Pulmonary hypertension in lambs with congenital diaphragmatic hernia: vasodilator prostaglandins, isoprenaline, and tolazoline

Prostanoids and phosphodiesterase inhibitors in experimental pulmonary hypertension

Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis, characterized by intimal lesions, medial hypertrophy, and adventitial thickening of precapillary pulmonary arteries. Several approved therapies are currently available for the treatment of PAH, of which intravenous epoprostenol is the best explored over the past decade. Newly available oral endothelin receptor antagonists, although clinically efficacious, bear the risk of liver toxicity in a significant portion of patients. Substances that stimulate the formation of the second messengers cyclic adenosine monophosphate (cAMP) or guanosine monophosphate (cGMP) have proved useful in the treatment of various forms of pre-capillary pulmonary hypertension. These second messengers of the endogenous vasodilator mediators that include prostacyclin and nitric oxide (NO) are hydrolyzed by cyclic nucleotide phosphodiesterases (PDEs), a class of enzymes from which 11 isoforms have been characterized. This chapter highlights developments in the treatment of experimental pulmonary hypertension with special attention to prostanoids and PDE inhibitors. We summarize findings for the acute vasodilatory as well as chronic effects of prostanoids, PDE inhibitors, or combinations of both, in animal models of pulmonary hypertension.

Vitamin A deficiency (VAD), teratogenic, and surgical models of congenital diaphragmatic hernia (CDH)

Congenital diaphragmatic hernia (CDH) is a congenital malformation that occurs with a frequency of 0.08 to 0.45 per 1,000 births. Children with CDH are born with the abdominal contents herniated through the diaphragm and exhibit an associated pulmonary hypoplasia which is frequently accompanied by severe morbidity and mortality. Although the etiology of CDH is largely unknown, considerable progress has been made in understanding its molecular mechanisms through the usage of genetic, teratogenic, and surgical models. The following review focuses on the teratogenic and surgical models of CDH and the possible molecular mechanisms of nitrofen (a diphenyl ether, formerly used as an herbicide) in both induction of CDH and pulmonary hypoplasia. In addition, the mechanisms of other compounds including several anti-inflammatory agents that have been linked to CDH will be discussed. Furthermore, this review will also explore the importance of vitamin A in lung and diaphragm development and the possible mechanisms of teratogen interference in vitamin A homeostasis. Continued exploration of these models will bring forth a clearer understanding of CDH and its molecular underpinnings, which will ultimately facilitate development of therapeutic strategies.

Dual vasoactive effects of tolazoline on rabbit pulmonary arteries

OBJECTIVES

To determine the vasoactive effects of tolazoline on isolated rabbit pulmonary arteries.

DESIGN

Prospective, in vitro, randomized, controlled trial.

SETTING

Experimental laboratory in a university-affiliated hospital.

PARTICIPANTS

New Zealand White Rabbits.

INTERVENTIONS

The pulmonary artery rings were obtained via thoracotomy. Their vasoactive responses were assessed in the presence and absence of intact endothelium and with or without precontraction by norepinephrine (NE, 3 x 10(-6) M) or potassium chloride (KCl, 3 x 10(-2) M). Using a tissue bath preparation, cumulative concentration response curves of tolazoline were obtained at different concentrations (10(-9) to 10(-4) M) after a period of stabilization.

MEASUREMENTS AND MAIN RESULTS

Tolazoline caused vasoconstriction of isolated pulmonary arteries without any pretreatment. The magnitude of the constriction was dose related and reached 300 g/g wet tissue at a concentration of 10(-4) M. On KCl-precontracted pulmonary arteries, tolazoline caused significant dose-related vasoconstriction. On the NE-precontracted vessel rings, it elicited significant dose-dependent vasodilation up to 60% relaxation at 10(-5) M. All the above effects were endothelium independent.

CONCLUSIONS

Tolazoline has dual endothelium-independent vasoactive effects, causing vasoconstriction on isolated rabbit pulmonary arteries, either untreated or precontracted with KCl, and vasodilation on those precontracted with NE. Tolazoline may act as a competitive alpha-adrenoceptor blocking agent.

Newborn surgical emergencies. Congenital diaphragmatic hernia and extracorporeal membrane oxygenation

Bochdalek hernia is a posterolateral defect in the embryogenesis of the diaphragm. Abdominal contents enter the thorax during fetal development and result in pulmonary hypoplasia. A cause of respiratory distress in the newborn, the management of this disease has undergone dramatic changes. The defect requires surgical repair, but success depends more on preoperative and postoperative management of the associated physiologic derangements.

The modified Fontan procedure: physiology and anesthetic implications

The modified Fontan operation has gained wide acceptance as a functional corrective procedure for patients with CHD with single ventricle physiology. Long-term survival and palliation of symptoms are excellent with most patients able to lead normal lives. The absence of a pulmonary contractile ventricle means that the single ventricle is responsible for perfusion of both the pulmonary and systemic circulations. Elevated systemic venous pressure is required to overcome PVR and this state of systemic venous hypertension has a significant impact on the anesthetic and postoperative care of these patients.