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Tonko JB, Lambiase PD. Current and novel percutaneous epicardial access techniques for electrophysiological interventions: A comparison of procedural success and safety. J Cardiovasc Electrophysiol 2023; 34:2330-2341. [PMID: 37735956 DOI: 10.1111/jce.16069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/22/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023]
Abstract
Accessing the pericardial space safely and efficiently is an important skill for interventional cardiac electrophysiologist. With the increased recognition of the complexity of the 3-dimensional arrhythmogenic substrate due to advances in imaging and mapping technologies there has been an expansion of epicardial procedures in recent years. Equally, minimally invasive implantation of epicardial pacing, cardiac resynchronization, or defibrillation leads is expanding in specific patients where transvenous systems are contraindicated or their long term sequelae should be ideally avoided. Selective delivery of intrapericardial pharmacological antiarrhythmic therapy is yet another potential indication, albeit still investigational. The expanding indications for percutaneous epicardial procedures is contrasted by the still substantial risk and challenges associated with accessing the pericardial space. Myocardial perforation, coronary artery laceration, and damage to the surrounding organs are all recognized and feared complications. A number of innovative epicardial access techniques have been proposed to overcome the difficulties and risks of traditional dry subxiphoid punctures and may allow for more widespread use of epicardial access in the future. We review 10 different established and novel subxiphoidal epicardial access techniques describing procedural success rates, safety profile and overall experience. The technical aspects as well as access times and costs for extra equipment will be reviewed. Finally, an outlook of reported preclinical techniques awaiting in-human feasibility studies is provided.
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Affiliation(s)
- Johanna B Tonko
- Institute for Cardiovascular Science, University College London, London, UK
| | - Pier D Lambiase
- Institute for Cardiovascular Science, University College London, London, UK
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2
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Saljic A, Heijman J, Dobrev D. Recent Advances in Antiarrhythmic Drug Therapy. Drugs 2023; 83:1147-1160. [PMID: 37540446 PMCID: PMC10462572 DOI: 10.1007/s40265-023-01923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/05/2023]
Abstract
Cardiac arrhythmias remain a common cause of death and disability. Antiarrhythmic drugs (AADs) and antiarrhythmic agents remain a cornerstone of current cardiac arrhythmia management, despite moderate efficacy and the potential for significant adverse proarrhythmic effects. Due to conceptual, regulatory and financial considerations, the number of novel antiarrhythmic targets and agents in the development pipeline has decreased substantially during the last few decades. However, several promising candidates remain and there are exciting developments in repurposing and reformulating already existing drugs for indications related to cardiac arrhythmias. This review discusses the key conceptual considerations for the development of new antiarrhythmic agents, summarizes new compounds and formulations currently in clinical development for rhythm control of atrial fibrillation, and highlights the potential for drug repurposing. Finally, future directions in AAD development are discussed. Together with an ever-increasing understanding of the molecular mechanisms underlying cardiac arrhythmias, these components support a cautiously optimistic outlook towards improved pharmacological treatment opportunities for patients suffering from cardiac arrhythmias.
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Affiliation(s)
- Arnela Saljic
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Jordi Heijman
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Dobromir Dobrev
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Montréal Heart Institute and University de Montréal, Medicine and Research Center, Montréal, Canada.
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, USA.
- , Hufelandstrasse 55, 45122, Essen, Germany.
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Zahid M, Weber B, Yurko R, Islam K, Agrawal V, Lopuszynski J, Yagi H, Salama G. Cardiomyocyte-Targeting Peptide to Deliver Amiodarone. Pharmaceutics 2023; 15:2107. [PMID: 37631321 PMCID: PMC10459552 DOI: 10.3390/pharmaceutics15082107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Amiodarone is underutilized due to significant off-target toxicities. We hypothesized that targeted delivery to the heart would lead to the lowering of the dose by utilizing a cardiomyocyte-targeting peptide (CTP), a cell-penetrating peptide identified by our prior phage display work. METHODS CTP was synthesized thiolated at the N-terminus, conjugated to amiodarone via Schiff base chemistry, HPLC purified, and confirmed with MALDI/TOF. The stability of the conjugate was assessed using serial HPLCs. Guinea pigs (GP) were injected intraperitoneally daily with vehicle (7 days), amiodarone (7 days; 80 mg/kg), CTP-amiodarone (5 days; 26.3 mg/kg), or CTP (5 days; 17.8 mg/kg), after which the GPs were euthanized, and the hearts were excised and perfused on a Langendorff apparatus with Tyrode's solution and blebbistatin (5 µM) to minimize the contractions. Voltage (RH237) and Ca2+-indicator dye (Rhod-2/AM) were injected, and fluorescence from the epicardium split and was captured by two cameras at 570-595 nm for the cytosolic Ca2+ and 610-750 nm wavelengths for the voltage. Subsequently, the hearts were paced at 250 ms with programmed stimulation to measure the changes in the conduction velocities (CV), action potential duration (APD), and Ca2+ transient durations at 90% recovery (CaTD90). mRNA was extracted from all hearts, and RNA sequencing was performed with results compared to the control hearts. RESULTS The CTP-amiodarone remained stable for up to 21 days at 37 °C. At ~1/15th of the dose of amiodarone, the CTP-amiodarone decreased the CV in hearts significantly compared to the control GPs (0.92 ± 0.05 vs. 1.00 ± 0.03 ms, p = 0.0007), equivalent to amiodarone alone (0.87 ± 0.08 ms, p = 0.0003). Amiodarone increased the APD (192 ± 5 ms vs. 175 ± 8 ms for vehicle, p = 0.0025), while CTP-amiodarone decreased it significantly (157 ± 16 ms, p = 0.0136), similar to CTP alone (155 ± 13 ms, p = 0.0039). Both amiodarone and CTP-amiodarone significantly decreased the calcium transients compared to the controls. CTP-amiodarone and CTP decreased the CaTD90 to an extent greater than amiodarone alone (p < 0.001). RNA-seq showed that CTP alone increased the expression of DHPR and SERCA2a, while it decreased the expression of the proinflammatory genes, NF-kappa B, TNF-α, IL-1β, and IL-6. CONCLUSIONS Our data suggest that CTP can deliver amiodarone to cardiomyocytes at ~1/15th the total molar dose of the amiodarone needed to produce a comparable slowing of CVs. The ability of CTP to decrease the AP durations and CaTD90 may be related to its increase in the expression of Ca-handling genes, which merits further study.
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Affiliation(s)
- Maliha Zahid
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA;
| | - Beth Weber
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (B.W.); (G.S.)
| | - Ray Yurko
- Peptide Synthesis Facility, University of Pittsburgh, Pittsburgh, PA 15219, USA; (R.Y.); (K.I.)
| | - Kazi Islam
- Peptide Synthesis Facility, University of Pittsburgh, Pittsburgh, PA 15219, USA; (R.Y.); (K.I.)
| | - Vaishavi Agrawal
- Dietrich School of Arts and Sciences, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Jack Lopuszynski
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA;
| | - Hisato Yagi
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA 15201, USA;
| | - Guy Salama
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (B.W.); (G.S.)
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Zahid M, Weber B, Yurko R, Islam K, Agrawal V, Lopuszynski J, Yagi H, Salama G. Cardiomyocyte Targeting Peptide to Deliver Amiodarone. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.10.540206. [PMID: 37214919 PMCID: PMC10197706 DOI: 10.1101/2023.05.10.540206] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Background Amiodarone is underutilized due to significant off-target toxicities. We hypothesized that targeted delivery to the heart would lead to lowering of dose by utilizing a cardiomyocyte targeting peptide (CTP), a cell penetrating peptide identified by our prior phage display work. Methods CTP was synthesized thiolated at the N-terminus, conjugated to amiodarone via Schiff base chemistry, HPLC purified and confirmed with MALDI/TOF. Stability of the conjugate was assessed using serial HPLCs. Guinea pigs (GP) were injected intraperitoneally daily with vehicle (7 days), amiodarone (7 days; 80mg/Kg), CTP-amiodarone (5 days;26.3mg/Kg), or CTP (5 days; 17.8mg/Kg), after which GPs were euthanized, hearts excised, perfused on a Langendorff apparatus with Tyrode's solution and blebbistatin (5μM) to minimize contractions. Voltage (RH237) and Ca 2+ -indicator dye (Rhod-2/AM) were injected, fluorescence from the epicardium split and focused on two cameras capturing at 570-595nm for cytosolic Ca 2+ and 610-750nm wavelengths for voltage. Subsequently, hearts were paced at 250ms with programmed stimulation to measure changes in conduction velocities (CV), action potential duration (APD) and Ca 2+ transient durations at 90% recovery (CaTD 90 ). mRNA was extracted from all hearts and RNA sequencing performed with results compared to control hearts. Results CTP-amiodarone remained stable for up to 21 days at 37°C. At ∼1/15 th of the dose of amiodarone, CTP-amiodarone decreased CV in hearts significantly compared to control GPs (0.92±0.05 vs. 1.00±0.03m/s, p=0.0007), equivalent to amiodarone alone (0.87±0.08ms, p=0.0003). Amiodarone increased APD (192±5ms vs. 175±8ms for vehicle, p=0.0025), while CTP-amiodarone decreased it significantly (157±16ms, p=0.0136) similar to CTP alone (155±13ms, p=0.0039). Both amiodarone and CTP-amiodarone significantly decreased calcium transients compared to controls. CTP-amiodarone and CTP decreased CaTD 90 to an extent greater than amiodarone alone (p<0.001). RNA-seq showed that CTP alone increased the expression of DHPR and SERCA2a, while decreasing expression of proinflammatory genes NF-kappa B, TNF-α, IL-1β, and IL-6. Conclusions Our data suggests that CTP can deliver amiodarone to cardiomyocytes at ∼1/15 th the total molar dose of amiodarone needed to produce comparable slowing of CVs. The ability of CTP to decrease AP durations and CaTD 90 may be related to its increase in expression of Ca-handling genes, and merits further study.
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Affiliation(s)
- Maliha Zahid
- Dept. of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Beth Weber
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute and Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ray Yurko
- Peptide Synthesis Facility, University of Pittsburgh, Pittsburgh, PA
| | - Kazi Islam
- Peptide Synthesis Facility, University of Pittsburgh, Pittsburgh, PA
| | - Vaishavi Agrawal
- Dietrich School of Arts and Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Jack Lopuszynski
- Burnett School of Biomedical Sciences, University of Central Florida, Orlando, FL
| | - Hisato Yagi
- Dept. of Developmental Biology, University of Pittsburgh, Pittsburgh, PA
| | - Guy Salama
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute and Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Chen X, Sartor C, Zhang S, Baranchuk A, Ross-White A, Fernandez AL, El-Diasty M. Effectiveness of intra-operative topical amiodarone for prevention of postcardiac surgery new-onset atrial fibrillation: A review of current evidence. J Card Surg 2022; 37:5371-5378. [PMID: 36403267 DOI: 10.1111/jocs.17190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/29/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery and is associated with increased morbidity. Intraoperative topical amiodarone application on epicardial tissue has been shown to reduce systemic concentrations while maintaining therapeutic myocardial concentrations, thereby, lowering the risk of extracardiac adverse effects associated with oral and intravenous amiodarone therapy. However, the efficacy and safety of topical amiodarone in preventing POAF is unclear. OBJECTIVES This study summarizes the clinical studies to-date that have investigated the efficacy and safety of topical amiodarone administration in preventing POAF following cardiac surgery. METHODS A database search was conducted using Medline, Embase, and Cochrane Library to identify relevant studies. Abstracts were screened and data were extracted from relevant full-text articles that met the inclusion and exclusion criteria. RESULTS The search returned four studies with variable findings on the effect of topical amiodarone therapy on the incidence of POAF, cardiac effects, extracardiac effects, and hospital length of stay. CONCLUSION Prophylactic topical application of amiodarone may be effective and safe for preventing post-operative new-onset atrial fibrillation. Further investigation is required to evaluate the efficacy and safety of topical amiodadrone therapy before it can be widely integrated into current practice.
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Affiliation(s)
- Xingyu Chen
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Cam Sartor
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Shetuan Zhang
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Amanda Ross-White
- Queen's University Library, Queen's University, Kingston, Ontario, Canada
| | | | - Mohammad El-Diasty
- Cardiac Surgery Department, Queen's University, Kingston, Ontario, Canada
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Filgueira CS, Igo SR, Wang DK, Hirsch M, Schulz DG, Bruckner BA, Grattoni A. Technologies for intrapericardial delivery of therapeutics and cells. Adv Drug Deliv Rev 2019; 151-152:222-232. [PMID: 30797957 DOI: 10.1016/j.addr.2019.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/13/2019] [Accepted: 02/15/2019] [Indexed: 12/12/2022]
Abstract
The pericardium, which surrounds the heart, provides a unique enclosed volume and a site for the delivery of agents to the heart and coronary arteries. While strategies for targeting the delivery of therapeutics to the heart are lacking, various technologies and nanodelivery approaches are emerging as promising methods for site specific delivery to increase therapeutic myocardial retention, efficacy, and bioactivity, while decreasing undesired systemic effects. Here, we provide a literature review of various approaches for intrapericardial delivery of agents. Emphasis is given to sustained delivery approaches (pumps and catheters) and localized release (patches, drug eluting stents, and support devices and meshes). Further, minimally invasive access techniques, pericardial access devices, pericardial washout and fluid analysis, as well as therapeutic and cell delivery vehicles are presented. Finally, several promising new therapeutic targets to treat heart diseases are highlighted.
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Maslov M, Foianini S, Lovich M. Delivery of drugs, growth factors, genes and stem cells via intrapericardial, epicardial and intramyocardial routes for sustained local targeted therapy of myocardial disease. Expert Opin Drug Deliv 2017; 14:1227-1239. [PMID: 28276968 DOI: 10.1080/17425247.2017.1292249] [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] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Local myocardial delivery (LMD) of therapeutic agents is a promising strategy that aims to treat various myocardial pathologies. It is designed to deliver agents directly to the myocardium and minimize their extracardiac concentrations and side effects. LMD aims to enhance outcomes of existing therapies by broadening their therapeutic window and to utilize new agents that could not be otherwise be implemented systemically. Areas covered: This article provides a historical overview of six decades LMD evolution in terms of the approaches, including intrapericardial, epicardial, and intramyocardial delivery, and the wide array of classes of agents used to treat myocardial pathologies. We examines delivery of pharmaceutical compounds, targeted gene transfection and cell implantation techniques to produce therapeutic effects locally. We outline therapeutic indications, successes and failures as well as technical approaches for LMD. Expert opinion: While LMD is more complicated than conventional oral or intravenous administration, given recent advances in interventional cardiology, it is safe and may provide better therapeutic outcomes. LMD is complex as many factors impact pharmacokinetics and biologic result. The choice between routes of LMD is largely driven not only by the myocardial pathology but also by the nature and physicochemical properties of the therapeutic agents.
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Affiliation(s)
- Mikhail Maslov
- a Department of Anesthesiology, Pain Medicine and Critical Care , Steward St. Elizabeth's Medical Center/Tufts University School of Medicine , Boston , MA , USA
| | - Stephan Foianini
- a Department of Anesthesiology, Pain Medicine and Critical Care , Steward St. Elizabeth's Medical Center/Tufts University School of Medicine , Boston , MA , USA
| | - Mark Lovich
- a Department of Anesthesiology, Pain Medicine and Critical Care , Steward St. Elizabeth's Medical Center/Tufts University School of Medicine , Boston , MA , USA
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Robinson E, Kaushal S, Alaboson J, Sharma S, Belagodu A, Watkins C, Walker B, Webster G, McCarthy P, Ho D. Combinatorial release of dexamethasone and amiodarone from a nano-structured parylene-C film to reduce perioperative inflammation and atrial fibrillation. NANOSCALE 2016; 8:4267-4275. [PMID: 26838117 DOI: 10.1039/c5nr07456h] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Suppressing perioperative inflammation and post-operative atrial fibrillation requires effective drug delivery platforms (DDP). Localized anti-inflammatory and anti-arrhythmic agent release may be more effective than intravenous treatment to improve patient outcomes. This study utilized a dexamethasone (DEX) and amiodarone (AMIO)-loaded Parylene-C (PPX) nano-structured film to inhibit inflammation and atrial fibrillation. The PPX film was tested in an established pericardial adhesion rabbit model. Following sternotomy, the anterior pericardium was resected and the epicardium was abraded. Rabbits were randomly assigned to five treatment groups: control, oxidized PPX (PPX-Oxd), PPX-Oxd infused with DEX (PPX-Oxd[DEX]), native PPX (PPX), and PPX infused with DEX and AMIO (PPX[AMIO, DEX]). 4 weeks post-sternotomy, pericardial adhesions were evaluated for gross adhesions using a 4-point grading system and histological evaluation for epicardial neotissue fibrosis (NTF). Atrial fibrillation duration and time per induction were measured. The PPX[AMIO, DEX] group had a significant reduction in mean adhesion score compared with the control group (control 2.75 ± 0.42 vs. PPX[AMIO, DEX] 0.25 ± 0.42, P < 0.001). The PPX[AMIO, DEX] group was similar to native PPX (PPX 0.38 ± 0.48 vs. PPX[AMIO, DEX] 0.25 ± 0.42, P=NS). PPX-Oxd group adhesions were indistinguishable from controls (PPX-Oxd 2.83 ± 0.41 vs. control 2.75 ± 0.42, P=NS). NTF was reduced in the PPX[AMIO, DEX] group (0.80 ± 0.10 mm) compared to control (1.78 ± 0.13 mm, P < 0.001). Total duration of atrial fibrillation was decreased in rabbits with PPX[AMIO, DEX] films compared to control (9.5 ± 6.8 s vs. 187.6 ± 174.7 s, p = 0.003). Time of atrial fibrillation per successful induction decreased among PPX[AMIO, DEX] films compared to control (2.8 ± 1.2 s vs. 103.2 ± 178 s, p = 0.004). DEX/AMIO-loaded PPX films are associated with reduced perioperative inflammation and a diminished atrial fibrillation duration. Epicardial application of AMIO, DEX films is a promising strategy to prevent post-operative cardiac complications.
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Affiliation(s)
- Erik Robinson
- Department of Mechanical Engineering, Northwestern University, Evanston, Illinois 60208, USA.
| | - Sunjay Kaushal
- Division of Pediatric Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Justice Alaboson
- Department of Material Science and Engineering, Northwestern University, Evanston, Illinois 60208, USA
| | - Sudhish Sharma
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Amogh Belagodu
- Department of Chemical & Biological Engineering, Northwestern University, Evanston, Illinois 60208, USA
| | - Claire Watkins
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Brandon Walker
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Gregory Webster
- Division of Cardiology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Patrick McCarthy
- Division of Cardiac Surgery, the Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | - Dean Ho
- Department of Mechanical Engineering, Northwestern University, Evanston, Illinois 60208, USA. and Department of Biomedical Engineering, Northwestern University, Evanston, Illinois 60208, USA and Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois 60611, USA
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Habbab LM, Chu FV. Intrapericardial Amiodarone for the Prevention of Postoperative Atrial Fibrillation. J Card Surg 2016; 31:253-8. [DOI: 10.1111/jocs.12700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Louay M. Habbab
- Division of Cardiac Surgery; Department of Surgery; Hamilton General Hospital; McMaster University; Hamilton Ontario Canada
| | - F. Victor Chu
- Division of Cardiac Surgery; Department of Surgery; Hamilton General Hospital; McMaster University; Hamilton Ontario Canada
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Atrial overexpression of angiotensin-converting enzyme 2 improves the canine rapid atrial pacing-induced structural and electrical remodeling. Fan, ACE2 improves atrial substrate remodeling. Basic Res Cardiol 2015; 110:45. [PMID: 26143546 PMCID: PMC7101981 DOI: 10.1007/s00395-015-0499-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 05/17/2015] [Accepted: 05/26/2015] [Indexed: 01/30/2023]
Abstract
The purpose of this study was to investigate whether atrial overexpression of angiotensin-converting enzyme 2 (ACE2) by homogeneous transmural atrial gene transfer can reverse atrial remodeling and its mechanisms in a canine atrial-pacing model. Twenty-eight mongrel dogs were randomly divided into four groups: Sham-operated, AF-control, gene therapy with adenovirus-enhanced green fluorescent protein (Ad-EGFP) and gene therapy with Ad-ACE2 (Ad-ACE2) (n = 7 per subgroup). AF was induced in all dogs except the Sham-operated group by rapid atrial pacing at 450 beats/min for 2 weeks. Ad-EGFP and Ad-ACE2 group then received epicardial gene painting. Three weeks after gene transfer, all animals except the Sham group underwent rapid atrial pacing for another 3 weeks and then invasive electrophysiological, histological and molecular studies. The Ad-ACE2 group showed an increased ACE2 and Angiotensin-(1–7) expression, and decreased Angiotensin II expression in comparison with Ad-EGFP and AF-control group. ACE2 overexpression attenuated rapid atrial pacing-induced increase in activated extracellular signal-regulated kinases and mitogen-activated protein kinases (MAPKs) levels, and decrease in MAPK phosphatase 1(MKP-1) level, resulting in attenuation of atrial fibrosis collagen protein markers and transforming growth factor-β1. Additionally, ACE2 overexpression also modulated the tachypacing-induced up-regulation of connexin 40, down-regulation of connexin 43 and Kv4.2, and significantly decreased the inducibility and duration of AF. ACE2 overexpression could shift the renin–angiotensin system balance towards the protective axis, attenuate cardiac fibrosis remodeling associated with up-regulation of MKP-1 and reduction of MAPKs activities, modulate tachypacing-induced ion channels and connexin remodeling, and subsequently reduce the inducibility and duration of AF.
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11
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Myocardial drug distribution generated from local epicardial application: potential impact of cardiac capillary perfusion in a swine model using epinephrine. J Control Release 2014; 194:257-65. [PMID: 25234821 DOI: 10.1016/j.jconrel.2014.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/25/2014] [Accepted: 09/06/2014] [Indexed: 01/27/2023]
Abstract
Prior studies in small mammals have shown that local epicardial application of inotropic compounds drives myocardial contractility without systemic side effects. Myocardial capillary blood flow, however, may be more significant in larger species than in small animals. We hypothesized that bulk perfusion in capillary beds of the large mammalian heart not only enhances drug distribution after local release, but also clears more drug from the tissue target than in small animals. Epicardial (EC) drug releasing systems were used to apply epinephrine to the anterior surface of the left heart of swine in either point-sourced or distributed configurations. Following local application or intravenous (IV) infusion at the same dose rates, hemodynamic responses, epinephrine levels in the coronary sinus and systemic circulation, and drug deposition across the ventricular wall, around the circumference and down the axis, were measured. EC delivery via point-source release generated transmural epinephrine gradients directly beneath the site of application extending into the middle third of the myocardial thickness. Gradients in drug deposition were also observed down the length of the heart and around the circumference toward the lateral wall, but not the interventricular septum. These gradients extended further than might be predicted from simple diffusion. The circumferential distribution following local epinephrine delivery from a distributed source to the entire anterior wall drove drug toward the inferior wall, further than with point-source release, but again, not to the septum. This augmented drug distribution away from the release source, down the axis of the left ventricle, and selectively toward the left heart follows the direction of capillary perfusion away from the anterior descending and circumflex arteries, suggesting a role for the coronary circulation in determining local drug deposition and clearance. The dominant role of the coronary vasculature is further suggested by the elevated drug levels in the coronary sinus effluent. Indeed, plasma levels, hemodynamic responses, and myocardial deposition remote from the point of release were similar following local EC or IV delivery. Therefore, the coronary vasculature shapes the pharmacokinetics of local myocardial delivery of small catecholamine drugs in large animal models. Optimal design of epicardial drug delivery systems must consider the underlying bulk capillary perfusion currents within the tissue to deliver drug to tissue targets and may favor therapeutic molecules with better potential retention in myocardial tissue.
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12
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Beckerman Z, Azran A, Cohen O, Nir RR, Maessen JG, Bianco-Peled H, Bolotin G. A Novel Amiodarone-Eluting Biological Glue for Reducing Postoperative Atrial Fibrillation. J Cardiovasc Pharmacol Ther 2014; 19:481-91. [DOI: 10.1177/1074248414527640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, leading to increased morbidity and mortality. The aim of this preliminary study was to evaluate a novel drug delivery system for local release of amiodarone. Methods: In the current prospective study, 9 goats underwent attachment of right atrial (RA) epicardial electrodes. Alginate-based glue with amiodarone was applied to the RA of the treatment groups. Rapid atrial response (RAR) to burst pacing was assessed before application and in the third postoperative day (POD3). Average RAR frequency was defined as the average percentage of inductions resulting in RAR per animal. Myocardial and extracardiac tissue amiodarone concentrations were analyzed. Results: Differences in RAR proportions between baseline and POD3 were greater in the treatment group versus the control group ( P = .034). Average RAR frequency was reduced by 34% in the treatment group (baseline: 65%; POD3: 31%), while it was increased by 11.3% in the control (baseline:43.8%; POD3: 55%). The treatment group demonstrated a greater proportion of animals meeting the success criterion of net percentage reduction in RAR frequency greater than 25% ( P = .047). The average amount of total amiodarone detected in the RA was 104.4 ± 28.9 µg; the transmural concentration was linearly distributed ( P < .0001). Extracardiac tissue concentrations were below the detection level. Conclusions: Local alginate-based amiodarone delivery demonstrated an RAR frequency reduction of clinical importance in response to burst pacing. The electrophysiological response was achieved while maintaining below-detection systemic drug levels. Current findings may point to the system’s future applicability in reducing POAF risk in humans.
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Affiliation(s)
- Ziv Beckerman
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Adi Azran
- Chemical Engineering Department, Technion, Haifa, Israel
| | - Oved Cohen
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Rony-Reuven Nir
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Jos G. Maessen
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | | | - Gil Bolotin
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
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Maslov MY, Edelman ER, Wei AE, Pezone MJ, Lovich MA. High concentrations of drug in target tissues following local controlled release are utilized for both drug distribution and biologic effect: an example with epicardial inotropic drug delivery. J Control Release 2013; 171:201-7. [PMID: 23872515 DOI: 10.1016/j.jconrel.2013.06.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 06/28/2013] [Accepted: 06/29/2013] [Indexed: 12/16/2022]
Abstract
Local drug delivery preferentially loads target tissues with a concentration gradient from the surface or point of release that tapers down to more distant sites. Drug that diffuses down this gradient must be in unbound form, but such drug can only elicit a biologic effect through receptor interactions. Drug excess loads tissues, increasing gradients and driving penetration, but with limited added biological response. We examined the hypothesis that local application reduces dramatically systemic circulating drug levels but leads to significantly higher tissue drug concentration than might be needed with systemic infusion in a rat model of local epicardial inotropic therapy. Epinephrine was infused systemically or released locally to the anterior wall of the heart using a novel polymeric platform that provides steady, sustained release over a range of precise doses. Epinephrine tissue concentration, upregulation of cAMP, and global left ventricular response were measured at equivalent doses and at doses equally effective in raising indices of contractility. The contractile stimulation by epinephrine was linked to drug tissue levels and commensurate cAMP upregulation for IV systemic infusion, but not with local epicardial delivery. Though cAMP was a powerful predictor of contractility with local application, tissue epinephrine levels were high and variable--only a small fraction of the deposited epinephrine was utilized in second messenger signaling and biologic effect. The remainder of deposited drug was likely used in diffusive transport and distribution. Systemic side effects were far more profound with IV infusion which, though it increased contractility, also induced tachycardia and loss of systemic vascular resistance, which were not seen with local application. Local epicardial inotropic delivery illustrates then a paradigm of how target tissues differentially handle and utilize drug compared to systemic infusion.
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Affiliation(s)
- Mikhail Y Maslov
- Tufts University School of Medicine, Department of Anesthesiology and Pain Medicine, Steward St. Elizabeth's Medical Center, Boston, MA 02135, USA.
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