A multiscale computational comparison of the bicuspid and tricuspid aortic valves in relation to calcific aortic stenosis

Patients with bicuspid aortic valve (BAV) are more likely to develop a calcific aortic stenosis (CAS), as well as a number of other ailments, as compared to their cohorts with normal tricuspid aortic valves (TAV). It is currently unknown whether the increase in risk of CAS is caused by the geometric differences between the tricuspid and bicuspid valves or whether the increase in risk is caused by the same underlying factors that produce the geometric difference. CAS progression is understood to be a multiscale process, mediated at the cell level. In this study, we employ multiscale finite-element simulations of the valves. We isolate the effect of one geometric factor, the number of cusps, in order to explore its effect on multiscale valve mechanics, particularly in relation to CAS. The BAV and TAV are modeled by a set of simulations describing the cell, tissue, and organ length scales. These simulations are linked across the length scales to create a coherent multiscale model. At each scale, the models are three-dimensional, dynamic, and incorporate accurate nonlinear constitutive models of the valve leaflet tissue. We compare results between the TAV and BAV at each length scale. At the cell-scale, our region of interest is the location where calcification develops, near the aortic-facing surface of the leaflet. Our simulations show the observed differences between the tricuspid and bicuspid valves at the organ scale: the bicuspid valve shows greater flexure in the solid phase and stronger jet formation in the fluid phase relative to the tricuspid. At the cell-scale, however, we show that the region of interest is shielded against strain by the wrinkling of the fibrosa. Thus, the cellular deformations are not significantly different between the TAV and BAV in the calcification-prone region. This result supports the assertion that the difference in calcification observed in the BAV versus TAV may be due primarily to factors other than the simple geometric difference between the two valves.     

Coronary artery anomalies and aortic valve morphology in the Syrian hamster

In the Syrian hamster, anomalies in the origin of the left coronary artery are significantly associated with the bicuspid condition of the aortic valve. In this species, bicuspid aortic valves are expressions of a trait, the variation of which takes the form of a phenotypic continuum, ranging from a tricuspid aortic valve with no commissural fusion to a bicuspid aortic valve with the aortic sinuses located in ventrodorsal orientation and devoid of any raphe. The intermediate stages of the continuum are represented by tricuspid aortic valves with a more or less extensive fusion of the ventral commissure and bicuspid aortic valves with a more or less developed raphe located in the ventral aortic sinus. The present study was designed to decide whether there is a gap between tricuspid and bicuspid aortic valves regarding the incidence of coronary artery anomalies, or whether this incidence varies according to the different tricuspid and bicuspid morphotypes of the continuum. The study was carried out in Syrian hamsters belonging to a single inbred family with a high incidence of tricuspid aortic valves with fusion of the ventral commissure, bicuspid aortic valves, and anomalies in the origin of the left coronary artery, i.e. single right coronary artery ostium in aorta, anomalous origin of the left coronary artery from the pulmonary artery, and anomalous origin of the left coronary artery from the dorsal aortic sinus. The specimens were examined by means of a stereomicroscope and, in several cases, scanning electron microscopy was also used. The relationships between anomalous coronary artery patterns and aortic valve morphologies were tested using a logistic regression model. The results obtained indicate that there is no discontinuity between tricuspid and bicuspid aortic valves regarding the incidence of coronary artery anomalies. The probability of occurrence of anomalous coronary artery patterns increases continuously according to the deviation degree of the aortic valve from its normal (tricuspid) design. The present findings suggest that in the Syrian hamster, the morphogenetic mechanisms involved in the formation of congenital anomalous aortic valves and anomalies in the origin of the left coronary artery, respectively, are strongly related from an aetiological viewpoint.     

Exuberant accessory mitral valve tissue with possible true parachute mitral valve: a case report

ABSTRACT: INTRODUCTION: A parachute mitral valve is defined as a unifocal attachment of mitral valve chordae tendineae independent of the number of papillary muscles. Data from the literature suggests that the valve can be distinguished on the basis of morphological features as either a parachute-like asymmetrical mitral valve or a true parachute mitral valve. A parachute-like asymmetrical mitral valve has two papillary muscles; one is elongated and located higher in the left ventricle. A true parachute mitral valve has a single papillary muscle that receives all chordae, as was present in our patient. Patients with parachute mitral valves during childhood have multilevel left-side heart obstructions, with poor outcomes without operative treatment. The finding of a parachute mitral valve in an adult patient is extremely rare, especially as an isolated lesion. In adults, the unifocal attachment of the chordae results in a slightly restricted valve opening and, more frequently, valvular regurgitation. CASE PRESENTATION: A 40-year-old Caucasian female patient was admitted to a primary care physician due to her recent symptoms of heart palpitation and chest discomfort on effort. Transthoracic echocardiography showed chordae tendineae which were elongated and formed an unusual net shape penetrating into left ventricle cavity. The parasternal short axis view of her left ventricle showed a single papillary muscle positioned on one side in the posteromedial commissure receiving all chordae. Her mitral valve orifice was slightly eccentric and the chordae were converting into a single papillary muscle. Mitral regurgitation was present and it was graded as moderate to severe. Her left atrium was enlarged. There were no signs of mitral stenosis or a subvalvular ring. She did not have a bicuspid aortic valve or coarctation of the ascending aorta. The dimensions and systolic function of her left ventricle were normal. Our patient had a normal body habitus, without signs of heart failure. Her functional status was graded as class I according to the New York Heart Association grading. CONCLUSIONS: A recently published review found that, in the last several decades, there have been only nine adult patients with parachute mitral valve disease reported, of which five had the same morphological characteristics as our patient. This case presentation should encourage doctors, especially those involved in echocardiography, to contribute their own experience, knowledge and research in parachute mitral valve disease to enrich statistical and epidemiologic databases and aid clinicians in getting acquainted with this rare disease.     

Innervation of the guinea pig spleen studied by electron microscopy

The innervation of the guinea pig spleen was investigated by electron microscopy. Unmyelinated nerve fibers in the capsulotrabecular and arterial systems were found to contain large and small granular and small agranular synaptic vesicles in their terminals and are thought to be sympathetic adrenergic in nature. They influence the contraction of the smooth muscle cells by diffusion innervation in these systems. These nerve terminals were also scattered in both the red and the white pulp. Pulp nerves wrapped by Schwann cells were further enclosed by myofibroblastic reticular cells. This condition revealed that the pulp nerves pass through the connective-tissue spaces of the reticular fibers, which contain elastic fibers, collagenous fibrils, and lamina densa-like materials of the usual basement laminae. One of the target cells for the pulp nerves is considered to be the myofibroblastic reticular cell in the reticular meshwork. Neurotransmitter substances released from the naked adrenergic nerve terminals travel through the reticular fibers and may play a role, by both close association innervation and diffusion innervation, in the contraction of reticular cells to expose the reticular fibers. At the exposed sides, connective-tissue elements of the reticular fibers are bathed with blood plasma, and the included naked nerve terminals, devoid of Schwann cells but with basement laminae of these cells, face free cells at some distance or are in close association with free cells, especially lymphocytes, macrophages, and plasma cells. The close ultrastructural relationship between the naked adrenergic nerve terminals and immunocytes strongly suggests that there is an intimate relationship between the immune system and the sympathetic nervous system through both close association innervation and diffusion innervation. Thus splenic adrenergic nerves of the guinea pig may play a triple role in 1) contraction of smooth muscle cells to regulate blood flow in the organ, 2) induction of the exposure of reticular fibers by contraction of the reticular cells in order to form a close relationship of the nerve terminals with the immunocytes, and 3) subsequent neuroimmunomodulation of the immunocytes.     

Imaging analysis of collagen fiber networks in cusps of porcine aortic valves: effect of their local distribution and alignment on valve functionality

The cusps of native aortic valve (AV) are composed of collagen bundles embedded in soft tissue, creating a heterogenic tissue with asymmetric alignment in each cusp. This study compares native collagen fiber networks (CFNs) with a goal to better understand their influence on stress distribution and valve kinematics. Images of CFNs from five porcine tricuspid AVs are analyzed and fluid-structure interaction models are generated based on them. Although the valves had similar overall kinematics, the CFNs had distinctive influence on local mechanics. The regions with dilute CFN are more prone to damage since they are subjected to higher stress magnitudes.     

Mechanical properties of human mitral valve chordae tendineae: variation with size and strain rate.

A knowledge of the mechanical properties of valve tissue is a necessary prerequisite for a better understanding of valvular behavior and design of prosthetic heart valves. Elastic response of chordae tendineae under strain rates of 0.05 cm min(-1)(6.25% min(-1)) to 12.7 cm min(-1)(1600% min(-1)) were obtained by the application of an uniaxial tensile stress using an Instron machine. The chordae exhibited viscoelastic properties in that extensibility decreased with increasing strain rates. The approximate maximum physiological strain rate of the chordae was estimated from echocardiographic traces at the instant of valve closure, and a high value of 29 (S.D. equals 9) cm s(-1) (2000% s(-1)) was found. The breaking strain and stress were found to have values of 21.4 plus or minus 0.5% and 3.1 plus or minus 0.1 times 10(8) dyn cm(-2) respectively, and were independent of strain rates (1 dyn equals 10(-5) N). These values are typical of collagen fibers. The final modulus, before the proportional limit, was found to be about 10(9) dyn cm(-2), which is again typical of collagen fibers. In addition, smaller chordae exhibited less extensibility than the larger chordae. This behavior could be due to structural and functional differences and allows the more centrally inserted chordae to maintain an even valve surface during valve closure.     

Systolic fluid–structure interaction model of the congenitally bicuspid aortic valve: assessment of modelling requirements

A transient fluid–structure interaction (FSI) model of a congenitally bicuspid aortic valve has been developed which allows simultaneous calculation of fluid flow and structural deformation. The valve is modelled during the systolic phase (the stage when blood pressure is elevated within the heart to pump blood to the body). The geometry was simplified to represent the bicuspid aortic valve in two dimensions. A congenital bicuspid valve is compared within the aortic root only and within the aortic arch. Symmetric and asymmetric cusps were simulated, along with differences in mechanical properties. A moving arbitrary Lagrange–Euler mesh was used to allow FSI. The FSI model requires blood flow to induce valve opening and induced strains in the region of 10%. It was determined that bicuspid aortic valve simulations required the inclusion of the ascending aorta and aortic arch. The flow patterns developed were sensitive to cusp asymmetry and differences in mechanical properties. Stiffening of the valve amplified peak velocities, and recirculation which developed in the ascending aorta. Model predictions demonstrate the need to take into account the category, including any existing cusp asymmetry, of a congenital bicuspid aortic valve when simulating its fluid flow and mechanics.     

Vascular-nervous relationships in the valves of the heart]

Method of silver nitrate impregnation was used in order to study 50 preparations of not-changed atrioventricular valves of the heart of domestic bulls and 30 preparations of the same valves of adult humans. It has been shown that in heart valves there are certain relationships between striated muscle fibres, blood vessels and nerve elements. The nerve structures of the valves are represented by nerve bundles of different thickness. In their composition there are comparatively thin non-myelinated and thicker myelinated fibres. Towards the free edge of cusps the nerve bundles become thinner and the nerve trunks give off separate thin nerve fibres disposed along the vessels of a capillary type and in some places getting around them. In certain portions of cusps the nerve bundles, some of which have zigzag sinuosity, cross blood vessels in different directions. In man the major mass of blood vessels and nerve elements are disposed near the base of the valve cusps, accompanying the muscle fibre bundles penetrating from the base side. In the bull heart valves an amount of blood vessels and nerve elements is found in considerable portions of the cusps not connected with muscle fibres.     

Distribution, origin and sensitivity to capsaicin of primary afferent substance P-immunoreactive nerves in the heart

This report is intended as an overview of the distribution, origin and sensitivity to capsaicin of substance P-immunoreactive (SP-I) primary afferent cardiac nerves. Immunohistochemical and physiological methods were employed to compare the presence and density of these nerve fibers in the guinea pig and rat hearts. SP-I fibers are numerous in the guinea pig heart including the parietal pericardium, atria, ventricles, valves, coronary arteries and around intrinsic cardiac ganglion cells. The rat heart contains few SP-I fibers. Vagotomy does not influence the number of intensity of immunoreactive fibers in the guinea pig heart. By stimulating the atrium or ventricle and recording from the second or third thoracic dorsal roots Ad1, Ad2 and C fibers were demonstrated in the atria, but only Ad fibers in the guinea pig ventricle; in addition, only Ad fibers were recorded from the vagus nerves. Only Ad1 fibers were demonstrated in the rat heart. Treatment with capsaicin depletes the SP-I and decreases the conduction velocity of C-fibers and some Ad2 fibers in the guinea pig heart. We suggest that SP-I primary afferent nerve fibers are unmyelinated (C-type) or small myelinated (Ad2-type) nerves in the guinea pig heart and that their cell bodies of origin are predominantly in dorsal root ganglia.     

Biochemical characterization of individual normal, floppy and rheumatic human mitral valves.

Human mitral valves (32 floppy and 17 rheumatic) obtained at surgery were analysed and compared with 35 normal (autopsy) valves. Total amounts of collagen, proteoglycan and elastin were increased approx. 3-fold in floppy and rheumatic valves. The water content of rheumatic cusps was lower than normal. The most significant changes in floppy valves were the 59% increase in mean value of the proteoglycan content, a large increase in the ease of extractability of proteoglycans from 26.7 to 57.2% of the total and a 62% increase in mean value of the elastin content in the anterior cusps. Normal human mitral valve cusps contained a mean proportion of 29.3 (and chordae 26.6) type III collagen (as % of total types III + I collagen), the values increasing significantly to 33.2 and 36.3% respectively in chronic rheumatic disease. The ratio observed in floppy valves depended on the extent of secondary surface fibrosis, which could be demonstrated histologically; in valve cusps with considerable secondary fibrosis, the percentage of type III increased significantly (to 34.4%), whereas it decreased significantly (to 25.2%) when fibrosis was negligible. It is concluded that the ratio of collagen types in floppy valves reflects the extent of secondary fibrosis rather than the pathogenesis of the disrupted collagen in the central core of the valve.     

Neuropeptide Y immunoreactivity in the mammalian liver: pattern of innervation and coexistence with tyrosine hydroxylase immunoreactivity

Summary The distribution of nerve fibers displaying neuropeptide Y immunoreactivity in relationship to the catecholaminergic innervation of rat, guinea pig, and rabbit liver was investigated by single- and double-label immunofluorescence methods. In all three species, neuropeptide Y-immunoreactive fibers are prominent in association with the vasculature, biliary pathway, and stromal compartment. The neuropeptide Y innervation of the parenchyma, on the other hand, differs among the three species in term of density. It is quite sparse in the rat and rabbit, particularly in the former species. In the guinea pig liver, numerous single, varicose neuropeptide Y-containing nerve fibers innervate the hepatic parenchyma; often, thin processes surround single hepatocytes and lie close to sinusoids. The immunoreactive pattern of tyrosine hydroxylase, a marker for catecholaminergic neurons and fibers, is comparable to that of neuropeptide Y. Most neuropeptide Y-containing nerve fibers also contain tyrosine hydroxylase immunoreactivity, in all three species, with the exception of the rabbit parenchyma, where a substantial proportion of catecholaminergic fibers lack immunoreactivity for neuropeptide Y. Finally, systemic administration of the sympathetic neurotoxin, 6-hydroxydopamine, in rats and guinea pigs resulted in virtually complete elimination of both neuropeptide Y- and tyrosine hydroxylase-immunoreactive fibers. These findings are consistent with the hypothesis that neuropeptide Y-containing nerve fibers form a subpopulation of the sympathetic innervation of the mammalian liver, which is likely to originate from prevertebral sympathetic ganglia.     

Biaxial mechanical properties of the native and glutaraldehyde-treated aortic valve cusp: Part II--A structural constitutive model

We have formulated the first constitutive model to describe the complete measured planar biaxial stress-strain relationship of the native and glutaraldehyde-treated aortic valve cusp using a structurally guided approach. When applied to native, zero-pressure fixed, and low-pressure fixed cusps, only three parameters were needed to simulate fully the highly anisotropic, and nonlinear in-plane biaxial mechanical behavior. Differences in the behavior of the native and zero- and low-pressure fixed cusps were found to be primarily due to changes in the effective fiber stress-strain behavior. Further, the model was able to account for the effects of small (< 10 deg) misalignments in the cuspal specimens with respect to the biaxial test axes that increased the accuracy of the model material parameters. Although based upon a simplified cuspal structure, the model underscored the role of the angular orientation of the fibers that completely accounted for extreme mechanical anisotropy and pronounced axial coupling. Knowledge of the mechanics of the aortic cusp derived from this model may aid in the understanding of fatigue damage in bioprosthetic heart valves and, potentially, lay the groundwork for the design of tissue-engineered scaffolds for replacement heart valves.     

Age-related characteristics of the distribution and attachment of chordae tendineae to the valves of the human heart

In 50 cardiac preparations of persons of various age (children, teenagers, adolescents, persons of mature and elderly age) distribution of various branches of the tendinous chordae (basic, marginal, commissural, rough zone) and level of their fixation to the ventricular surface of the right and left cusps of the atrioventricular valves have been studied. The tendinous chordae in direction from the apex of the papillary muscles towards the cusps of the atrioventricular valves are divided into the branches of the 2d--9th orders. Total quantity increase of the tendinous chordae is noted in the mature age, especially those of the 1st order in the left ventricle, and their decrease in the elderly age with an increase of the chordae of the 4th, 5th and 6th orders. Single chordae of the 8th and 9th orders can be found in elderly persons. Certain age specificities are revealed in fixation of various tendinous chordae to the cusps of the atrioventricular valves; they are surely connected with functional peculiarities of their different zones, that ensure air-tightness of the atrioventricular openings. There are quantitative differences of the tendinous chordae, fixed to certain cusps of the left (anterior) and right (anterior, posterior) atrioventricular valves; this is evidently connected with the role of the cusps mentioned in the mechanism of the valves closing.     

Circulating activated and effector memory T cells are associated with calcification and clonal expansions in bicuspid and tricuspid valves of calcific aortic stenosis

We sought to delineate further the immunological significance of T lymphocytes infiltrating the valve leaflets in calcific aortic stenosis (CAS) and determine whether there were associated alterations in circulating T cells. Using clonotypic TCR β-chain length and sequence analysis we confirmed that the repertoire of tricuspid CAS valves contains numerous expanded T cell clones with varying degrees of additional polyclonality, which was greatest in cases with severe calcification. We now report a similar proportion of clonal expansions in the much younger bicuspid valve CAS cases. Peripheral blood flow cytometry revealed elevations in HLA-DR(+) activated CD8 cells and in the CD8(+)CD28(null)CD57(+) memory-effector subset that were significantly greater in both bicuspid and tricuspid CAS cases with more severe valve calcification. Lesser increases of CD4(+)CD28(null) T cells were identified, principally in cases with concurrent atherosclerotic disease. Upon immunostaining the CD8 T cells in all valves were mainly CD28(null), and CD8 T cell percentages were greatest in valves with oligoclonal repertoires. T cell clones identified by their clonotypic sequence as expanded in the valve were also found expanded in the circulating blood CD28(null)CD8(+) T cells and to a lesser degree in the CD8(+)CD28(+) subset, directly supporting the relationship between immunologic events in the blood and the valve. The results suggest that an ongoing systemic adaptive immune response is occurring in cases with bicuspid and tricuspid CAS, involving circulating CD8 T cell activation, clonal expansion, and differentiation to a memory-effector phenotype, with trafficking of T cells in expanded clones between blood and the valve.     

THE VALUE OF ECHOCARDIOGRAPHY IN THE MANAGEMENT OF ACUTE AORTIC INSUFFICIENCY

Three cases of acute rupture of the aortic cusp complicating bacterial endocarditis are described. Special emphasis is placed on the value of serial echocardiography as a means of identifying progressive changes in aortic valve anatomy during the destructive process of the disease. Prior to the results of blood cultures, an echocardiogram confirmed a diagnosis of vegetations on the valve cusps. It also demonstrated flailing of the aortic cusp, which was confirmed at operation. Echocardiographic findings of flailing aortic valves in these patients coincided with the onset of acute aortic insufficiency and contributed to the timing of surgical intervention for replacement of the affected valves.     

Stresses in the closed mitral valve: a model study

In the present model study on the closed mitral valve, tensile force in the chordae tendineae is related to transvalvular pressure using a mathematical model of mechanics of the closed mitral valve. Circumferential stress as well as bending stress in the valve leaflets were neglected. Without precisely knowing the mechanical properties of the leaflet material, geometry of the leaflets was estimated by applying Laplace's law, which relates leaflet stress to leaflet curvature. Independent of shape of the mitral valve orifice, under all circumstances tensile force in the chordae tendineae was calculated to be equal or greater than half the force exerted on the mitral valve orifice by the transvalvular pressure.     

Ectatic blood vessels in port-wine stains lack innervation: possible role in pathogenesis.

The innervation pattern of port-wine stains was investigated using indirect immunohistochemistry with antibodies to protein gene product 9.5 (PGP 9.5), neuron-specific enolase (NSE), calcitonin gene-related peptide (CGRP), and neurofilament (NF). The pathologically dilated vessels in the middle and deep dermis were found to have defective innervation with only single or no nerve fibers in their vicinity, while other structures in the skin showed a normal density of fibers. NSE- and PGP-like immunoreactive (-LI) nerve fibers were observed innervating vessels with a normal morphology and other structures in the skin, such as sweat glands and hair follicles, as free nerve endings and in nerve bundles. The nerve bundles were often seen to pass the ectatic vessels without giving off any branches. CGRP-LI nerve fibers were detected running toward epidermis, whereas no fibers were found around the ectatic vessels. NF-LI fibers were seen innervating normal vessels in dermis, while in relation to the dilated vessels, no or only occasional fibers were observed. The lack of innervation may be of importance for the development of the disease as a result of decreased tonus of the vessels and/or a loss of neuronal trophic factors.     

Retrieval of a Micra transcatheter pacing system in a heart with a preexisting lead

We report the case of a 74-year-old man with a previously implanted pacemaker lead. He had undergone Medtronic? Micra Transcatheter Pacing System (TPS, Medtronic plc, MN, USA) implantation because of lead fracture. We implanted a new TPS and retrieved the dislodged one. We used a multiple-loop snare (EN snare^®) and an 8.5F steerable sheath (Agilis NXT; St. Jude Medical, St Paul, MN, USA). The TPS was obstructed by the chordae tendineae of the tricuspid valve and the pacemaker lead. We pushed the TPS to the apex site; this enabled us to move the TPS away from the chordae tendineae and pacemaker lead. The TPS body was caught in the inferior vena cava and was successfully retrieved. To our knowledge, this is the first case reporting TPS retrieval in a heart with preexisting lead.     

Acetylcholinesterase-positive and paraformaldehyde-induced-fluorescence-positive innervation in the upper eyelid of the sheep (Ovis aries)

This is the first study which describes the innervation of some eyelid structures, such as the glands of Moll and the glands of Zeiss. It is also the first to investigate the innervation pattern of the eyelid as a whole. We have studied the acetylcholinesterase-positive and paraformaldehyde-induced-fluorescence-positive (FIF+) innervation pattern of the different structures that constitute the upper eyelid of the sheep. There is widespread acetylcholinesterase-positive innervation in the epithelium, but not such an abundant FIF+ innervation. Both types of innervation are represented in the connective tissue by trunks or fibers that are distributed towards the different structures immersed within them. In the glands of Zeiss, cholinesterase-positive innervation is much more widespread than FIF innervation. On the contrary, the glands of Moll present denser FIF+ innervation than acetylcholinesterase-positive innervation. The Meibomian glands and the lachrymal glands show a rich acetylcholinesterase-positive and FIF+ innervation. Eyelid muscle innervation is mainly acetylcholinesterase-positive. In the conjunctive membrane there is no acetylcholinesterase-positive innervation, and only scarce FIF+ fibers can be demonstrated.     

Comparative study of the autonomic innervation of the mammalian ovary,with particular regard to the follicular system

Summary The autonomic innervation of the ovary was studied in 12 mammalian species utilizing the cholinesterase method in combination with pseudocholinesterase inhibition for the cholinergic component, and glyoxylic acid histochemistry together with fluorometric determination of noradrenaline for the adrenergic component. Ovaries from cow, sheep, cat, and guinea pig were very richly supplied with adrenergic nerves in the cortical stroma, particularly enclosing follicles in various stages of development. In the follicular wall the nerve terminals were located in the theca externa, where they ran parallel to the follicular surface. Numerous adrenergic terminals also surrounded ovarian blood vessels. The adrenergic innervation was of intermediary density in the human ovary and in the pig, dog, cat, and opossum. Ovaries from rabbit, mouse and hamster had a sparse adrenergic nerve supply. The amount of intraovarian adrenergic nerves agreed well with the tissue concentration of noradrenaline in the various species. The cholinergic innervation was generally less well developed, but had the same distribution as the adrenergic system around blood vessels and in the ovarian stroma, including follicular walls.