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Asimakos AT, Vassiliou AG, Keskinidou C, Spetsioti S, Antonoglou A, Vrettou CS, Mourelatos P, Diamantopoulos A, Pratikaki M, Athanasiou N, Jahaj E, Gallos P, Kotanidou A, Dimopoulou I, Orfanos SE, Katsaounou P. Persistent Endothelial Lung Damage and Impaired Diffusion Capacity in Long COVID. J Pers Med 2023; 13:1351. [PMID: 37763119 PMCID: PMC10533128 DOI: 10.3390/jpm13091351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Since the beginning of the pandemic, both COVID-19-associated coagulopathy biomarkers and a plethora of endothelial biomarkers have been proposed and tested as prognostic tools of severity and mortality prediction. As the pandemic is gradually being controlled, attention is now focusing on the long-term sequelae of COVID-19. In the present study, we investigated the role of endothelial activation/dysfunction in long COVID syndrome. This observational study included 68 consecutive long COVID patients and a healthy age and sex-matched control group. In both groups, we measured 13 endothelial biomarkers. Moreover, in the long COVID patients, we evaluated fatigue and dyspnea severity, lung diffusion capacity (DLCO), and the 6-min walk (6MWT) test as measures of functional capacity. Our results showed that markers of endothelial activation/dysfunction were higher in long COVID patients, and that soluble intracellular adhesion molecule 1 (sICAM-1) and soluble vascular adhesion molecule 1 (sVCAM-1) negatively correlated with lung diffusion and functional capacity (sICAM-1 vs. DLCO, r = -0.306, p = 0.018; vs. 6MWT, r = -0.263, p = 0.044; and sVCAM-1 vs. DLCO, r= -0.346, p = 0.008; vs. 6MWT, r = -0.504, p < 0.0001). In conclusion, evaluating endothelial biomarkers alongside clinical tests might yield more specific insights into the pathophysiological mechanisms of long COVID manifestations.
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Affiliation(s)
- Andreas T. Asimakos
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Alice G. Vassiliou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Chrysi Keskinidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Stavroula Spetsioti
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Archontoula Antonoglou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Charikleia S. Vrettou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Panagiotis Mourelatos
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, 106 76 Athens, Greece; (P.M.); (A.D.)
| | - Aristidis Diamantopoulos
- Department of Endocrinology Diabetes and Metabolism, National Expertise Center for Rare Endocrine Diseases, Evangelismos Hospital, 106 76 Athens, Greece; (P.M.); (A.D.)
| | - Maria Pratikaki
- Biochemical Department, Evangelismos Hospital, 106 76 Athens, Greece;
| | - Nikolaos Athanasiou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Edison Jahaj
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Parisis Gallos
- Computational Biomedicine Laboratory, Department of Digital Systems, University of Piraeus, 185 34 Piraeus, Greece;
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Ioanna Dimopoulou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Stylianos E. Orfanos
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
| | - Paraskevi Katsaounou
- First Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.T.A.); (A.G.V.); (C.K.); (S.S.); (A.A.); (C.S.V.); (N.A.); (E.J.); (A.K.); (I.D.); (S.E.O.)
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Langleben D, Orfanos SE, Fox BD, Messas N, Giovinazzo M, Catravas JD. The Paradox of Pulmonary Vascular Resistance: Restoration of Pulmonary Capillary Recruitment as a Sine Qua Non for True Therapeutic Success in Pulmonary Arterial Hypertension. J Clin Med 2022; 11:jcm11154568. [PMID: 35956182 PMCID: PMC9369805 DOI: 10.3390/jcm11154568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022] Open
Abstract
Exercise-induced increases in pulmonary blood flow normally increase pulmonary arterial pressure only minimally, largely due to a reserve of pulmonary capillaries that are available for recruitment to carry the flow. In pulmonary arterial hypertension, due to precapillary arteriolar obstruction, such recruitment is greatly reduced. In exercising pulmonary arterial hypertension patients, pulmonary arterial pressure remains high and may even increase further. Current pulmonary arterial hypertension therapies, acting principally as vasodilators, decrease calculated pulmonary vascular resistance by increasing pulmonary blood flow but have a minimal effect in lowering pulmonary arterial pressure and do not restore significant capillary recruitment. Novel pulmonary arterial hypertension therapies that have mainly antiproliferative properties are being developed to try and diminish proliferative cellular obstruction in precapillary arterioles. If effective, those agents should restore capillary recruitment and, during exercise testing, pulmonary arterial pressure should remain low despite increasing pulmonary blood flow. The effectiveness of every novel therapy for pulmonary arterial hypertension should be evaluated not only at rest, but with measurement of exercise pulmonary hemodynamics during clinical trials.
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Affiliation(s)
- David Langleben
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
- Correspondence: ; Tel.: +1-514-340-7531
| | - Stylianos E. Orfanos
- 1st Department of Critical Care and Pulmonary Services, Pulmonary Hypertension Center, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, 10676 Athens, Greece
| | - Benjamin D. Fox
- Pulmonary Division, Yitzchak Shamir Hospital, Tel Aviv University, Tzrifin 69978, Israel
| | - Nathan Messas
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - Michele Giovinazzo
- Center for Pulmonary Vascular Disease, Azrieli Heart Center and Lady Davis Research Institute, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada
| | - John D. Catravas
- Frank Reidy Research Center for Bioelectrics, Old Dominion University, Norfolk, VA 23529, USA
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Li H, Zhang Y, Wang S, Yue Y, Liu Q, Huang S, Peng H, Zhang Y, Zeng W, Wu Z. Dapagliflozin has No Protective Effect on Experimental Pulmonary Arterial Hypertension and Pulmonary Trunk Banding Rat Models. Front Pharmacol 2021; 12:756226. [PMID: 34790128 PMCID: PMC8591217 DOI: 10.3389/fphar.2021.756226] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/19/2021] [Indexed: 12/17/2022] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors, a novel class of hypoglycemic drugs, show excellent cardiovascular benefits, and have further improved heart failure outcomes, significantly reducing cardiovascular and all-cause mortality irrespective of diabetes status. However, the efficacy of SGLT2 inhibitors in pulmonary arterial hypertension (PAH) and right ventricular (RV) dysfunction remains unknown. This study aimed to evaluate the effects of dapagliflozin in rats with PAH and RV dysfunction. PAH was induced in rats by monocrotaline (MCT) subcutaneous injection (60 mg/kg). Isolated RV dysfunction was induced in another group of rats by pulmonary trunk banding (PTB). Dapagliflozin (1.5 mg/kg) was administered daily via oral gavage one day (prevention groups) or two weeks (reversal groups) after modeling. Echocardiography and hemodynamic assessments were used to observe pulmonary vascular resistance and RV function. Histological staining was used to observe pulmonary vascular and RV remodeling. As compared with MCT group, dapagliflozin treatment did not significantly improve the survival of rats. Pulmonary arterial media wall thickness in MCT group was significantly increased, but dapagliflozin did not significantly improved vascular remodeling both in the prevention group and reversal group. In MCT group, RV hypertrophy index, RV area, the fibrosis of RV increased significantly, and RV function decreased significantly. Consistently, dapagliflozin did not show protective effect on the RV remodeling and function. In the PTB model, we also did not find the direct effect of dapagliflozin on the RV. This is a negative therapeutic experiment, suggesting human trials with dapagliflozin for PAH or RV failure should be cautious.
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Affiliation(s)
- Huayang Li
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China
| | - Yitao Zhang
- Department of Cardiovascular, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shunjun Wang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China
| | - Yuan Yue
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China
| | - Quan Liu
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China
| | - Suiqing Huang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China
| | - Huajing Peng
- Department of Cardiovascular, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yi Zhang
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China
| | - Weijie Zeng
- Department of Cardiovascular, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China
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4
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Vassiliou AG, Kotanidou A, Dimopoulou I, Orfanos SE. Endothelial Damage in Acute Respiratory Distress Syndrome. Int J Mol Sci 2020; 21:ijms21228793. [PMID: 33233715 PMCID: PMC7699909 DOI: 10.3390/ijms21228793] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 01/01/2023] Open
Abstract
The pulmonary endothelium is a metabolically active continuous monolayer of squamous endothelial cells that internally lines blood vessels and mediates key processes involved in lung homoeostasis. Many of these processes are disrupted in acute respiratory distress syndrome (ARDS), which is marked among others by diffuse endothelial injury, intense activation of the coagulation system and increased capillary permeability. Most commonly occurring in the setting of sepsis, ARDS is a devastating illness, associated with increased morbidity and mortality and no effective pharmacological treatment. Endothelial cell damage has an important role in the pathogenesis of ARDS and several biomarkers of endothelial damage have been tested in determining prognosis. By further understanding the endothelial pathobiology, development of endothelial-specific therapeutics might arise. In this review, we will discuss the underlying pathology of endothelial dysfunction leading to ARDS and emerging therapies. Furthermore, we will present a brief overview demonstrating that endotheliopathy is an important feature of hospitalised patients with coronavirus disease-19 (COVID-19).
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Affiliation(s)
- Alice G. Vassiliou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Anastasia Kotanidou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Ioanna Dimopoulou
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
| | - Stylianos E. Orfanos
- 1st Department of Critical Care Medicine & Pulmonary Services, School of Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, 106 76 Athens, Greece; (A.G.V.); (A.K.); (I.D.)
- 2nd Department of Critical Care, School of Medicine, National and Kapodistrian University of Athens, Attikon Hospital, 124 62 Athens, Greece
- Correspondence: or ; Tel.: +30-2107-235-521
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5
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Gaynitdinova VV, Avdeev SN. [Novel Biomarkers of Pulmonary Hypertension]. ACTA ACUST UNITED AC 2019; 59:84-94. [PMID: 31322094 DOI: 10.18087/cardio.2019.7.10259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 11/18/2022]
Abstract
Pulmonary hypertension (PH) is a clinical syndrome characterized by a progressive increase in pulmonary vascular resistance (PVR), which leads to remodeling of the right ventricle (RV), right heart failure and premature death of patients. Early diagnosis and monitoring of disease progression are crucial for making decisions about the necessary therapy. The gold standard for the diagnosis of pulmonary hypertension is the right heart catheterization. The estimation of systolic pressure in pulmonary artery by means of transthoracic echocardiography is also used for monitoring the course of the disease. At present, there is still a need for non-invasive biomarkers that reflect pathological changes in pulmonary arterial vessels and allow diagnosing of PH. Our review outlines the new data about some biomarkers potentially useful for diagnosis and prognostication of PH. These biomarkers (mid-regional pro-adrenomedullin, carboxyterminal pro-endothelin-1, copeptin, asymmetric dimethylarginine, growth differentiation factor 15, and others) are classified based on their relationship to endothelial cell dysfunction, inflammation, epigenetics, cardiac function, oxidative stress, extracellular matrix. The determination of biomarkers that are of diagnostic value for predicting the severity, progression of PH and response to therapy, in a simple blood test or condensate of exhaled air, can significantly reduce treatment costs and improve PH management.
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Affiliation(s)
| | - S N Avdeev
- Sechenov First Moscow State Medical University (Sechenov University); Pulmonology Research Institute
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Vonk Noordegraaf A, Chin KM, Haddad F, Hassoun PM, Hemnes AR, Hopkins SR, Kawut SM, Langleben D, Lumens J, Naeije R. Pathophysiology of the right ventricle and of the pulmonary circulation in pulmonary hypertension: an update. Eur Respir J 2019; 53:13993003.01900-2018. [PMID: 30545976 PMCID: PMC6351344 DOI: 10.1183/13993003.01900-2018] [Citation(s) in RCA: 294] [Impact Index Per Article: 58.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 01/07/2023]
Abstract
The function of the right ventricle determines the fate of patients with pulmonary hypertension. Since right heart failure is the consequence of increased afterload, a full physiological description of the cardiopulmonary unit consisting of both the right ventricle and pulmonary vascular system is required to interpret clinical data correctly. Here, we provide such a description of the unit and its components, including the functional interactions between the right ventricle and its load. This physiological description is used to provide a framework for the interpretation of right heart catheterisation data as well as imaging data of the right ventricle obtained by echocardiography or magnetic resonance imaging. Finally, an update is provided on the latest insights in the pathobiology of right ventricular failure, including key pathways of molecular adaptation of the pressure overloaded right ventricle. Based on these outcomes, future directions for research are proposed. State of the art and research perspectives in pathophysiology of the right ventricle and of the pulmonary circulation in pulmonary hypertension with theoretical and practical aspectshttp://ow.ly/18v830mgLiP
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Affiliation(s)
- Anton Vonk Noordegraaf
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Kelly Marie Chin
- Division of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, TX, USA
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University and Stanford Cardiovascular Institute, Palo Alto, CA, USA
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Steven Mark Kawut
- Penn Cardiovascular Institute, Dept of Medicine, and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David Langleben
- Center for Pulmonary Vascular Disease, Cardiology Division, Jewish General Hospital and McGill University, Montreal, QC, Canada
| | - Joost Lumens
- Maastricht University Medical Center, CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Université de Bordeaux, LIRYC (L'Institut de Rythmologie et Modélisation Cardiaque), Bordeaux, France
| | - Robert Naeije
- Dept of Cardiology, Erasme University Hospital, Brussels, Belgium.,Laboratory of Cardiorespiratory Exercise Physiology, Faculty of Motor Sciences, Université Libre de Bruxelles, Brussels, Belgium
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Activated Protein C has No Effect on Pulmonary Capillary Endothelial Function in Septic Patients with Acute Respiratory Distress Syndrome: Association of Endothelial Dysfunction with Mortality. Infect Dis Ther 2018; 7:15-25. [PMID: 29549655 PMCID: PMC5856732 DOI: 10.1007/s40121-018-0192-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Pulmonary capillary endothelium-bound (PCEB) angiotensin-converting enzyme (ACE) activity is a direct and quantifiable index of pulmonary endothelial function that decreases early in acute respiratory distress syndrome (ARDS) and correlates with its severity. Endothelial dysfunction is a major pathophysiology that underlies sepsis-related ARDS. Recombinant human activated protein C (rhAPC), now withdrawn from the market, has been used in the recent past as an endothelial-protective treatment in patients with septic organ dysfunction. METHODS We investigated the effect of rhAPC on pulmonary endothelial function in 19 septic patients suffering from ARDS. Applying indicator-dilution type techniques, we measured single-pass transpulmonary percent metabolism (%M) and hydrolysis (v) of the synthetic, biologically inactive, and highly specific for ACE substrate, 3H-benzoyl-Phe-Ala-Pro (BPAP), under first-order reaction conditions, and calculated lung functional capillary surface area before and after treatment with rhAPC. RESULTS Pulmonary endothelium ACE activity was severely impaired in septic patients with ARDS, and was not affected by rhAPC treatment. Additionally, poor outcome was related to a more profound decrease in PCEB-ACE activity. Angiotensin-converting enzyme-substrate utilization was statistically significantly lower in non-survivors as compared to survivors, with no changes over time within each group: BPAP %M: 32.7 ± 3.4% at baseline to 25.6 ± 2.9% at day 7 in survivors versus 20.8 ± 2.8 to 15.5 ± 5%, respectively, in non-survivors (p = 0.044), while hydrolysis (v): 0.41 ± 0.06 at baseline to 0.30 ± 0.04 at day 7 in survivors compared to 0.24 ± 0.04 to 0.18 ± 0.06, respectively, in non-survivors (p = 0.049). CONCLUSION rhAPC administration in septic patients with ARDS did not improve PCEB-ACE activity indices. However, these indices might be useful in the early recognition of septic patients with ARDS at high risk of mortality.
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Higo K, Kubota K, Miyanaga S, Miyata M, Nakajo M, Jinguji M, Ohishi M. Impairment of Iodine-123-Metaiodobenzylguanidine (<sup>123</sup>I-MIBG) Uptake in Patients with Pulmonary Artery Hypertension. Int Heart J 2018; 59:112-119. [DOI: 10.1536/ihj.16-629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kenjuro Higo
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Kayoko Kubota
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Sunao Miyanaga
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Masaaki Miyata
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Masatoyo Nakajo
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Megumi Jinguji
- Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University
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9
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Langleben D, Orfanos S. Vasodilator responsiveness in idiopathic pulmonary arterial hypertension: identifying a distinct phenotype with distinct physiology and distinct prognosis. Pulm Circ 2017; 7:588-597. [PMID: 28632001 PMCID: PMC5841907 DOI: 10.1177/2045893217714231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 05/17/2017] [Indexed: 01/03/2023] Open
Abstract
Within the cohort of patients suffering from idiopathic pulmonary arterial hypertension (IPAH) is a group that responds dramatically (VR-PAH) to an acute vasodilator challenge and that has excellent long-term hemodynamic improvement and prognosis on high dose calcium channel blockers compared with vasodilator non-responders (VN-PAH). For the purposes of diagnosing VR-PAH, there is to date no test to replace the acute vasodilator challenge. However, recent studies have identified markers that may aid in the identification of VR-PAH, including peripheral blood lymphocyte RNA expression levels of desmogelin-2 and Ras homolog gene family member Q, and plasma levels of provirus integration site for Moloney murine leukemia virus. Genome wide-array studies of peripheral blood DNA have demonstrated differences in disease specific genetic variants between VR-PAH and NR-PAH, with particular convergence on cytoskeletal function pathways and Wnt signaling pathways. These studies offer hope for future non-invasive identification of VR-PAH, and insights into pathogenesis that may lead to novel therapies. Examination of the degree of pulmonary microvascular perfusion in PAH has offered additional insights. During the acute vasodilator challenge, VR-PAH patients demonstrate true vasodilation with recruitment and increased perfusion of the capillary bed, while VN-PAH patients are unable to recruit vasculature. In the very few reports of lung histology, VR-PAH has more medial thickening in the precapillary arterioles, while VN-PAH has the classic histology of PAH, including intimal thickening. VR-PAH is a disorder with a phenotype distinct from VN-PAH and other types of PAH, and should be considered separately in the classification of PAH.
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Affiliation(s)
- David Langleben
- Center for Pulmonary Vascular Disease, Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec Canada
| | - Stylianos Orfanos
- Pulmonary Hypertension Clinic, Department of Critical Care, Attikon Hospital, National and Kapodistirian University of Athens, Athens, Greece
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10
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Zhao J, Wang Q, Liu Y, Tian Z, Guo X, Wang H, Lai J, Huang C, Yang X, Li M, Zeng X. Clinical characteristics and survival of pulmonary arterial hypertension associated with three major connective tissue diseases: A cohort study in China. Int J Cardiol 2017; 236:432-437. [DOI: 10.1016/j.ijcard.2017.01.097] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/16/2017] [Indexed: 10/20/2022]
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Ramjug S, Hussain N, Hurdman J, Billings C, Charalampopoulos A, Elliot CA, Kiely DG, Sabroe I, Rajaram S, Swift AJ, Condliffe R. Idiopathic and Systemic Sclerosis-Associated Pulmonary Arterial Hypertension: A Comparison of Demographic, Hemodynamic, and MRI Characteristics and Outcomes. Chest 2017; 152:92-102. [PMID: 28223154 DOI: 10.1016/j.chest.2017.02.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 01/03/2017] [Accepted: 02/01/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous studies have identified survival in systemic sclerosis (SSc)-associated pulmonary arterial hypertension (SSc-PAH) as being worse than in idiopathic pulmonary arterial hypertension (IPAH). We investigated differences between these conditions by comparing demographic, hemodynamic, and radiological characteristics and outcomes in a large cohort of incident patients. METHODS Six hundred fifty-one patients diagnosed with IPAH or SSc-associated precapillary pulmonary hypertension were included. Patients with pulmonary disease or two or more risk factors for left heart disease were identified, leaving a primary analysis set of 375 subjects. Subgroup analysis using cardiac magnetic resonance (CMR) imaging was performed. RESULTS Median survival was 7.8 years in IPAH and 3 years in SSc-PAH (P < .001). Patients with SSc-PAH were older with less severe hemodynamics but lower gas transfer (diffusing capacity for carbon monoxide [Dlco]). Independent prognostic factors were age, SSc, Dlco, pulmonary artery saturation, and stroke volume. After excluding patients with normal or only mildly elevated resistance, there was no difference in the relationship between pulmonary vascular resistance (PVR) and compliance in IPAH and SSc-PAH. The relationship between mean pulmonary arterial pressure (mPAP) and systolic pulmonary arterial pressure (sPAP) in IPAH was identical to that previously reported (mPAP = 0.61 sPAP + 2 mm Hg). The relationship in SSc-PAH was similar: mPAP = 0.58 sPAP + 2 mm Hg (P value for difference with IPAH = 0.095). The correlation between ventricular mass index assessed at CMR imaging and PVR was stronger in SSc-PAH. CONCLUSIONS The reasons for poorer outcomes in SSc-PAH are likely to be multifactorial, including but not limited to older age and reduced gas transfer.
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Affiliation(s)
- Sheila Ramjug
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, England
| | - Nehal Hussain
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, England
| | - Judith Hurdman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, England
| | - Catherine Billings
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, England
| | | | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, England
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, England
| | - Ian Sabroe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, England; Department of Infection and Immunity, University of Sheffield, Sheffield, England
| | - Smitha Rajaram
- Department of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, England
| | - Andrew J Swift
- Academic Department of Radiology, University of Sheffield, Sheffield, England; Department of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, England
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, England.
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Peng H, Xiao Y, Deng X, Luo J, Hong C, Qin X. The Warburg effect: A new story in pulmonary arterial hypertension. Clin Chim Acta 2016; 461:53-8. [DOI: 10.1016/j.cca.2016.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/19/2016] [Accepted: 07/23/2016] [Indexed: 10/21/2022]
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13
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Anwar A, Ruffenach G, Mahajan A, Eghbali M, Umar S. Novel biomarkers for pulmonary arterial hypertension. Respir Res 2016; 17:88. [PMID: 27439993 PMCID: PMC4955255 DOI: 10.1186/s12931-016-0396-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/04/2016] [Indexed: 12/29/2022] Open
Abstract
Pulmonary arterial hypertension is a deadly disease characterized by elevated pulmonary arterial pressures leading to right ventricular hypertrophy and failure. The confirmatory gold standard test is the invasive right heart catheterization. The disease course is monitored by pulmonary artery systolic pressure measurement via transthoracic echocardiography. A simple non-invasive test to frequently monitor the patients is much needed. Search for a novel biomarker that can be detected by a simple test is ongoing and many different options are being studied. Here we review some of the new and unique pre-clinical options for potential pulmonary hypertension biomarkers. These biomarkers can be broadly categorized based on their association with endothelial cell dysfunction, inflammation, epigenetics, cardiac function, oxidative stress, metabolism,extracellular matrix, and volatile compounds in exhaled breath condensate. A biomarker that can be detected in blood, urine or breath condensate and correlates with disease severity, progression and response to therapy may result in significant cost reduction and improved patient outcomes.
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Affiliation(s)
- Anjum Anwar
- Departmentof Anesthesiology, Stanford University, Palo Alto, CA, USA
| | - Gregoire Ruffenach
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Mansoureh Eghbali
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA
| | - Soban Umar
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
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14
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Goldenberg NM, Kuebler WM. Endothelial cell regulation of pulmonary vascular tone, inflammation, and coagulation. Compr Physiol 2016; 5:531-59. [PMID: 25880504 DOI: 10.1002/cphy.c140024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The pulmonary endothelium represents a heterogeneous cell monolayer covering the luminal surface of the entire lung vasculature. As such, this cell layer lies at a critical interface between the blood, airways, and lung parenchyma, and must act as a selective barrier between these diverse compartments. Lung endothelial cells are able to produce and secrete mediators, display surface receptor, and cellular adhesion molecules, and metabolize circulating hormones to influence vasomotor tone, both local and systemic inflammation, and coagulation functions. In this review, we will explore the role of the pulmonary endothelium in each of these systems, highlighting key regulatory functions of the pulmonary endothelial cell, as well as novel aspects of the pulmonary endothelium in contrast to the systemic cell type. The interactions between pulmonary endothelial cells and both leukocytes and platelets will be discussed in detail, and wherever possible, elements of endothelial control over physiological and pathophysiological processes will be examined.
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Affiliation(s)
- Neil M Goldenberg
- The Keenan Research Centre for Biomedical Science of St. Michael's, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Ontario, Canada
| | - Wolfgang M Kuebler
- The Keenan Research Centre for Biomedical Science of St. Michael's, Toronto, Ontario, Canada; German Heart Institute Berlin, Germany; Institute of Physiology, Charité-Universitätsmedizin Berlin, Germany; Department of Surgery, University of Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Ontario,Canada
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15
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Adrovic A, Oztunc F, Barut K, Koka A, Gojak R, Sahin S, Demir T, Kasapcopur O. The frequency of pulmonary hypertension in patients with juvenile scleroderma. Bosn J Basic Med Sci 2015; 15:30-5. [PMID: 26614849 DOI: 10.17305/bjbms.2015.596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/25/2015] [Accepted: 07/26/2015] [Indexed: 01/15/2023] Open
Abstract
Juvenile scleroderma (JS) represents a rarely seen group of connective tissue diseases with multiple organ involvement. Cardiac involvement in JSS is well known and, although rare in children, it may be an important cause of mortality and morbidity. Therefore, an early determination of cardio-vascular and pulmonary involvement is of the most relevance to reduce the mortality in patients with juvenile scleroderma. The aim of the study was to explore the non-invasive methods (Doppler echocardiography, pulmonary function tests), Forced vital capacity (FVC) and Carbon monoxide diffusion capacity (DLCO) in the assessment of the cardiopulmonary involvement in patients with JS. The assessment of pulmonary arterial pressure (PAP) and risk factors for pulmonary arterial hypertension (PAH) were made by the measurement of maximum tricuspid insufficiency (TI), end-diastolic pulmonary insufficiency (PI), ratio of acceleration time (AT) to ejection time (ET) (AT/ET), right atrial pressure (RAP) and contraction of vena cava inferior during inspiration. Thirty-five patients with confirmed JS were included in the study. The mean age of onset of the disease was 9.57 years (median 10 years, range 2-18 years). The mean disease duration and follow-up time was 2 years (median 1 year, range 0.5-8 years) and 3.57 years (median 2 years, range 0.5-14.5 years), respectively.The values of all the analyzed parameters including TI, PI, AT/ET, PAP, FVC and DLCO were found to be within normal ranges in all the patients tested, confirming an uncommonness of cardiopulmonary involvement in patients with juvenile scleroderma.
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Affiliation(s)
- Amra Adrovic
- Department of Pediatric Rheumatology, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey.
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16
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Kang KY, Jeon CH, Choi SJ, Yoon BY, Choi CB, Lee CH, Suh CH, Lee CW, Cho CS, Nam EJ, Koh EM, Kim HY, Choi HJ, Kim HA, Jun JB, Lee J, Kim J, Ji JD, Min JK, Kim KJ, Shin K, So MW, Kwon SR, Kim SK, Nah SS, Kwok SK, Lee SK, Lee SW, Park SH, Park W, Park YB, Lee YH, Lee SS, Yoo DH. Survival and prognostic factors in patients with connective tissue disease-associated pulmonary hypertension diagnosed by echocardiography: results from a Korean nationwide registry. Int J Rheum Dis 2015. [PMID: 26214170 DOI: 10.1111/1756-185x.12645] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Pulmonary arterial hypertension (PAH) is a major cause of mortality in connective tissue disease (CTD). The survival rates and mortality-predictive factors of a nationwide registry of Korean patients with CTD-PH measured by echocardiography were determined. METHODS Patients with CTD-PH were enrolled between April 2008 and December 2012. Hemodynamic parameters and clinical data (WHO-functional class [FC], organ involvement, laboratory tests and treatment agents) were recorded. Survival rates were calculated by using the Kaplan-Meier method. Mortality-associated factors were examined by Cox proportional hazards regression analysis. RESULTS In total, 174 incident PH cases (61 with systemic lupus erythematosus, 50 with systemic sclerosis, 10 with mixed CTD, 22 with rheumatoid arthritis (RA) and 31 with other CTDs) were diagnosed by Doppler echocardiography. Of these, 25 (14%) died during the 3.8 ± 2.7 year follow-up period after PH diagnosis. The 1- and 3-year survival rates were 90.7% and 87.3%, respectively. Compared to the other CTD-PHs, RA-PH had the lowest survival rates (56% 3 year survival; P = 0.022). Multiple regression analysis revealed that low diffusion capacity of carbon monoxide (DLCO), pleural effusion and diabetes mellitus were poor prognostic factors (P = 0.008, 0.04 and 0.009, respectively). Anti-UI-RNP (ribonucleoprotein) antibody positivity was protective (P = 0.022). In patients with WHO-FC III/IV, patients who received vasodilators had lower mortality than those who did not (P = 0.038). CONCLUSIONS In Korean patients with CTD-PH, the 3-year survival rate was 87%. Low diffusion capacity of carbon monoxide (DLCO), pleural effusion and diabetes mellitus were independent poor prognostic factors. Anti-UI-RNP antibody was protective. Prompt PAH-specific vasodilator therapy may improve the survival of patients with severe CTD-PH.
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Affiliation(s)
- Kwi Young Kang
- Department of Internal Medicine, Incheon Saint Mary's Hospital, Catholic University of Korea, Incheon, Korea
| | - Chan Hong Jeon
- Department of Internal Medicine, Hospital Bucheon, Soonchunhyang University, Bucheon, Korea
| | - Sung Jae Choi
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Bo Young Yoon
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Chan-Bum Choi
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Chang Hoon Lee
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Choong Won Lee
- Department of Internal Medicine, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Chul Soo Cho
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eon Jeong Nam
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Eun-Mi Koh
- Department of Internal Medicine, Sungkyunkwan University, Seoul, Korea
| | - Ho-Youn Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyo Jin Choi
- Division of Rheumatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Bum Jun
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Jaejoon Lee
- Department of Internal Medicine, Sungkyunkwan University, Seoul, Korea
| | - Jinseok Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Dae Ji
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Jun Ki Min
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Jo Kim
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kichul Shin
- Department of Internal Medicine, Borame Hospital, Seoul National University, Seoul, Korea
| | - Min Wook So
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong Ryul Kwon
- Departments of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Seong-Kyu Kim
- Department of Internal Medicine, Catholic University of Daegu, Daegu, Korea
| | - Seong-Su Nah
- Department of Internal Medicine, Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo-Kon Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, Dong-A University, Pusan, Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Park
- Departments of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Yong-Beom Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Ho Lee
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Shin-Seok Lee
- Department of Rheumatology, Chonnam National University Medical School, Kwangju, Korea
| | - Dae Hyun Yoo
- Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea
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17
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Langleben D, Orfanos SE, Giovinazzo M, Schlesinger RD, Hirsch AM, Blenkhorn F, Lesenko L, Armaganidis A, Catravas JD. Acute vasodilator responsiveness and microvascular recruitment in idiopathic pulmonary arterial hypertension. Ann Intern Med 2015; 162:154-6. [PMID: 25599356 DOI: 10.7326/m14-1402] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- David Langleben
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
| | - Stylianos E. Orfanos
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
| | - Michele Giovinazzo
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
| | - Robert D. Schlesinger
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
| | - Andrew M. Hirsch
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
| | - Fay Blenkhorn
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
| | - Lyda Lesenko
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
| | - Apostolos Armaganidis
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
| | - John D. Catravas
- From McGill University, Montréal, Quebec, Canada; Attikon Hospital, Athens, Greece; and Old Dominion University, Norfolk, Virginia
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18
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Dupuis J, Harel F, Nguyen QT. Molecular imaging of the pulmonary circulation in health and disease. Clin Transl Imaging 2014; 2:415-426. [PMID: 25360422 PMCID: PMC4209091 DOI: 10.1007/s40336-014-0076-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/15/2014] [Indexed: 11/29/2022]
Abstract
The pulmonary circulation, at the unique crossroads between the left and the right heart, is submitted to large physiologic hemodynamic variations and possesses numerous important metabolic functions mediated through its vast endothelial surface. There are many pathologic conditions that can directly or indirectly affect the pulmonary vasculature and modify its physiology and functions. Pulmonary hypertension, the end result of many of these affections, is unfortunately diagnosed too late in the disease process, meaning that there is a crying need for earlier diagnosis and surrogate markers of disease progression and regression. By targeting endothelial, medial and adventitial targets of the pulmonary vasculature, novel molecular imaging agents could provide early detection of physiologic and biologic perturbation in the pulmonary circulation. This review provides the rationale for the development of molecular imaging agents for the diagnosis and follow-up of disorders of the pulmonary circulation and discusses promising targets for SPECT and positron emission tomographic imaging.
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Affiliation(s)
- Jocelyn Dupuis
- Research Center, Montreal Heart Institute, 5000 Belanger Street, Montreal, QC H1T 1C8 Canada ; Department of Medicine, Université de Montréal, Montreal, QC Canada
| | - François Harel
- Research Center, Montreal Heart Institute, 5000 Belanger Street, Montreal, QC H1T 1C8 Canada ; Department of Radiology, Radio-Oncology and Nuclear Medicine Université de Montréal, Montreal, QC Canada
| | - Quang T Nguyen
- Research Center, Montreal Heart Institute, 5000 Belanger Street, Montreal, QC H1T 1C8 Canada
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19
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Glynos C, Athanasiou C, Kotanidou A, Korovesi I, Kaziani K, Livaditi O, Dimopoulou I, Maniatis NA, Tsangaris I, Roussos C, Armaganidis A, Orfanos SE. Preclinical pulmonary capillary endothelial dysfunction is present in brain dead subjects. Pulm Circ 2013; 3:419-25. [PMID: 24015344 PMCID: PMC3757838 DOI: 10.4103/2045-8932.113189] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pulmonary endothelium is a major metabolic organ affecting pulmonary and systemic vascular homeostasis. Brain death (BD)-induced physiologic and metabolic derangements in donors’ lungs, in the absence of overt lung pathology, may cause pulmonary dysfunction and compromise post-transplant graft function. To explore the impact of BD on pulmonary endothelium, we estimated pulmonary capillary endothelium-bound (PCEB)-angiotensin converting enzyme (ACE) activity, a direct and quantifiable index of pulmonary endothelial function, in eight brain-dead patients and ten brain-injured mechanically ventilated controls. No subject suffered from acute lung injury or any other overt lung pathology. Applying indicator-dilution type techniques, we measured single-pass transpulmonary percent metabolism (%M) and hydrolysis (v) of the synthetic, biologically inactive, and highly specific for ACE substrate 3H-benzoyl-Phe-Ala-Pro, under first order reaction conditions, and calculated lung functional capillary surface area (FCSA). Substrate %M (35 ± 6.8%) and v (0.49 ± 0.13) in BD patients were decreased as compared to controls (55.9 ± 4.9, P = 0.033 and 0.9 ± 0.15, P = 0.033, respectively), denoting decreased pulmonary endothelial enzyme activity at the capillary level; FCSA, a reflection of endothelial enzyme activity per vascular bed, was also decreased (BD patients: 1,563 ± 562 mL/min vs 4,235 ± 559 in controls; P = 0.003). We conclude that BD is associated with subtle pulmonary endothelial injury, expressed by decreased PCEB-ACE activity. The applied indicator-dilution type technique provides direct and quantifiable indices of pulmonary endothelial function at the bedside that may reveal the existence of preclinical lung pathology in potential lung donors.
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Affiliation(s)
- Constantinos Glynos
- First Department of Critical Care and Pulmonary Services, Evangelismos Hospital, University of Athens Medical School, Athens, Greece ; G. P. Livanos and M. Simou Laboratories, Evangelismos Hospital, University of Athens Medical School, Athens, Greece
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20
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Pulmonary hypertension in parenchymal lung disease. Pulm Med 2012; 2012:684781. [PMID: 23094153 PMCID: PMC3474989 DOI: 10.1155/2012/684781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 09/07/2012] [Indexed: 01/23/2023] Open
Abstract
Idiopathic pulmonary arterial hypertension (IPAH) has been extensively investigated, although it represents a less common form of the pulmonary hypertension (PH) family, as shown by international registries. Interestingly, in types of PH that are encountered in parenchymal lung diseases such as interstitial lung diseases (ILDs), chronic obstructive pulmonary disease (COPD), and many other diffuse parenchymal lung diseases, some of which are very common, the available data is limited. In this paper, we try to browse in the latest available data regarding the occurrence, pathogenesis, and treatment of PH in chronic parenchymal lung diseases.
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21
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Costa M, Ronchi F, Ivanow A, Carmona A, Casarini D, Slocombe R. Association between circulating angiotensin-converting enzyme and exercise-induced pulmonary haemorrhage in Thoroughbred racehorses. Res Vet Sci 2012; 93:993-4. [DOI: 10.1016/j.rvsc.2011.10.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 09/29/2011] [Accepted: 10/16/2011] [Indexed: 10/14/2022]
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22
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Langleben D, Orfanos SE. Systemic Sclerosis and Early-Onset Pulmonary Hypertension. Chest 2010; 138:238-9. [DOI: 10.1378/chest.10-0501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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23
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Chung L, Liu J, Parsons L, Hassoun PM, McGoon M, Badesch DB, Miller DP, Nicolls MR, Zamanian RT. Characterization of connective tissue disease-associated pulmonary arterial hypertension from REVEAL: identifying systemic sclerosis as a unique phenotype. Chest 2010; 138:1383-94. [PMID: 20507945 DOI: 10.1378/chest.10-0260] [Citation(s) in RCA: 299] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND REVEAL (the Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management) is the largest US cohort of patients with pulmonary arterial hypertension (PAH) confirmed by right-sided heart catheterization (RHC), providing a more comprehensive subgroup characterization than previously possible. We used REVEAL to analyze the clinical features of patients with connective tissue disease-associated PAH (CTD-APAH). METHODS All newly and previously diagnosed patients with World Health Organization (WHO) group 1 PAH meeting RHC criteria at 54 US centers were consecutively enrolled. Cross-sectional and 1-year mortality and hospitalization analyses from time of enrollment compared CTD-APAH to idiopathic disease and systemic sclerosis (SSc) to systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD), and rheumatoid arthritis (RA). RESULTS Compared with patients with idiopathic disease (n = 1,251), patients with CTD-APAH (n = 641) had better hemodynamics and favorable right ventricular echocardiographic findings but a higher prevalence of pericardial effusions, lower 6-min walk distance (300.5 ± 118.0 vs 329.4 ± 134.7 m, P = .01), higher B-type natriuretic peptide (BNP) levels (432.8 ± 789.1 vs 245.6 ± 427.2 pg/mL, P < .0001), and lower diffusing capacity of carbon monoxide (Dlco) (44.9% ± 18.0% vs 63.6% ± 22.1% predicted, P < .0001). One-year survival and freedom from hospitalization were lower in the CTD-APAH group (86% vs 93%, P < .0001; 67% vs 73%, P = .03). Compared with patients with SSc-APAH (n = 399), those with other CTDs (SLE, n = 110; MCTD, n = 52; RA, n = 28) had similar hemodynamics; however, patients with SSc-APAH had the highest BNP levels (552.2 ± 977.8 pg/mL), lowest Dlco (41.2% ± 16.3% predicted), and poorest 1-year survival (82% vs 94% in SLE-APAH, 88% in MCTD-APAH, and 96% in RA-APAH). CONCLUSIONS Patients with SSc-APAH demonstrate a unique phenotype with the highest BNP levels, lowest Dlco, and poorest survival of all CTD-APAH subgroups. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00370214; URL: clinicaltrials.gov.
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Affiliation(s)
- Lorinda Chung
- VA Palo Alto Health Care System, Palo Alto, CA 94304, USA.
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24
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Takahashi Y, Haga S, Ishizaka Y, Mimori A. Autoantibodies to angiotensin-converting enzyme 2 in patients with connective tissue diseases. Arthritis Res Ther 2010; 12:R85. [PMID: 20470389 PMCID: PMC2911869 DOI: 10.1186/ar3012] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2009] [Revised: 03/12/2010] [Accepted: 05/14/2010] [Indexed: 12/18/2022] Open
Abstract
Introduction Angiotensin-converting enzyme (ACE) 2, a homolog of ACE, converts angiotensin (Ang) II into Ang(1-7), and the vasoprotective effects of Ang(1-7) have been documented. We explored the hypothesis that serum autoantibodies to ACE2 predispose patients with connective tissue diseases to constrictive vasculopathy, pulmonary arterial hypertension (PAH), or persistent digital ischemia. Methods Serum was examined from 42 patients with systemic lupus erythematosus (SLE), scleroderma, or mixed connective tissue disease. Eighteen vasculopathy patients with PAH (five cases) and/or persistent digital ischemia (16 cases) were compared with 24 patients without these vasculopathies (control patients) for serum reactivity to purified recombinant human ACE2, using an ELISA. Results The sera from 17 of the 18 (94%) vasculopathy patients had ELISA scores above the baseline level determined using control sera from 28 healthy subjects, and the mean ELISA score in the vasculopathy patients was significantly higher than that in the control patients (P < 0.0005). The relative activity of serum ACE2, which was defined using a reference serum, correlated inversely with the ELISA scores for serum anti-ACE2 antibodies in the 18 vasculopathy patients (R2 = 0.6872). The IgG fraction from vasculopathy patients, but not from healthy subjects, inhibited ACE2 activities in vitro. Consistent with this, immunosuppressive therapy given to one SLE patient with digital necrosis markedly decreased the anti-ACE2 antibody titer and restored serum ACE2 activity. Conclusions Autoantibodies to ACE2 may be associated with constrictive vasculopathies.
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Affiliation(s)
- Yuko Takahashi
- Division of Rheumatic Diseases, Research Institute, International Medical Center of Japan, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
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Bogaard HJ, Natarajan R, Henderson SC, Long CS, Kraskauskas D, Smithson L, Ockaili R, McCord JM, Voelkel NF. Chronic Pulmonary Artery Pressure Elevation Is Insufficient to Explain Right Heart Failure. Circulation 2009; 120:1951-60. [DOI: 10.1161/circulationaha.109.883843] [Citation(s) in RCA: 402] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The most important determinant of longevity in pulmonary arterial hypertension is right ventricular (RV) function, but in contrast to experimental work elucidating the pathobiology of left ventricular failure, there is a paucity of data on the cellular and molecular mechanisms of RV failure.
Methods and Results—
A mechanical animal model of chronic progressive RV pressure overload (pulmonary artery banding, not associated with structural alterations of the lung circulation) was compared with an established model of angioproliferative pulmonary hypertension associated with fatal RV failure. Isolated RV pressure overload induced RV hypertrophy without failure, whereas in the context of angioproliferative pulmonary hypertension, RV failure developed that was associated with myocardial apoptosis, fibrosis, a decreased RV capillary density, and a decreased vascular endothelial growth factor mRNA and protein expression despite increased nuclear stabilization of hypoxia-induced factor-1α. Induction of myocardial nuclear factor E2-related factor 2 and heme-oxygenase 1 with a dietary supplement (Protandim) prevented fibrosis and capillary loss and preserved RV function despite continuing pressure overload.
Conclusion—
These data brought into question the commonly held concept that RV failure associated with pulmonary hypertension is due strictly to the increased RV afterload.
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Affiliation(s)
- Harm J. Bogaard
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
| | - Ramesh Natarajan
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
| | - Scott C. Henderson
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
| | - Carlin S. Long
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
| | - Donatas Kraskauskas
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
| | - Lisa Smithson
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
| | - Ramzi Ockaili
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
| | - Joe M. McCord
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
| | - Norbert F. Voelkel
- From the Divisions of Pulmonary and Critical Care (H.J.B., R.N., D.K., L.S., N.F.V.) and Cardiology (R.O.), Department of Medicine, and Department of Anatomy and Neurobiology (S.C.H.), Virginia Commonwealth University, Richmond; Department of Pulmonary Medicine, VU University Medical Center, Amsterdam, the Netherlands (H.J.B.); and Divisions of Cardiology (C.S.L.) and Pulmonary Sciences (J.M.M.), Department of Medicine, University of Colorado at Denver and Health Sciences Center, Aurora
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Inhaled vasodilators for pulmonary hypertension in left heart disease: Should we start considering?*. Crit Care Med 2009; 37:1155-6. [DOI: 10.1097/ccm.0b013e318196fd50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Orfanos SE, Hirsch AM, Giovinazzo M, Armaganidis A, Catravas JD, Langleben D. Pulmonary capillary endothelial metabolic function in chronic thromboembolic pulmonary hypertension. J Thromb Haemost 2008; 6:1275-80. [PMID: 18532994 DOI: 10.1111/j.1538-7836.2008.03046.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) causes physical plugging of large pulmonary arteries as well as a distal micro-vasculopathy. Pulmonary endothelium is an active metabolic tissue in normal humans. The effects of CTEPH on pulmonary endothelial metabolism are unknown. OBJECTIVES We studied pulmonary capillary endothelium-bound angiotensin converting enzyme (ACE) activity as an index of endothelial metabolism in patients with CTEPH. PATIENTS/METHODS We measured single-pass transpulmonary per cent metabolism (%M) and hydrolysis of an ACE synthetic substrate and calculated functional capillary surface area (FCSA), normalized to body surface area (BSA), in 13 patients with CTEPH and 23 controls. RESULTS Mean %M for CTEPH (71.6 +/- 4.0% SE) was similar to controls (74.7 +/- 2.7%). Substrate hydrolysis (v) was similar for CTEPH (1.47 +/- 0.22) and controls (1.51 +/- 0.11). However, FCSA/BSA was reduced (P < 0.01) for CTEPH (1530 +/- 218 mL min(-1)*m(-2)) as compared with controls (2948 +/- 245). CONCLUSIONS The metabolically functional pulmonary capillary bed is reduced in CTEPH. However, because %M and hydrolysis are preserved, this points to a reduction in functional capillary surface area rather than reduced ACE activity on the pulmonary capillary endothelial cell. The reduction in functional capillary surface area may just be a result of decreased capillary recruitment because of upstream vascular plugging by chronic organized thrombus.
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Affiliation(s)
- S E Orfanos
- Second Department of Critical Care, University of Athens Medical School and Pulmonary Hypertension Clinic, Attikon Hospital, Athens-Haidari, Greece
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Maniatis NA, Kotanidou A, Catravas JD, Orfanos SE. Endothelial pathomechanisms in acute lung injury. Vascul Pharmacol 2008; 49:119-33. [PMID: 18722553 PMCID: PMC7110599 DOI: 10.1016/j.vph.2008.06.009] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 06/09/2008] [Indexed: 12/14/2022]
Abstract
Acute lung injury (ALI) and its most severe extreme the acute respiratory distress syndrome (ARDS) refer to increased-permeability pulmonary edema caused by a variety of pulmonary or systemic insults. ALI and in particular ARDS, are usually accompanied by refractory hypoxemia and the need for mechanical ventilation. In most cases, an exaggerated inflammatory and pro-thrombotic reaction to an initial stimulus, such as systemic infection, elicits disruption of the alveolo-capillary membrane and vascular fluid leak. The pulmonary endothelium is a major metabolic organ promoting adequate pulmonary and systemic vascular homeostasis, and a main target of circulating cells and humoral mediators under injury; pulmonary endothelium is therefore critically involved in the pathogenesis of ALI. In this review we will discuss mechanisms of pulmonary endothelial dysfunction and edema generation in the lung with special emphasis on the interplay between the endothelium, the immune and hemostatic systems, and highlight how these principles apply in the context of defined disorders and specific insults implicated in ALI pathogenesis.
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Affiliation(s)
| | - Anastasia Kotanidou
- “M. Simou” Laboratory, University of Athens Medical School, Athens, Greece
- 1st Department of Critical Care, Evangelismos Hospital, University of Athens Medical School, Athens, Greece
| | - John D. Catravas
- Vascular Biology Center, Medical College of Georgia, Augusta, GA, United States
| | - Stylianos E. Orfanos
- “M. Simou” Laboratory, University of Athens Medical School, Athens, Greece
- 2nd Department of Critical Care, Attikon Hospital, University of Athens Medical School, Athens, Greece
- Corresponding author. 2nd Department of Critical Care, Attikon Hospital, 1, Rimini St., 124 62, Haidari, Athens, Greece. Tel.: +30 210 7235521; fax: +30 210 7239127.
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