bay leaf. If you like a smooth sauce, place in blender container and blend for 30 to 45 seconds.
- This sauce freezes well and may be made in large quantities. Yield: 2 1/2 to 3 cups.


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Christopher Heine | May 25, 2012 | Comments
ClickZ speaks with marketing director for the global brand about social media initiatives.
Samsung is gearing up its social media efforts for the London Olympics and other digital marketing endeavors this summer. So ClickZ last week caught up with Gail Conroy, Samsung North America's director of brand and consumer marketing, in order to discover how the global brand views Facebook, Twitter and Pinterest.
"[Pinterest] is really exploding," she said. "It will be a good channel for us to engage with consumers."
We spoke with Conroy after a press junket that promoted Samsung's NX Series smart camera at New York's CitiField, home of the New York Mets. Among other topics, in the video below, she discusses why social media is so important to a tech brand nowadays, as well addressing marketing to moms.
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Christopher Heine was a senior writer for ClickZ through June 2012. He covered social media, sports/entertainment marketing, retail, and more. Heine's work has also appeared via Mashable, Brandweek, DM News, MarketingSherpa, and other tech- and ad-centric publications. USA Today, Bloomberg Radio, and The Los Angeles Times have cited him as an expert journalist.
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Guy Fieri 3-qt. Stock Pot with Lid
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Guy Fieri 3-qt. Stock Pot with Lid
Weights & Dimensions
|Material: Stainless steel
|Product Type: Stock pots
|Lids Included: Yes
|Capacity: 3 Quarts
|Country of Manufacture: China
About the ManufacturerIn 2007, Guy Fieri met the designers of Ergo Chef at a gourmet show. He used the cutlery on stage during his demo and was given a set to take home. After a year of wear and tear in his kitchen, he was hooked on the quality and design of Ergo Chef's product. Before he knew it, he was teaming up with Ergo Chef to develop his own collection. They sketched a range of designs lookin' for the select few that really rocked technically and aesthetically! Guy Fieri's products feature a combination of the best materials with a design that will blow your mind! As a chef, restaurant owner, and TV personality, he has high expectations for his equipment and these knives meet and exceed all of them.
Guy Fieri 3-qt. Stock Pot with Lid
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OUR SKU # GFE10303-qt. Stock Pot with Lid is also sometimes listed under the following manufacturer numbers: 5106834


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Find out more information about Motels & Hotels, Hotel Accomodation, Motel Accomodation and... read moreTravel Services including quotes, reviews or special coupon offers in dLook's business listings within . Through dLook search you can refine your preferred search area or results further from national down to a local suburb and then you may vary search terms to find results such as access information, guide information, early check in, restaurants or cleaning service and more in this category and in the areas that match a product or service type. Use the free quotes facility to seek quotes, read reviews, seek discount coupons or learn more about these businesses, products or services. Or just email or call a business displayed using the listing information to find out more about the Motels & Hotels range of products and services on offer. Premium listings also feature social media information including Facebook pages, Twitter feeds and often a promotional video from YouTube click through to find more.
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Frankie and the Heartstrings are indebted to a lineage of vintage indie bands like Pulp, Orange Juice and The Smiths, th
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BackgroundThis attempt to bring the Advanced Dungeons & Dragons genre to the Nintendo Entertainment System has you controlling several different characters (eight to be exact), on your way to succeed on your journey to heroicness and power. This side-scroller only lets you play one character at a time, but once you master this, then you can become to the AD&D master!
- Genre: Fantasy Role-Playing (Mac)
- Theme(s): Fantasy, Medieval
- Perspective(s): Flat side view
- Developer: FCI, Inc.
- Publisher: Pony Canyon
Released North America Dec 1, 1988
- Also known as:
- Advanced Dungeons and Dragons: Hero of Lance in Japan
Dungeons and Dragons Series
- Dungeons & Dragons: Chronicles of Mystara
- Dungeons & Dragons Online: Eberron Unlimited
- Dungeons & Dragons Online: Stormreach
- Advanced Dungeons and Dragons: Eye of the Beholder
- Advanced Dungeons and Dragons: Eye of the Beholder II: The Legend of Darkmoon
- AD&D: Heroes of the Lance


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MINNESOTA NEWS ROUNDUP: U.S. House and Senate trying again for Farm Bill
WASHINGTON, D.C. -- Farm Bill negotiators are back at it, trying to work out a number of differences between the U-S House and Senate -- including a big dispute over food stamp funding. First District Minnesota Congressman Tim Walz urged his conference committee colleagues to also think about renewable energy. Walz says the U-S spends over a billion dollars a day importing oil from countries that hate us.


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As the Wichita Falls Police Department dusts off old homicide case files, they hope to mark as many of them solved as possible.
list of unsolved homicides
The following is a list of open homicide cases obtained from the Wichita Falls Police Department. The list does not include missing people. As…