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Evans CE, Zhang X, Machireddy N, Zhao YY. The Unexpected Protective Role of Thrombosis in Sepsis-Induced Inflammatory Lung Injury Via Endothelial Alox15. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.29.23287934. [PMID: 37034726 PMCID: PMC10081399 DOI: 10.1101/2023.03.29.23287934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
BACKGROUND Patients with sepsis-induced acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) commonly suffer from severe pulmonary thrombosis, but clinical trials of anti-coagulant therapies in sepsis and ARDS patients have failed. ARDS patients with thrombocytopenia also exhibit increased mortality, and widespread pulmonary thrombosis is often seen in coronavirus disease 2019 (COVID-19) ARDS patients. METHODS Employing different amounts of microbeads to induce various levels of pulmonary thrombosis. Acute lung injury was induced by either lipopolysaccharide i.p. or cecal ligation and puncture. Endothelial cell (EC)-targeted nanoparticle coupled with CDH5 promoter was employed to delivery plasmid DNA expressing the CRISPR/Cas9 system for EC-specific gene knockout or expressing Alox15 for EC-specific overexpression. Additionally, thrombocytopenia was induced by genetic depletion of platelets using DTR Pf4Cre mice by breeding Pf4 Cre mice into the genetic background of DTR mice. RESULTS We show that while severe pulmonary thrombosis or thrombocytopenia augments sepsis-induced ALI, the induction of mild pulmonary thrombosis conversely reduces endothelial cell (EC) apoptosis, ALI, and mortality via sustained expression of endothelial arachidonate 15-lipoxygenase (Alox15). Endothelial Alox15 knockout via EC-targeted nanoparticle delivery of CRISPR/Cas9 plasmid DNA in adult mice abolished the protective impact of mild lung thrombosis. Conversely, overexpression of endothelial Alox15 inhibited the increases in ALI caused by severe pulmonary thrombosis. The clinical relevance of the findings was validated by the observation of reduced ALOX15-expressing ECs in lung autopsy samples of ARDS patients. Additionally, restoration of pulmonary thrombosis in thrombocytopenic mice also normalized endotoxemia-induced ALI. CONCLUSION We have demonstrated that moderate levels of thrombosis protect against sepsis-induced inflammatory lung injury via endothelial Alox15. Overexpression of Alox5 inhibits severe pulmonary thrombosis-induced increase of ALI. Thus, activation of ALOX15 signaling represents a promising therapeutic strategy for treatment of ARDS, especially in sub-populations of patients with thrombocytopenia and/or severe pulmonary thrombosis.
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Sartim MA, Nogueira RC, Cavalcante TTA, Sousa LO, Monteiro WM, Cintra ACO, Neto-Neves EM, Sampaio SV. Hemodynamic impairment induced by Crotoxin using in vivo and ex vivo approach in a rat model. Int J Biol Macromol 2023; 232:123408. [PMID: 36709813 DOI: 10.1016/j.ijbiomac.2023.123408] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023]
Abstract
Crotalus durissus snakebite represent 10 % of snakebite cases in Brazil, which cardiovascular disorders are associated with severe cases. Considering crotoxin (CTX) as the major venom component, the present study aimed to evaluate the hemodynamic alterations induced by CTX using in vivo and ex vivo approaches in a rat model. In vivo cardiac function parameters were analyzed from anesthetized rats treated with CTX or saline only (Sham), along with serum creatine kinase MB (CK-MB) and lung myeloperoxidase. From the same animals, hearts were isolated and functional parameters evaluated in Langendorff method ex vivo. CTX binding to myoblast cell line in vitro were evaluated using confocal microscopy and flow cytometry. CTX was capable of reducing arterial and diastolic blood pressure, heart rate, along with left ventricle pressure development or decay during systole (LVdP/dtmax and LVdP/dtmin) in vivo, however no differences were found in the ex vivo approach, showing that intrinsic heart function was preserved. In vitro, CTX binding to myoblast cell line was mitigated by hexamethonium, a nicotinic acetylcholine receptor antagonist. The present study has shown that CTX induce hemodynamic failure in rats, which can help improve the clinical management of cardiovascular alterations during Crotalus durissus snakebite.
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Affiliation(s)
- Marco A Sartim
- Department of Clinical Analysis, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil; Department of Research and Development, University Nilton Lins, Manaus, Brazil; Department of Teaching and Research, Fundação de Medicina Tropical, Heitor Vieira Dourado, Manaus, Brazil
| | - Renato C Nogueira
- Department of Pharmacology, Ribeirao Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Lucas O Sousa
- Department of Clinical Analysis, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Wuelton M Monteiro
- Department of Teaching and Research, Fundação de Medicina Tropical, Heitor Vieira Dourado, Manaus, Brazil; Amazonas State University, Manaus, Brazil
| | - Adélia C O Cintra
- Department of Clinical Analysis, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Evandro M Neto-Neves
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitoria, Brazil
| | - Suely V Sampaio
- Department of Clinical Analysis, Toxicology and Food Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil.
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Guerra-López JA, Amezcua-Castillo LM, González-Pacheco H, Amezcua-Guerra LM. Levels of Vascular Endothelial Growth Factor and Its Association with Pulmonary Embolism in COVID-19. J Interferon Cytokine Res 2022; 42:444-448. [PMID: 35559721 DOI: 10.1089/jir.2022.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is associated with pulmonary embolism, a condition mechanistically related to vascular endothelial growth factor (VEGF). Our objective was to identify whether VEGF levels, measured at hospital admission, may predict the occurrence of pulmonary embolism (and other thrombosis) during hospitalization. Of a total of 139 patients included in the study, a pulmonary embolism occurred in 4%, other thrombosis in 16%, and 80% remained thrombus free. Clinical and laboratory data at admission were similar among groups. VEGF levels were elevated in COVID-19 patients compared with 38 healthy controls (50.7 versus 15.0 pg/mL; P < 0.001), with an area under the receiver operating characteristic curve of 0.776. At a cutoff point >15.7 pg/mL, VEGF showed 64.7% sensitivity, 92.1% specificity, and a positive likelihood ratio of 8.2 to discriminate COVID-19. In COVID-19, VEGF levels were not different in patients with pulmonary embolism, other thrombosis, and thrombus-free patients (15.0 versus 84.0 versus 48.5 pg/mL, respectively; P = 0.19). VEGF correlated with C-reactive protein (ρ = 0.25), fibrinogen (ρ = 0.28), ferritin (ρ = 0.18), and the neutrophil-to-lymphocyte ratio (ρ = 0.20). Our study showed that VEGF is elevated in sera from patients with COVID-19 on arrival at the hospital and its levels correlate with inflammatory markers, although they are unable to predict the appearance of pulmonary embolism during hospitalization.
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Affiliation(s)
- Jazmin A Guerra-López
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | | | - Luis M Amezcua-Guerra
- Department of Immunology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.,Department of Health Care, Universidad Autónoma Metropolitana-Xochimilco, Mexico City, Mexico
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Karpov AA, Vaulina DD, Smirnov SS, Moiseeva OM, Galagudza MM. Rodent models of pulmonary embolism and chronic thromboembolic pulmonary hypertension. Heliyon 2022; 8:e09014. [PMID: 35295664 PMCID: PMC8919224 DOI: 10.1016/j.heliyon.2022.e09014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/06/2021] [Accepted: 02/21/2022] [Indexed: 11/26/2022] Open
Abstract
Pulmonary embolism (PE) is the third most prevalent cardiovascular disease. It is associated with high in-hospital mortality and the development of acute and chronic complications. New approaches aimed at improving the prognosis of patients with PE are largely dependent on reliable animal models. Mice, rats, hamsters, and rabbits, are currently most commonly used for PE modeling because of their ethical acceptability and economic feasibility. This article provides an overview of the main approaches to PE modeling, and the advantages and disadvantages of each method. Special attention is paid to experimental endpoints, including morphological, functional, and molecular endpoints. All approaches to PE modeling can be broadly divided into three main groups: 1) induction of thromboembolism, either by thrombus formation in vivo or by injection of in vitro prepared blood clots; 2) introduction of particles of non-thrombotic origin; and 3) surgical procedures. The choice of a specific model and animal species is determined based on the objectives of the study. Rodent models of chronic thromboembolic pulmonary hypertension (CTEPH), which is the most devastating complication of PE, are also described. CTEPH models are especially challenging because of insufficient knowledge about the pathogenesis and high fibrinolytic activity of rodent plasma. The CTEPH model should demonstrate a persistent increase in pulmonary artery pressure and stable reduction of the vascular bed due to recurrent embolism. Based on the analysis of available evidence, one might conclude that currently, there is no single optimal method for modeling PE and CTEPH.
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Zagorski J, Neto‐Neves E, Alves NJ, Fisher AJ, Kline JA. Modulation of soluble guanylate cyclase ameliorates pulmonary hypertension in a rat model of chronic thromboembolic pulmonary hypertension by stimulating angiogenesis. Physiol Rep 2022; 10:e15156. [PMID: 35001565 PMCID: PMC8743875 DOI: 10.14814/phy2.15156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 04/15/2023] Open
Abstract
Acute pulmonary embolism (PE) does not always resolve after treatment and can progress to chronic thromboembolic disease (CTED) or the more severe chronic thromboembolic pulmonary hypertension (CTEPH). The mechanisms surrounding the likelihood of PE resolution or progress to CTED/CTEPH remain largely unknown. We have developed a rat model of CTEPH that closely resembles the human disease in terms of hemodynamics and cardiac manifestations. Embolization of rats with polystyrene microspheres followed by suppression of angiogenesis with the inhibitor of vascular endothelial growth factor receptor 2 (VEGF-R2) SU5416 results in transient, acute pulmonary hypertension that progresses into chronic PE with PH with sustained right ventricular systolic pressures exceeding 70 mmHg (chronic pulmonary embolism [CPE] model). This model is similar to the widely utilized hypoxia/SU5416 model with the exception that the "first hit" is PE. Rats with CPE have impaired right heart function characterized by reduced VO2 Max, reduced cardiac output, and increased Fulton index. None of these metrics are adversely affected by PE alone. Contrast-mediated CT imaging of lungs from rats with PE minus SU5416 show large increases in pulmonary vascular volume, presumably due to an angiogenic response to acute PE/PH. Co-treatment with SU5416 suppresses angiogenesis and produces the CTEPH-like phenotype. We report here that treatment of CPE rats with agonists for soluble guanylate cyclase, a source of cGMP which is in turn a signal for angiogenesis, markedly increases angiogenesis in lungs, and ameliorates the cardiac deficiencies in the CPE model. These results have implications for future development of therapies for human CTEPH.
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Affiliation(s)
- John Zagorski
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Present address:
Department of MedicineIndiana University School of MedicineRiley R2 435, 950 W. Walnut St.IndianapolisIndiana46202USA
| | - Evandro Neto‐Neves
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Present address:
Department of PharmacologyRiberiao Proto Medical SchoolUniversity of San PauloSau PauloBrazil
| | - Nathan J. Alves
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Amanda J. Fisher
- Department of AnesthesiaIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jeffrey A. Kline
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
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Zhang Y, Tang S, Yang W, Du F. let-7b-5p suppresses the proliferation and migration of pulmonary artery smooth muscle cells via down-regulating IGF1. Clinics (Sao Paulo) 2022; 77:100051. [PMID: 35636162 PMCID: PMC9156868 DOI: 10.1016/j.clinsp.2022.100051] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/12/2022] [Accepted: 05/06/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Some previous studies indicated that the excessive proliferation and migration of Pulmonary Artery Smooth Muscle Cells (PASMCs) could be observed in pulmonary artery intima after Pulmonary Embolism (PE) occurred. In addition, recent studies identified some miRNAs that are differentially expressed in the blood of PE patients, which might be used as a diagnostic biomarker for PE, including let-7a-5p, let-7b-5p, and miR-150-5p. Hence, the authors sought to explore the effects of let-7b-5p in PASMC proliferation and migration and the corresponding regulatory mechanism. METHODS Platelet-Derived Growth Factor (PDGF) was utilized to induce the hyper-proliferation model in PASMCs. The mRNA and protein expression levels were detected by RT-qPCR and western blot, respectively. The proliferation of PASMCs was evaluated by the detection of PCNA expression, as well as CCK-8 and Edu assays. Wound healing and Transwell assays were exploited to assess the migration ability of PASMCs. The targets of let-7b-5p were predicted based on two bioinformatics online tools. Dual-luciferase and Ago2 pull-down assays were applied to confirm the interaction between let-7b-5p and IGF1. RESULTS 40 ng/mL PDGF was selected as the optimal concentration to induce PASMCs. let-7b-5p mimics suppressed the proliferation and migration of PDGF-induced PASMCs, while let-7b-5p inhibitor led to the opposite result. In further mechanism exploration, IGF1 was predicted and confirmed as the direct target gene of let-7b-5p. The promotion role of IGF1 overexpression on the proliferation and migration of PDGF-induced PASMCs was dramatically countered by let-7b-5p mimics. CONCLUSION let-7b-5p prohibits the proliferation and migration of PDGF-induced PASMCs by modulating IGF1.
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Affiliation(s)
- Yadi Zhang
- Department of Respiratory Medicine, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230011, China
| | - Sihui Tang
- Department of Respiratory Medicine, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230011, China
| | - Wanchun Yang
- Department of Respiratory Medicine, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230011, China
| | - Fangbing Du
- Department of Respiratory Medicine, The Second People's Hospital of Hefei, Hefei Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230011, China.
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Bian H, Han N, Wang L, Wang X, Cho K, Yin J, Jiang B. Effects of Salvianolic Acid B/ginsenoside Rg1 Combination Against Chronic Pulmonary Embolism Induced by Polystyrene Microspheres. Folia Biol (Praha) 2021. [DOI: 10.3409/fb_69-4.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary embolism (PE) is the most life-threatening complication of venous thromboembolism, but few effective treatments have been discovered to attenuate chronic PE currently. In this study, we investigated the protective effects of salvianolic acid B (SalB) and ginsenoside Rg1 (Rg1)
combination (SalB/Rg1) on chronic PE and explored the potential mechanisms. The PE model was induced by 45 μm polystyrene microspheres and 20 mg/kg of SalB/Rg1 was administered to PE rats intraperitoneally. A histopathological analysis of the lungs and heart was performed through hematoxylin
and eosin staining and immunohistochemical analysis. The pulmonary index and right ventricular cardiomyocyte cross-sectional area were evaluated. SalB/Rg1 markedly downregulated pulmonary index, attenuated pulmonary interstitial changes, suppressed neutrophil infiltration, prevented collagen
deposition, and inhibited MMP-9 activities in the lung. We also found that SalB/Rg1 improved right ventricular hypertrophy accompanied by reducing the cardiomyocyte cross-sectional area. These data suggest that SalB/Rg1 played a protective role against microsphere-induced PE and holds a high
potential for the treatment of PE in the future.
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Affiliation(s)
- Huimiao Bian
- School of Traditional Chinese Material, Shenyang Pharmaceutical University, Shenyang, China
| | - Na Han
- School of Traditional Chinese Material, Shenyang Pharmaceutical University, Shenyang, China
| | - Linlin Wang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Xiaoyu Wang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Kenka Cho
- University of Medical and Health Care, Hanayashiki-Midorigaoka, Takarazuka, Japan
| | - Jun Yin
- School of Traditional Chinese Material, Shenyang Pharmaceutical University, Shenyang, China
| | - Baohong Jiang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
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James JL, Tongpob Y, Srinivasan V, Crew RC, Bappoo N, Doyle B, Gerneke D, Clark AR, Wyrwoll CS. Three-dimensional visualisation of the feto-placental vasculature in humans and rodents. Placenta 2021; 114:8-13. [PMID: 34418753 DOI: 10.1016/j.placenta.2021.08.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 11/19/2022]
Abstract
Adequate development of the feto-placental circulation is critical for placental exchange function and healthy fetal growth. Understanding the structure of this circulation and how it informs fetal outcomes is important both in the human placenta, and the rodent, a purported comparative experimental model. Vascular casting and micro-CT imaging approaches enable detailed quantification of the complex vascular relationships in the feto-circulation, and provide detailed data to parameterise in silico models. Here, to assist researchers to apply these technically challenging methods we provide detailed approaches to cast and image; 1) human placentas at the cotyledon-level, and 2) whole rodent placentas.
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Affiliation(s)
- J L James
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Y Tongpob
- School of Human Sciences, The University of Western Australia, Perth, WA, Australia; Faculty of Medical Science, Naresuan University, Phitsanulok, Thailand
| | - V Srinivasan
- Auckland Bioengineering Institute, University of Auckland, New Zealand
| | - R C Crew
- School of Human Sciences, The University of Western Australia, Perth, WA, Australia
| | - N Bappoo
- School of Human Sciences, The University of Western Australia, Perth, WA, Australia; Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre and the UWA Centre for Medical Research, The University of Western Australia, WA, Australia; School of Engineering, The University of Western Australia, Perth, WA, 6009, Australia
| | - B Doyle
- Vascular Engineering Laboratory, Harry Perkins Institute of Medical Research, QEII Medical Centre and the UWA Centre for Medical Research, The University of Western Australia, WA, Australia; School of Engineering, The University of Western Australia, Perth, WA, 6009, Australia; Australian Research Council Centre for Personalised Therapeutics Technologies, Australia; Centre for Cardiovascular Science, The University of Edinburgh, UK
| | - D Gerneke
- Auckland Bioengineering Institute, University of Auckland, New Zealand
| | - A R Clark
- Auckland Bioengineering Institute, University of Auckland, New Zealand
| | - C S Wyrwoll
- School of Human Sciences, The University of Western Australia, Perth, WA, Australia.
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Alba GA, Atri D, Darbha S, Singh I, Tapson VF, Lewis MI, Chun HJ, Yu YR, Maron BA, Rajagopal S. Chronic Thromboembolic Pulmonary Hypertension: the Bench. Curr Cardiol Rep 2021; 23:141. [PMID: 34410515 DOI: 10.1007/s11886-021-01572-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon complication of acute pulmonary embolism (PE), in which the red, platelet-rich thrombus does not resolve but forms into an organized yellow, fibrotic scar-like obstruction in the pulmonary vasculature. Here we review the pathobiology of CTEPH. RECENT FINDINGS Our current knowledge has predominantly been informed by studies of human samples and animal models that are inherently limited in their ability to recapitulate all aspects of the disease. These studies have identified alterations in platelet biology and inflammation in the formation of a scar-like thrombus that comprised endothelial cells, myofibroblasts, and immune cells, along with a small vessel pulmonary arterial hypertension-like vasculopathy. The development of CTEPH-specific therapies is currently hindered by a limited knowledge of its pathobiology. The development of new CTEPH medical therapies will require new insights into its pathobiology that bridge the gap from bench to bedside.
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Affiliation(s)
- George A Alba
- Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Deepak Atri
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sriranjani Darbha
- College of Natural Sciences, The University of Texas, Austin, TX, USA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael I Lewis
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hyung J Chun
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Cardiovascular Research Center, Yale School of Medicine, New Haven, CT, USA
| | - Yen-Rei Yu
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Section of Cardiology, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
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Dignam JP, Scott TE, Kemp-Harper BK, Hobbs AJ. Animal models of pulmonary hypertension: Getting to the heart of the problem. Br J Pharmacol 2021; 179:811-837. [PMID: 33724447 DOI: 10.1111/bph.15444] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022] Open
Abstract
Despite recent therapeutic advances, pulmonary hypertension (PH) remains a fatal disease due to the development of right ventricular (RV) failure. At present, no treatments targeted at the right ventricle are available, and RV function is not widely considered in the preclinical assessment of new therapeutics. Several small animal models are used in the study of PH, including the classic models of exposure to either hypoxia or monocrotaline, newer combinational and genetic models, and pulmonary artery banding, a surgical model of pure RV pressure overload. These models reproduce selected features of the structural remodelling and functional decline seen in patients and have provided valuable insight into the pathophysiology of RV failure. However, significant reversal of remodelling and improvement in RV function remains a therapeutic obstacle. Emerging animal models will provide a deeper understanding of the mechanisms governing the transition from adaptive remodelling to a failing right ventricle, aiding the hunt for druggable molecular targets.
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Affiliation(s)
- Joshua P Dignam
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tara E Scott
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia.,Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University Parkville Campus, Parkville, Victoria, Australia
| | - Barbara K Kemp-Harper
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Sztechman D, Żera T, Czarzasta K, Wojciechowska M, Szczepańska-Sadowska E, Cudnoch-Jędrzejewska A. Transthoracic echocardiography: from guidelines for humans to cardiac ultrasound of the heart in rats. Physiol Meas 2020; 41:10TR02. [PMID: 33164918 DOI: 10.1088/1361-6579/abb3a3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Ultrasound examination of the heart is a cornerstone of clinical evaluation of patients with established or suspected cardiovascular conditions. Advancements in ultrasound imaging technology have brought transthoracic echocardiography to preclinical murine models of cardiovascular diseases. The translational potential of cardiac ultrasound is critically important in rat models of myocardial infarction and ischemia-reperfusion injury, congestive heart failure, arterial hypertension, cardiac hypertrophy, pulmonary hypertension, right heart failure, Takotsubo cardiomyopathy, hypertrophic and dilated cardiomyopathies, developmental disorders, and metabolic syndrome. Modern echocardiographic machines capable of high-frame-rate image acquisition and fitted with high-frequency transducers allow for cardiac ultrasound in rats that yields most of the echocardiographic measurements and indices recommended by international guidelines for cardiac ultrasound in human patients. Among them are dimensions of cardiac chambers and walls, indices of systolic and diastolic cardiac function, and valvular function. In addition, measurements of cardiac dimensions and ejection fraction can be significantly improved by intravenous administration of ultrasound enhancing agents (UEAs). In this article we discuss echocardiography in rats, describe a technique for minimally invasive intravenous administration of UEAs via the saphenous vein and present a step-by-step approach to cardiac ultrasound in rats.
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Affiliation(s)
- Dorota Sztechman
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Banacha 1B, 02-097 Warsaw, Poland
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Andersen A, van der Feen DE, Andersen S, Schultz JG, Hansmann G, Bogaard HJ. Animal models of right heart failure. Cardiovasc Diagn Ther 2020; 10:1561-1579. [PMID: 33224774 PMCID: PMC7666958 DOI: 10.21037/cdt-20-400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022]
Abstract
Right heart failure may be the ultimate cause of death in patients with acute or chronic pulmonary hypertension (PH). As PH is often secondary to other cardiovascular diseases, the treatment goal is to target the underlying disease. We do however know, that right heart failure is an independent risk factor, and therefore, treatments that improve right heart function may improve morbidity and mortality in patients with PH. There are no therapies that directly target and support the failing right heart and translation from therapies that improve left heart failure have been unsuccessful, with the exception of mineralocorticoid receptor antagonists. To understand the underlying pathophysiology of right heart failure and to aid in the development of new treatments we need solid animal models that mimic the pathophysiology of human disease. There are several available animal models of acute and chronic PH. They range from flow induced to pressure overload induced right heart failure and have been introduced in both small and large animals. When initiating new pre-clinical or basic research studies it is key to choose the right animal model to ensure successful translation to the clinical setting. Selecting the right animal model for the right study is hence important, but may be difficult due to the plethora of different models and local availability. In this review we provide an overview of the available animal models of acute and chronic right heart failure and discuss the strengths and limitations of the different models.
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Affiliation(s)
- Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Diederik E. van der Feen
- Center for Congenital Heart Diseases, University Medical Center Groningen, Groningen, The Netherlands
| | - Stine Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Harm Jan Bogaard
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Lahm T, Douglas IS, Archer SL, Bogaard HJ, Chesler NC, Haddad F, Hemnes AR, Kawut SM, Kline JA, Kolb TM, Mathai SC, Mercier O, Michelakis ED, Naeije R, Tuder RM, Ventetuolo CE, Vieillard-Baron A, Voelkel NF, Vonk-Noordegraaf A, Hassoun PM. Assessment of Right Ventricular Function in the Research Setting: Knowledge Gaps and Pathways Forward. An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2019; 198:e15-e43. [PMID: 30109950 DOI: 10.1164/rccm.201806-1160st] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Right ventricular (RV) adaptation to acute and chronic pulmonary hypertensive syndromes is a significant determinant of short- and long-term outcomes. Although remarkable progress has been made in the understanding of RV function and failure since the meeting of the NIH Working Group on Cellular and Molecular Mechanisms of Right Heart Failure in 2005, significant gaps remain at many levels in the understanding of cellular and molecular mechanisms of RV responses to pressure and volume overload, in the validation of diagnostic modalities, and in the development of evidence-based therapies. METHODS A multidisciplinary working group of 20 international experts from the American Thoracic Society Assemblies on Pulmonary Circulation and Critical Care, as well as external content experts, reviewed the literature, identified important knowledge gaps, and provided recommendations. RESULTS This document reviews the knowledge in the field of RV failure, identifies and prioritizes the most pertinent research gaps, and provides a prioritized pathway for addressing these preclinical and clinical questions. The group identified knowledge gaps and research opportunities in three major topic areas: 1) optimizing the methodology to assess RV function in acute and chronic conditions in preclinical models, human studies, and clinical trials; 2) analyzing advanced RV hemodynamic parameters at rest and in response to exercise; and 3) deciphering the underlying molecular and pathogenic mechanisms of RV function and failure in diverse pulmonary hypertension syndromes. CONCLUSIONS This statement provides a roadmap to further advance the state of knowledge, with the ultimate goal of developing RV-targeted therapies for patients with RV failure of any etiology.
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15
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Neto-Neves EM, Pinheiro LC, Nogueira RC, Portella RL, Batista RI, Tanus-Santos JE. Sodium nitrite improves hypertension-induced myocardial dysfunction by mechanisms involving cardiac S-nitrosylation. J Mol Cell Cardiol 2019; 134:40-50. [DOI: 10.1016/j.yjmcc.2019.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 12/15/2022]
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16
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Wang M, Gu S, Liu Y, Yang Y, Yan J, Zhang X, An X, Gao J, Hu X, Su P. miRNA-PDGFRB/HIF1A-lncRNA CTEPHA1 Network Plays Important Roles in the Mechanism of Chronic Thromboembolic Pulmonary Hypertension. Int Heart J 2019; 60:924-937. [DOI: 10.1536/ihj.18-479] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Maozhou Wang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Song Gu
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Yan Liu
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Yuanhua Yang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Jun Yan
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Xitao Zhang
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Xiangguang An
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Jie Gao
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Xiaowei Hu
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
| | - Pixiong Su
- Heart Center & Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University
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17
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Mulchrone A, Kellihan HB, Forouzan O, Hacker TA, Bates ML, Francois CJ, Chesler NC. A Large Animal Model of Right Ventricular Failure due to Chronic Thromboembolic Pulmonary Hypertension: A Focus on Function. Front Cardiovasc Med 2019; 5:189. [PMID: 30687717 PMCID: PMC6333696 DOI: 10.3389/fcvm.2018.00189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/13/2018] [Indexed: 11/13/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a debilitating disease that progresses to right ventricular (RV) failure and death if left untreated. Little is known regarding the progression of RV failure in this disease, greatly limiting effective prognoses, and therapeutic interventions. Large animal models enable the use of clinical techniques and technologies to assess progression and diagnose failure, but the existing large animal models of CTEPH have not been shown to replicate the functional consequences of the RV, i.e., RV failure. Here, we created a canine embolization model of CTEPH utilizing only microsphere injections, and we used a combination of right heart catheterization (RHC), echocardiography (echo), and magnetic resonance imaging (MRI) to quantify RV function. Over the course of several months, CTEPH led to a 6-fold increase in pulmonary vascular resistance (PVR) in four adult, male beagles. As evidenced by decreased cardiac index (0.12 ± 0.01 v. 0.07 ± 0.01 [L/(min*kg)]; p < 0.05), ejection fraction (0.48 ± 0.02 v. 0.31 ± 0.02; p < 0.05), and ventricular-vascular coupling ratio (0.95 ± 0.09 v. 0.45 ± 0.05; p < 0.05), as well as decreased tricuspid annular plane systolic excursion (TAPSE) (1.37 ± 0.06 v. 0.86 ± 0.05 [cm]; p < 0.05) and increased end-diastolic volume index (2.73 ± 0.06 v. 2.98 ± 0.02 [mL/kg]; p < 0.05), the model caused RV failure. The ability of this large animal CTEPH model to replicate the hemodynamic consequences of the human disease suggests that it could be utilized for future studies to gain insight into the pathophysiology of CTEPH development, following further optimization.
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Affiliation(s)
- Ashley Mulchrone
- Department of Biomedical Engineering, Univeristy of Wisconsin-Madison, Madison, WI, United States
| | - Heidi B Kellihan
- School of Veterinary Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Omid Forouzan
- Department of Biomedical Engineering, Univeristy of Wisconsin-Madison, Madison, WI, United States
| | - Timothy A Hacker
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
| | - Melissa L Bates
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA, United States.,Department of Pediatrics, University of Iowa, Iowa City, IA, United States
| | | | - Naomi C Chesler
- Department of Biomedical Engineering, Univeristy of Wisconsin-Madison, Madison, WI, United States.,Department of Medicine, University of Wisconsin-Madison, Madison, WI, United States
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18
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Xiong PY, Potus F, Chan W, Archer SL. Models and Molecular Mechanisms of World Health Organization Group 2 to 4 Pulmonary Hypertension. Hypertension 2018; 71:34-55. [PMID: 29158355 PMCID: PMC5777609 DOI: 10.1161/hypertensionaha.117.08824] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Ping Yu Xiong
- From the Department of Medicine and Queen's Cardiopulmonary Unit (QCPU) (P.Y.X., F.P., W.C., S.L.A.) and Biomedical and Molecular Sciences (P.Y.X.), Queen's University, Kingston, Ontario, Canada
| | - Francois Potus
- From the Department of Medicine and Queen's Cardiopulmonary Unit (QCPU) (P.Y.X., F.P., W.C., S.L.A.) and Biomedical and Molecular Sciences (P.Y.X.), Queen's University, Kingston, Ontario, Canada
| | - Winnie Chan
- From the Department of Medicine and Queen's Cardiopulmonary Unit (QCPU) (P.Y.X., F.P., W.C., S.L.A.) and Biomedical and Molecular Sciences (P.Y.X.), Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- From the Department of Medicine and Queen's Cardiopulmonary Unit (QCPU) (P.Y.X., F.P., W.C., S.L.A.) and Biomedical and Molecular Sciences (P.Y.X.), Queen's University, Kingston, Ontario, Canada.
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19
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Stam K, van Duin RWB, Uitterdijk A, Cai Z, Duncker DJ, Merkus D. Exercise facilitates early recognition of cardiac and vascular remodeling in chronic thromboembolic pulmonary hypertension in swine. Am J Physiol Heart Circ Physiol 2017; 314:H627-H642. [PMID: 29167118 DOI: 10.1152/ajpheart.00380.2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) develops in 4% of patients after pulmonary embolism and is accompanied by an impaired exercise tolerance, which is ascribed to the increased right ventricular (RV) afterload in combination with a ventilation/perfusion (V/Q) mismatch in the lungs. The present study aimed to investigate changes in arterial Po2 and hemodynamics in response to graded treadmill exercise during development and progression of CTEPH in a novel swine model. Swine were chronically instrumented and received multiple pulmonary embolisms by 1) microsphere infusion (Spheres) over 5 wk, 2) endothelial dysfunction by administration of the endothelial nitric oxide synthase inhibitor Nω-nitro-l-arginine methyl ester (L-NAME) for 7 wk, 3) combined pulmonary embolisms and endothelial dysfunction (L-NAME + Spheres), or 4) served as sham-operated controls (sham). After a 9 wk followup, embolization combined with endothelial dysfunction resulted in CTEPH, as evidenced by mean pulmonary artery pressures of 39.5 ± 5.1 vs. 19.1 ± 1.5 mmHg (Spheres, P < 0.001), 22.7 ± 2.0 mmHg (L-NAME, P < 0.001), and 20.1 ± 1.5 mmHg (sham, P < 0.001), and a decrease in arterial Po2 that was exacerbated during exercise, indicating V/Q mismatch. RV dysfunction was present after 5 wk of embolization, both at rest (trend toward increased RV end-systolic lumen area, P = 0.085, and decreased stroke volume index, P = 0.042) and during exercise (decreased stroke volume index vs. control, P = 0.040). With sustained pulmonary hypertension, RV hypertrophy (Fulton index P = 0.022) improved RV function at rest and during exercise, but this improvement was insufficient in CTEPH swine to result in an exercise-induced increase in cardiac index. In conclusion, embolization in combination with endothelial dysfunction results in CTEPH in swine. Exercise increased RV afterload, exacerbated the V/Q mismatch, and unmasked RV dysfunction. NEW & NOTEWORTHY Here, we present the first double-hit chronic thromboembolic pulmonary hypertension swine model. We show that embolization as well as endothelial dysfunction is required to induce sustained pulmonary hypertension, which is accompanied by altered exercise hemodynamics and an exacerbated ventilation/perfusion mismatch during exercise.
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Affiliation(s)
- Kelly Stam
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Richard W B van Duin
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - André Uitterdijk
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Zongye Cai
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Dirk J Duncker
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
| | - Daphne Merkus
- Experimental Cardiology, Department of Cardiology, Thoraxcenter, Cardiovascular Research Institute COEUR, Erasmus Medical Center Rotterdam , Rotterdam , The Netherlands
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20
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Neto-Neves EM, Frump AL, Vayl A, Kline JA, Lahm T. Isolated heart model demonstrates evidence of contractile and diastolic dysfunction in right ventricles from rats with sugen/hypoxia-induced pulmonary hypertension. Physiol Rep 2017; 5:5/19/e13438. [PMID: 29038355 PMCID: PMC5641930 DOI: 10.14814/phy2.13438] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/31/2017] [Accepted: 08/16/2017] [Indexed: 01/29/2023] Open
Abstract
Although extensively used for the study of left ventricular function, limited experience exists with the isolated heart model in the evaluation of right ventricular (RV) function. In particular, no published experience exists with this tool in sugen/hypoxia‐induced pulmonary hypertension (SuHx‐PH), a frequently used model of severe and progressive PH. We sought to characterize markers of RV contractile and diastolic function in SuHx‐PH and to establish their relationship with markers of maladaptive RV remodeling. Hearts were excised from anesthetized Sprague Dawley rats with or without SuHx‐PH and perfused via the aorta using a Langendorff preparation. We explored the Frank–Starling relationship of RV function (RV developed pressure, dP/dtmax, and dP/dtmin; all normalized to RV mass) by increasing RV end‐diastolic pressure (RVEDP) from 0 to 40 mmHg. Functional studies were complemented by quantification of RV pro‐apoptotic signaling (bcl2/bax), procontractile signaling (apelin), and stress response signaling (p38MAPK activation). Pearson's correlation analysis was performed for functional and biochemical parameters. SuHx‐RVs exhibited severe RV dysfunction with marked hypertrophy and decreased echocardiographic cardiac output. For any given RVEDP, SuHx‐RVs demonstrated less developed pressure and lower dP/dtmax, as well as less pronounced dP/dtmin, suggestive of decreased contractile and diastolic function. SuHx‐RVs exhibited decreased bcl2/bax ratios, apelin expression, and p38MAPK activation. Bcl2/bax and apelin RNA abundance correlated positively with RV developed pressure and dP/dtmax and negatively with dP/dtmin. p38MAPK activation correlated positively with RV developed pressure. We conclude that SuHx‐RVs exhibit severe contractile and diastolic dysfunction. Increased pro‐apoptotic signaling and attenuated procontractile and stress response signaling may contribute to these functional alterations.
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Affiliation(s)
- Evandro M Neto-Neves
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrea L Frump
- Department of Medicine, Division of Pulmonary, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alexandra Vayl
- Department of Medicine, Division of Pulmonary, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana .,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
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