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Bali AD, Sharma T, Villela MA, Naidu SS, Goldberg J. Interventional Therapies and Mechanical Circulatory Support for Acute Pulmonary Embolism. J Card Fail 2024; 30:1319-1329. [PMID: 39389743 DOI: 10.1016/j.cardfail.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 07/03/2024] [Accepted: 07/30/2024] [Indexed: 10/12/2024]
Abstract
Acute pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality, with most PE-related mortality associated with acute right ventricular (RV) failure. Despite an increase in attention to acute PE with new endovascular devices for therapy and the adoption of multidisciplinary clinical treatment teams, mortality rates remain high in patients who present with PE-related hemodynamic compromise. Currently, the advanced treatment modalities for acute high-risk and intermediate high-risk PE are limited to several interventional modalities-open surgical embolectomy and systemic fibrinolytic agents. The purpose of this state-of-the-art review is to describe modern therapeutic techniques and strategies (both interventional and surgical) and the role of mechanical circulatory support (MCS) for hemodynamic compromise in PE.
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Affiliation(s)
- Atul D Bali
- Department of Cardiology, Lenox Hill Hospital, New York, NY.
| | - Tanya Sharma
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
| | | | - Srihari S Naidu
- Department of Cardiology, Westchester Medical Center, Valhalla, NY
| | - Joshua Goldberg
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, NY
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2
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Goldberg JB, Giri J, Kobayashi T, Ruel M, Mittnacht AJC, Rivera-Lebron B, DeAnda A, Moriarty JM, MacGillivray TE. Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e628-e647. [PMID: 36688837 DOI: 10.1161/cir.0000000000001117] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.
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Darquenne C, Borojeni AA, Colebank MJ, Forest MG, Madas BG, Tawhai M, Jiang Y. Aerosol Transport Modeling: The Key Link Between Lung Infections of Individuals and Populations. Front Physiol 2022; 13:923945. [PMID: 35795643 PMCID: PMC9251577 DOI: 10.3389/fphys.2022.923945] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/24/2022] [Indexed: 12/18/2022] Open
Abstract
The recent COVID-19 pandemic has propelled the field of aerosol science to the forefront, particularly the central role of virus-laden respiratory droplets and aerosols. The pandemic has also highlighted the critical need, and value for, an information bridge between epidemiological models (that inform policymakers to develop public health responses) and within-host models (that inform the public and health care providers how individuals develop respiratory infections). Here, we review existing data and models of generation of respiratory droplets and aerosols, their exhalation and inhalation, and the fate of infectious droplet transport and deposition throughout the respiratory tract. We then articulate how aerosol transport modeling can serve as a bridge between and guide calibration of within-host and epidemiological models, forming a comprehensive tool to formulate and test hypotheses about respiratory tract exposure and infection within and between individuals.
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Affiliation(s)
- Chantal Darquenne
- Department of Medicine, University of California, San Diego, San Diego, CA, United States
| | - Azadeh A.T. Borojeni
- Department of Medicine, University of California, San Diego, San Diego, CA, United States
| | - Mitchel J. Colebank
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, United States
| | - M. Gregory Forest
- Departments of Mathematics, Applied Physical Sciences, and Biomedical Engineering, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Balázs G. Madas
- Environmental Physics Department, Centre for Energy Research, Budapest, Hungary
| | - Merryn Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Yi Jiang
- Department of Mathematics and Statistics, Georgia State University, Atlanta, GA, United States
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Johnson DW, Roy TK, Secomb TW. Analysis of flow resistance in the pulmonary arterial circulation: implications for hypoxic pulmonary vasoconstriction. J Appl Physiol (1985) 2021; 131:1211-1218. [PMID: 34410848 DOI: 10.1152/japplphysiol.00128.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hypoxic pulmonary vasoconstriction (HPV) plays an essential role in distributing blood in the lung to enhance ventilation-perfusion matching and blood oxygenation. In this study, a theoretical model of the pulmonary vasculature is used to predict the effects of vasoconstriction over specified ranges of vessel diameters on pulmonary vascular resistance (PVR). The model is used to evaluate the ability of hypothesized mechanisms of HPV to account for observed levels of PVR elevation during hypoxia. The vascular structure from pulmonary arteries to capillaries is represented using scaling laws. Vessel segments are modeled as resistive elements and blood flow rates are computed from physical principles. Direct vascular responses to intravascular oxygen levels have been proposed as a mechanism of HPV. In the lung, significant changes in oxygen level occur only in vessels less than 60 μm in diameter. The model shows that observed levels of hypoxic vasoconstriction in these vessels alone cannot account for the elevation of PVR associated with HPV. However, the elevation in PVR associated with HPV can be accounted for if larger upstream vessels also constrict. These results imply that upstream signaling by conducted responses to engage constriction of arterioles plays an essential role in the elevation of PVR during HPV.NEW & NOTEWORTHY A theoretical model of the pulmonary vasculature is used to predict the effects of vasoconstriction over specified ranges of vessel diameters on pulmonary vascular resistance (PVR). The model shows that observed levels of hypoxic vasoconstriction in terminal vessels cannot account for the elevation of PVR associated with hypoxic pulmonary vasoconstriction (HPV). Upstream signaling by conducted responses to engage constriction of arterioles, therefore, plays an essential role in the elevation of PVR during HPV.
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Affiliation(s)
- David W Johnson
- Physiological Sciences Graduate Program, University of Arizona, Tucson, Arizona
| | - Tuhin K Roy
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Timothy W Secomb
- Physiological Sciences Graduate Program, University of Arizona, Tucson, Arizona.,Department of Physiology, University of Arizona, Tucson, Arizona
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Ebrahimi BS, Tawhai MH, Kumar H, Burrowes KS, Hoffman EA, Wilsher ML, Milne D, Clark AR. A computational model of contributors to pulmonary hypertensive disease: impacts of whole lung and focal disease distributions. Pulm Circ 2021; 11:20458940211056527. [PMID: 34820115 PMCID: PMC8607494 DOI: 10.1177/20458940211056527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022] Open
Abstract
Pulmonary hypertension has multiple etiologies and so can be difficult to diagnose, prognose, and treat. Diagnosis is typically made via invasive hemodynamic measurements in the main pulmonary artery and is based on observed elevation of mean pulmonary artery pressure. This static mean pressure enables diagnosis, but does not easily allow assessment of the severity of pulmonary hypertension, nor the etiology of the disease, which may impact treatment. Assessment of the dynamic properties of pressure and flow data obtained from catheterization potentially allows more meaningful assessment of the strain on the right heart and may help to distinguish between disease phenotypes. However, mechanistic understanding of how the distribution of disease in the lung leading to pulmonary hypertension impacts the dynamics of blood flow in the main pulmonary artery and/or the pulmonary capillaries is lacking. We present a computational model of the pulmonary vasculature, parameterized to characteristic features of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension to help understand how the two conditions differ in terms of pulmonary vascular response to disease. Our model incorporates key features known to contribute to pulmonary vascular function in health and disease, including anatomical structure and multiple contributions from gravity. The model suggests that dynamic measurements obtained from catheterization potentially distinguish between distal and proximal vasculopathy typical of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. However, the model suggests a non-linear relationship between these data and vascular structural changes typical of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension which may impede analysis of these metrics to distinguish between cohorts.
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Affiliation(s)
| | - Merryn H. Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Haribalan Kumar
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Kelly S. Burrowes
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Eric A. Hoffman
- Department of Radiology, University of Iowa, Iowa City, IA,
USA
| | - Margaret L. Wilsher
- Respiratory Services, Auckland City Hospital, Auckland, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland,
Auckland, New Zealand
| | - David Milne
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Alys R. Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Hypoxic pulmonary vasoconstriction as a regulator of alveolar-capillary oxygen flux: A computational model of ventilation-perfusion matching. PLoS Comput Biol 2021; 17:e1008861. [PMID: 33956786 PMCID: PMC8130924 DOI: 10.1371/journal.pcbi.1008861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 05/18/2021] [Accepted: 03/04/2021] [Indexed: 11/19/2022] Open
Abstract
The relationship between regional variabilities in airflow (ventilation) and blood flow (perfusion) is a critical determinant of gas exchange efficiency in the lungs. Hypoxic pulmonary vasoconstriction is understood to be the primary active regulator of ventilation-perfusion matching, where upstream arterioles constrict to direct blood flow away from areas that have low oxygen supply. However, it is not understood how the integrated action of hypoxic pulmonary vasoconstriction affects oxygen transport at the system level. In this study we develop, and make functional predictions with a multi-scale multi-physics model of ventilation-perfusion matching governed by the mechanism of hypoxic pulmonary vasoconstriction. Our model consists of (a) morphometrically realistic 2D pulmonary vascular networks to the level of large arterioles and venules; (b) a tileable lumped-parameter model of vascular fluid and wall mechanics that accounts for the influence of alveolar pressure; (c) oxygen transport accounting for oxygen bound to hemoglobin and dissolved in plasma; and (d) a novel empirical model of hypoxic pulmonary vasoconstriction. Our model simulations predict that under the artificial test condition of a uniform ventilation distribution (1) hypoxic pulmonary vasoconstriction matches perfusion to ventilation; (2) hypoxic pulmonary vasoconstriction homogenizes regional alveolar-capillary oxygen flux; and (3) hypoxic pulmonary vasoconstriction increases whole-lobe oxygen uptake by improving ventilation-perfusion matching. The relationship between regional ventilation (airflow) and perfusion (blood flow) is a major determinant of gas exchange efficiency. Atelactasis and pulmonary vascular occlusive diseases, such as acute pulmonary embolism, are characterized by ventilation-perfusion mismatching and decreased oxygen in the bloodstream. Despite the physiological and medical importance of ventilation-perfusion matching, there are gaps in our knowledge of the regulatory mechanisms that maintain adequate gas exchange under pathological and normal conditions. Hypoxic pulmonary vasoconstriction is understood to be the primary regulator of ventilation-perfusion matching, where upstream arterioles constrict to direct blood flow away from areas that have low oxygen supply, yet it is not understood how this mechanism affects oxygen transport at the system level. In this study we present a computational model of the ventilation-perfusion matching and hypoxic pulmonary vasoconstriction to better understand how physiological regulation at the regional level scales to affect oxygen transport at the system level. Our model simulations predict that this regulatory mechanism improves the spatial overlap of airflow and blood flow, which serves to increase the uptake of oxygen into the bloodstream. This improved understanding of ventilation-perfusion matching may offer insights into the etiology of, and therapeutic interventions for diseases characterized by ventilation-perfusion mismatching.
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Clark AR, Burrowes KS, Tawhai MH. Integrative Computational Models of Lung Structure-Function Interactions. Compr Physiol 2021; 11:1501-1530. [PMID: 33577123 DOI: 10.1002/cphy.c200011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Anatomically based integrative models of the lung and their interaction with other key components of the respiratory system provide unique capabilities for investigating both normal and abnormal lung function. There is substantial regional variability in both structure and function within the normal lung, yet it remains capable of relatively efficient gas exchange by providing close matching of air delivery (ventilation) and blood delivery (perfusion) to regions of gas exchange tissue from the scale of the whole organ to the smallest continuous gas exchange units. This is despite remarkably different mechanisms of air and blood delivery, different fluid properties, and unique scale-dependent anatomical structures through which the blood and air are transported. This inherent heterogeneity can be exacerbated in the presence of disease or when the body is under stress. Current computational power and data availability allow for the construction of sophisticated data-driven integrative models that can mimic respiratory system structure, function, and response to intervention. Computational models do not have the same technical and ethical issues that can limit experimental studies and biomedical imaging, and if they are solidly grounded in physiology and physics they facilitate investigation of the underlying interaction between mechanisms that determine respiratory function and dysfunction, and to estimate otherwise difficult-to-access measures. © 2021 American Physiological Society. Compr Physiol 11:1501-1530, 2021.
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Affiliation(s)
- Alys R Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Kelly S Burrowes
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Merryn H Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Li P, Gu L, Bian Q, Tan J, Jiao D, Wu F, Xu Z, Wang L. Effects of prostaglandin E 1 nebulization of ventilated lung under 60%O 2 one lung ventilation on patients' oxygenation and oxidative stress: a randomised controlled trial. Respir Res 2020; 21:113. [PMID: 32404117 PMCID: PMC7218546 DOI: 10.1186/s12931-020-01380-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/01/2020] [Indexed: 11/10/2022] Open
Abstract
Background High FiO2 during one-lung ventilation (OLV) can improve oxygenation, but increase the risk of atelectasis and oxidative stress. The aim of this study was to analyze whether Prostaglandin E1 (PGE1) can improve oxygenation and attenuate oxidative stress during OLV under a lower FiO2. Method Ninety patients selectively undergoing thoracotomy for esophageal cancer were randomly divided into three groups (n = 30/group): Group P (FiO2 = 0.6, inhaling PGE1 0.1 μg/kg), Group L (FiO2 = 0.6) and Group C (FiO2 = 1.0). The primary outcomes were oxygenation and pulmonary shunt during OLV. Secondary outcomes included haemodynamics, respiratory mechanics and oxidative stress in serum. Results Patients in Group P had significantly higher PaO2 and lower shunt fraction in 30 min of OLV compared with Group L. Compared with Group C, patients in Group P had similar levels of PaO2/FiO2 in 60 min and higher levels of PaO2/FiO2 at 2 h during OLV. The levels of PvO2 and SvO2 in Group P and Group L were significantly lower than Group C. Patients in Group P and Group L had significantly higher levels of superoxide dismutase and lower levels of malondialdehyde than Group C. No significant differences were found in SPO2, ETCO2, PaCO2, Paw, HR and MAP among the three groups. The complications in Group C were significantly higher than another two groups. Conclusion PGE1 can maintain adequate oxygenation in patients with low FiO2 (0.6) during OLV. Reducing FiO2 to 0.6 during OLV can decrease the levels of oxidative stress and complications after OLV. Trial registration chictr.org.cn identifier: ChiCTR1800017100.
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Affiliation(s)
- Pengyi Li
- Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, No. 42 Baiziting, Xuanwu District, Nanjing, 210009, China
| | - Lianbing Gu
- Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, No. 42 Baiziting, Xuanwu District, Nanjing, 210009, China
| | - Qingming Bian
- Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, No. 42 Baiziting, Xuanwu District, Nanjing, 210009, China
| | - Jing Tan
- Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, No. 42 Baiziting, Xuanwu District, Nanjing, 210009, China
| | - Dian Jiao
- Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, No. 42 Baiziting, Xuanwu District, Nanjing, 210009, China
| | - Fei Wu
- Renji Clinical School, Shanghai Jiao Tong University School of Medicine, Shanghai, 200000, China
| | - Zeping Xu
- Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, No. 42 Baiziting, Xuanwu District, Nanjing, 210009, China
| | - Lijun Wang
- Department of Anesthesiology, Jiangsu Cancer Hospital & Jiangsu Institute of Cancer Research & The Affiliated Cancer Hospital of Nanjing Medical University, No. 42 Baiziting, Xuanwu District, Nanjing, 210009, China.
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Lyhne MD, Kline JA, Nielsen-Kudsk JE, Andersen A. Pulmonary vasodilation in acute pulmonary embolism - a systematic review. Pulm Circ 2020; 10:2045894019899775. [PMID: 32180938 PMCID: PMC7057411 DOI: 10.1177/2045894019899775] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/18/2019] [Indexed: 01/17/2023] Open
Abstract
Acute pulmonary embolism is the third most common cause of cardiovascular death. Pulmonary embolism increases right ventricular afterload, which causes right ventricular failure, circulatory collapse and death. Most treatments focus on removal of the mechanical obstruction caused by the embolism, but pulmonary vasoconstriction is a significant contributor to the increased right ventricular afterload and is often left untreated. Pulmonary thromboembolism causes mechanical obstruction of the pulmonary vasculature coupled with a complex interaction between humoral factors from the activated platelets, endothelial effects, reflexes and hypoxia to cause pulmonary vasoconstriction that worsens right ventricular afterload. Vasoconstrictors include serotonin, thromboxane, prostaglandins and endothelins, counterbalanced by vasodilators such as nitric oxide and prostacyclins. Exogenous administration of pulmonary vasodilators in acute pulmonary embolism seems attractive but all come with a risk of systemic vasodilation or worsening of pulmonary ventilation-perfusion mismatch. In animal models of acute pulmonary embolism, modulators of the nitric oxide-cyclic guanosine monophosphate-protein kinase G pathway, endothelin pathway and prostaglandin pathway have been investigated. But only a small number of clinical case reports and prospective clinical trials exist. The aim of this review is to give an overview of the causes of pulmonary embolism-induced pulmonary vasoconstriction and of experimental and human investigations of pulmonary vasodilation in acute pulmonary embolism.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeffrey Allen Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Ebrahimi BS, Tawhai MH, Kumar H, Clark AR. Wave reflection in an anatomical model of the pulmonary circulation in local and global hypertensive disease. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:4973-4976. [PMID: 31946976 DOI: 10.1109/embc.2019.8857948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pulmonary hypertension is a disease of the pulmonary vasculature which can occur for many different reasons, including pathological remodeling of the pulmonary vessels and occlusion of these vessels (amongst others). Pulmonary hypertension can lead to right heart failure and significantly reduces the quality of life of patients living with the condition. It is difficult to distinguish clinically between different classifications of pulmonary hypertension, and doing so accurately is critical for the management of an individual's condition. In addition, different presentations of the disease (e.g. occlusion versus remodeling) can put different strains on the right heart, despite patients having very similar elevations in pulmonary artery pressure. In this study we use an anatomically based model of the pulmonary circulation to predict pressure and flow wave transmission and reflection in two different kinds of pulmonary hypertension - primary pulmonary hypertension, and chronic thrombotic pulmonary embolism (CTEPH), to enable analysis of the impact of disease type on impedance spectra in the main pulmonary artery.
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11
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Endogenously released adenosine causes pulmonary vasodilation during the acute phase of pulmonary embolization in dogs. IJC HEART & VASCULATURE 2019; 24:100396. [PMID: 31334333 PMCID: PMC6620623 DOI: 10.1016/j.ijcha.2019.100396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/25/2019] [Accepted: 06/24/2019] [Indexed: 11/22/2022]
Abstract
Background Endogenous adenosine levels increase under stress in various organs. Exogenously administered adenosine is a well-known pulmonary vasodilator. However, the physiology and therapeutic potential of endogenous adenosine during alteration in pulmonary hemodynamics such as pulmonary embolism is not elucidated. We hypothesized that the adenosine level increases following an acute elevation of pulmonary resistance, resulting in pulmonary vasodilation. Methods We induced acute pulmonary embolization by injecting plastic beads in anesthetized dogs. Plasma adenosine levels, defined as the product of plasma adenosine concentration and simultaneous cardiac output, were assessed from blood samples from the superior vena cava, main pulmonary artery (MPA), and ascending aorta 1 and 10 min following injection. Hemodynamics were assessed with (n = 3) and without (n = 8) administration of the adenosine receptor blocker, 8-(p-sulfophenyl)theophylline (8SPT). Results Mean pulmonary arterial pressure (PAP) increased from 11 ± 1 mmHg, peaking at 28 ± 4 mmHg at 52 ± 13 s after injection. During this period, total pulmonary resistance (TPR) elevated from 11 ± 1 to 33 ± 6 Wood unit. Plasma adenosine levels increased in the MPA from 14.5 ± 2 to 38.8 ± 7 nmol/min 1 min after injection. TPR showed greater elevation under 8SPT treatment, to 96 ± 12 Wood unit at PAP peak. Conclusions Endogenously released adenosine after acute pulmonary embolization is one of the initial pulmonary vasodilators. The immediate surge in plasma adenosine levels in the MPA could lead to a hypothesis that adenosine is released by the right heart in response to pressure overload. Adenosine levels increased after experimental acute pulmonary embolization. Plasma adenosine levels immediately rose in the main pulmonary artery. Adenosine is one of the initial pulmonary vasodilators after embolization. Released adenosine could originate from the right heart following pressure overload.
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12
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Abstract
The pulmonary circulation carries deoxygenated blood from the systemic veins through the pulmonary arteries to be oxygenated in the capillaries that line the walls of the pulmonary alveoli. The pulmonary circulation carries the cardiac output with a relatively low driving pressure, and so differs considerably in structure and function from the systemic circulation to maintain a low-resistance vascular system. The pulmonary circulation is often considered to be a quasi-static system in both experimental and computational studies of pulmonary perfusion and its matching to ventilation (air flow) for exchange. However, the system is highly dynamic, with cardiac output and regional perfusion changing with posture, exercise, and over time. Here we review this dynamic system, with a focus on understanding the physiology of pulmonary vascular dynamics across spatial and temporal scales, and the changes to these dynamics that are reflective of disease. © 2019 American Physiological Society. Compr Physiol 9:1081-1100, 2019.
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Affiliation(s)
- Alys Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Merryn Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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13
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Abstract
Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis. PE is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Management of PE has evolved recently with the availability of local thrombolysis; mechanical extraction devices; hemodynamic support devices, like extracorporeal membrane oxygenation; and surgical embolectomy. There has been development of multidisciplinary PE response teams nationwide to optimize the care of patients with VTE. This review describes the epidemiology of PE, discusses diagnostic strategies and current and emerging treatments for VTE, and considers post-PE follow-up care.
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Affiliation(s)
- Eno-Obong Essien
- Division of Internal Medicine Residency Program, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Parth Rali
- Division of Thoracic Surgery and Medicine, Pulmonary Embolism Response Team (PERT), Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| | - Stephen C Mathai
- John Hopkins Hospital, 830 East Monument Street, 1830 Building 5th Floor Pulmonary, Baltimore, MD 21287, USA
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Xu X, Shi L, Ma X, Su H, Ma G, Wu X, Ying K, Zhang R. RhoA-Rho associated kinase signaling leads to renin-angiotensin system imbalance and angiotensin converting enzyme 2 has a protective role in acute pulmonary embolism. Thromb Res 2019; 176:85-94. [PMID: 30784777 DOI: 10.1016/j.thromres.2019.02.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/31/2019] [Accepted: 02/13/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Acute pulmonary embolism (APE) is a cardiovascular disease with high morbidity and mortality. Although the anatomical obstruction of the pulmonary vascular bed initiates APE, recent studies have suggested that vasoconstrictors in the renin-angiotensin system (RAS) play a role in the severity of APE. MATERIALS AND METHODS We performed a 5-year retrospective clinical study to analyze the key RAS components in APE patients, including angiotensin converting enzyme (ACE), ACE2, angiotensin II (Ang II) and angiotensin 1-7(Ang(1-7)). The role of RhoA-Rho associated kinase (ROCK) signaling in regulating RAS vasoconstrictors was detected in rat pulmonary artery endothelial cells and in an APE rat model. RESULTS In clinical study, we found that the levels of RAS vasoconstrictors were correlated with the clinical classification of APE patients, ACE and Ang II were unregulated, whereas ACE2 and Ang(1-7) were downregulated in the high-risk group compared to the healthy volunteers. In animal study, we found that activated RhoA-ROCK signaling was responsible for the imbalance in RAS vasoconstrictors both in vitro and in vivo, and further evidence indicated that ROCK inhibitors (Y27632 or HA1077) and an ACE2 activator (Resorcinol naphthalein) restored the dysregulated RAS vasoconstrictors significantly and had a protective role in an APE rat model. CONCLUSIONS Our study revealed that RhoA-ROCK signaling leads to RAS imbalance in APE patients, and ACE2 activation might be a novel therapeutic target in APE treatment.
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Affiliation(s)
- Xiaoling Xu
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Liuhong Shi
- Department of Ultrasound, the Second Affiliated Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Xiuqing Ma
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Hua Su
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Guofeng Ma
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Xiaohong Wu
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Kejing Ying
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China
| | - Ruifeng Zhang
- Department of Pulmonary and Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, China.
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15
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Ajalloueian F, Lemon G, Hilborn J, Chronakis IS, Fossum M. Bladder biomechanics and the use of scaffolds for regenerative medicine in the urinary bladder. Nat Rev Urol 2018; 15:155-174. [DOI: 10.1038/nrurol.2018.5] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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16
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Himmat S, Alzamil A, Aboelnazar N, Hatami S, White C, Dromparis P, Mengel M, Freed D, Nagendran J. A Decrease in Hypoxic Pulmonary Vasoconstriction Correlates With Increased Inflammation During Extended Normothermic Ex Vivo Lung Perfusion. Artif Organs 2017; 42:271-279. [PMID: 29266272 DOI: 10.1111/aor.13017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/12/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023]
Abstract
Normothermic ex vivo lung perfusion (EVLP) is an evolving technology to evaluate function of donor lungs to determine suitability for transplantation. We hypothesize that hypoxic pulmonary vasoconstriction (HPV) during EVLP will provide a more sensitive parameter of lung function to determine donor lung quality for lung transplantation. Eight porcine lungs were procured, and subsequently underwent EVLP with autologous blood and STEEN solution for 10 h. Standard physiologic parameters including dynamic compliance, peak airway pressure, and pulmonary vascular resistance (PVR) remained stable (P = 0.055), mean oxygenation (PO2 /FiO2 ) was 400 ± 18 mm Hg on average throughout perfusion. Response to hypoxia resulted in a robust increase in PVR (ΔPVR) up to 4 h of perfusion, however the HPV response then blunted beyond T6 (P < 0.01). The decrease in HPV response inversely correlated to cytokine concentrations of Interleukin-6 and tumor necrosis factor-α (P < 0.01). Despite acceptable lung oxygenation and standard physiologic parameters during 10 h of EVLP, there is a subclinical deterioration of lung function. HPV challenges can be performed during EVLP as a simple and more sensitive index of pulmonary vascular reactivity.
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Affiliation(s)
- Sayed Himmat
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Almothana Alzamil
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Nader Aboelnazar
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Sanaz Hatami
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Christopher White
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Peter Dromparis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Mengel
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Darren Freed
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.,Division of Cardiac Surgery, Department of Surgery, Alberta Transplant Institute, Edmonton, Alberta, Canada.,Canadian National Transplant Research Program, Canadian Institute for Health Research, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.,Division of Cardiac Surgery, Department of Surgery, Alberta Transplant Institute, Edmonton, Alberta, Canada.,Canadian National Transplant Research Program, Canadian Institute for Health Research, Edmonton, Alberta, Canada
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17
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Abstract
Respiratory disease is a significant problem worldwide, and it is a problem with increasing prevalence. Pathology in the upper airways and lung is very difficult to diagnose and treat, as response to disease is often heterogeneous across patients. Computational models have long been used to help understand respiratory function, and these models have evolved alongside increases in the resolution of medical imaging and increased capability of functional imaging, advances in biological knowledge, mathematical techniques and computational power. The benefits of increasingly complex and realistic geometric and biophysical models of the respiratory system are that they are able to capture heterogeneity in patient response to disease and predict emergent function across spatial scales from the delicate alveolar structures to the whole organ level. However, with increasing complexity, models become harder to solve and in some cases harder to validate, which can reduce their impact clinically. Here, we review the evolution of complexity in computational models of the respiratory system, including successes in translation of models into the clinical arena. We also highlight major challenges in modelling the respiratory system, while making use of the evolving functional data that are available for model parameterisation and testing.
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Affiliation(s)
- Alys R Clark
- 1 Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Haribalan Kumar
- 1 Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Kelly Burrowes
- 2 Department of Chemical and Materials Engineering, The University of Auckland, Auckland, New Zealand
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18
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Burrowes K, Doel T, Kim M, Vargas C, Roca J, Grau V, Kay D. A combined image-modelling approach assessing the impact of hyperinflation due to emphysema on regional ventilation–perfusion matching. COMPUTER METHODS IN BIOMECHANICS AND BIOMEDICAL ENGINEERING-IMAGING AND VISUALIZATION 2015. [DOI: 10.1080/21681163.2015.1023358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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19
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Hedges KL, Clark AR, Tawhai MH. Comparison of generic and subject-specific models for simulation of pulmonary perfusion and forced expiration. Interface Focus 2015; 5:20140090. [PMID: 25844154 PMCID: PMC4342950 DOI: 10.1098/rsfs.2014.0090] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
The goal of translating multiscale model analysis of pulmonary function into population studies is challenging because of the need to derive a geometric model for each subject. This could be addressed by using a generic model with appropriate customization to subject-specific data. Here, we present a quantitative comparison of simulating two fundamental behaviours of the lung-its haemodynamic response to vascular occlusion, and the forced expiration in 1 s (FEV1) following bronchoconstriction-in subject-specific and generic models. When the subjects are considered as a group, there is no significant difference between predictions of mean pulmonary artery pressure (mPAP), pulmonary vascular resistance or forced expiration; however, significant differences are apparent in the prediction of arterial oxygen, for both baseline and post-occlusion. Despite the apparent consistency of the generic and subject-specific models, a third of subjects had generic model under-prediction of the increase in mPAP following occlusion, and half had the decrease in arterial oxygen over-predicted; two subjects had considerable differences in the percentage reduction of FEV1 following bronchoconstriction. The generic model approach can be useful for physiologically directed studies but is not appropriate for simulating pathophysiological function that is strongly dependent on interaction with lung structure.
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Affiliation(s)
| | | | - Merryn H. Tawhai
- Auckland Bioengineering Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
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20
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Effects of different inspired oxygen fractions on sildenafil-induced pulmonary anti-hypertensive effects in a sheep model of acute pulmonary embolism. Life Sci 2015; 127:26-31. [DOI: 10.1016/j.lfs.2015.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 01/21/2015] [Accepted: 02/02/2015] [Indexed: 11/22/2022]
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