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. 1998 Sep;80(3):218–222. doi: 10.1136/hrt.80.3.218

Myocardial hibernation and stunning: from physiological principles to clinical practice

S Redwood 1, R Ferrari 1, M Marber 1
PMCID: PMC1761091  PMID: 9875076

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Figure 1  .

Figure 1  

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The relation between myocardial blood flow and systolic function, the "flow-function" relation, which was derived from short term experiments. When flow is reduced for longer periods (weeks to months), it is likely that this relation becomes much steeper.10 When myocardium is operating below this line, function is disproportionately depressed relative to flow—that is, the myocardium is stunned (S on the diagram). When myocardium is operating above this line function exceeds flow, and ischaemia is likely to result. Chronically hypoperfused myocardium, as a result of an epicardial stenosis restricting basal coronary flow, will be operating on the line (H in the diagram). Conversely, the situation S is the result of repetitive bouts of demand ischaemia in a segment of myocardium subtended by a stenosis that severely limits flow reserve, but not basal coronary flow. Myocardial blood flow is likely to vary owing to small alterations in transmyocardial vascular resistance, as a result of changes within the stenosis and/or microvasculature (see text). Since the chronic relation between perfusion and contraction is likely to be steeper than depicted, these small variations in flow may result in an interchange of H and S, without any appreciable change in systolic function. Following, inotropic stimulation, it is unlikely that myocardial blood flow will increase substantially. Thus myocardium operating at H will increase systolic function to point A, which will exceed that expected from blood flow, and it is likely that this increase in function will be curtailed by the onset of ischaemia. In stunned myocardium (S), function could increase to point B before function exceeds that expected from blood flow. Thus in both circumstances there can be a bimodal response to inotropes, and therefore the two cannot be reliably distinguished by stress echocardiography.

Figure 2  .

Figure 2  

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The electron microscopy appearance of a myocyte in a region of reversible left ventricular dysfunction, taken from a patient undergoing operative revascularisation. Sarcomeres, which normally occupy the myocyte, are confined to the subsarcolemmal margins (arrowhead). In addition, mitochondria are virtually absent and those that are present are small and round (arrows). Furthermore, there is marked glycogen accumulation (gl). [Photomicrograph supplied by Prof M Borgers, Department of Morphology, Janssen Research Foundation, Beerse, Belgium.]

Figure 3  .

Figure 3  

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The effect of brief coronary occlusion on systolic function in the dog. The dark shaded box indicates a short episode of ischaemia. The myocardium rapidly becomes dyskinetic and following restoration of flow there is a gradual return of function. This period between the episode of ischaemia and recovery of full function is known as stunning. (Adapted from Bolli et al.18)

Figure 4  .

Figure 4  

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The relation between resting and maximum myocardial blood flow at different degrees of stenosis severity. See text for details. (Adapted from Gould et al.19)

Figure 5  .

Figure 5  

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Repetitive stunning. The black boxes indicate short episodes of ischaemia. Contractility starts at 100% and rapidly falls during the first episode of ischaemia. Following restoration of flow, contractility starts to improve, but before it has returned to normal, a further episode of ischaemia ensues, resulting in a further reduction in contractility. Repeated short episodes of ischaemia may therefore result in an apparent chronic impairment of contractility (see text). (Adapted from Bolli.25)

Figure 6  .

Figure 6  

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Relation between coronary blood flow and coronary pressure. Adapted from Hoffman.31 See text for explanation.

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

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