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Hu B, Tian T, Li XT, Hao PP, Liu WC, Chen YG, Jiang TY, Chen PS, Cheng Y, Xue FS. Dexmedetomidine postconditioning attenuates myocardial ischemia/reperfusion injury by activating the Nrf2/Sirt3/SOD2 signaling pathway in the rats. Redox Rep 2023; 28:2158526. [PMID: 36738240 PMCID: PMC9904316 DOI: 10.1080/13510002.2022.2158526] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To observe the protective effects of dexmedetomidine (Dex) postconditioning on myocardial ischemia/reperfusion injury (IRI) and to explore its potential molecular mechanisms. METHODS One-hundred forty-seven male Sprague-Dawley rats were randomly divided into five groups receiving the different treatments: Sham, ischemia/reperfusion (I/R), Dex, Brusatol, Dex + Brusatol. By the in vivo rat model of myocardial IRI, cardioprotective effects of Dex postconditioning were evaluated by assessing serum CK-MB and cTnI levels, myocardial HE and Tunel staining and infarct size. Furthermore, the oxidative stress-related markers including intracellular ROS level, myocardial tissue MDA level, SOD and GSH-PX activities were determined. RESULTS Dex postconditioning significantly alleviated myocardial IRI, decreased intracellular ROS and myocardial tissue MDA level, increased SOD and GSH-PX activities. Dex postconditioning significantly up-regulated myocardial expression of Bcl-2, down-regulated Bax and cleaved caspase-3 and decreased cardiomyocyte apoptosis rate. furthermores, Dex postconditioning promoted Nrf2 nuclear translocation, increased myocardial expression of Sirt3 and SOD2 and decreased Ac-SOD2. However, brusatol reversed cardioprotective benefits of Dex postconditioning, significantly decreased Dex-induced Nrf2 nuclear translocation and reduced myocardial expression of Sirt3 and SOD2. CONCLUSIONS Dex postconditioning can alleviate myocardial IRI by suppressing oxidative stress and apoptosis, and these beneficial effects are at least partly mediated by activating the Nrf2/Sirt3/SOD2 signaling pathway.
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Affiliation(s)
- Bin Hu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Tian Tian
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Xin-Tao Li
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Pei-Pei Hao
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei-Chao Liu
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ying-Gui Chen
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Tian-Yu Jiang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Pei-Shan Chen
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yi Cheng
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China, Yi Cheng ; Fu-Shan Xue ; Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-An Road, Xi-Cheng District, Beijing100050, People’s Republic of China
| | - Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China, Yi Cheng ; Fu-Shan Xue ; Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yong-An Road, Xi-Cheng District, Beijing100050, People’s Republic of China
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Li Z, Dai R, Chen M, Huang L, Zhu K, Li M, Zhu W, Li Y, Xie N, Li J, Wang L, Lan F, Cao CM. p55γ degrades RIP3 via MG53 to suppress ischaemia-induced myocardial necroptosis and mediates cardioprotection of preconditioning. Cardiovasc Res 2023; 119:2421-2440. [PMID: 37527538 DOI: 10.1093/cvr/cvad123] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 05/04/2023] [Accepted: 06/13/2023] [Indexed: 08/03/2023] Open
Abstract
AIMS Regulated necrosis (necroptosis) and apoptosis are important biological features of myocardial infarction, ischaemia-reperfusion (I/R) injury, and heart failure. However, the molecular mechanisms underlying myocardial necroptosis remain elusive. Ischaemic preconditioning (IPC) is the most powerful intrinsic cardioprotection against myocardial I/R injury. In this study, we aimed to determine whether IPC suppresses I/R-induced necroptosis and the underlying molecular mechanisms. METHODS AND RESULTS We generated p55γ transgenic and knockout mice and used ligation of left anterior descending coronary artery to produce an in vivo I/R model. The effects of p55γ and its downstream molecules were subsequently identified using mass spectroscopy and co-immunoprecipitation and pulldown assays. We found that p55γ expression was down-regulated in failing human myocardium caused by coronary heart disease as well as in I/R mouse hearts. Cardiac-specific p55γ overexpression ameliorated the I/R-induced necroptosis. In striking contrast, p55γ deficiency (p55γ-/-) and cardiac-specific deletion of p55γ (p55γc-KO) worsened I/R-induced injury. IPC up-regulated p55γ expression in vitro and in vivo. Using reporter and chromatin immunoprecipitation assays, we found that Hif1α transcriptionally regulated p55γ expression and mediated the cardioprotection of IPC. IPC-mediated suppression of necroptosis was attenuated in p55γ-/- and p55γc-KO hearts. Mechanistically, p55γ overexpression decreased the protein levels of RIP3 rather than the mRNA levels, while p55γ deficiency increased the protein abundance of RIP3. IPC attenuated the I/R-induced up-regulation of RIP3, which was abolished in p55γ-deficient mice. Up-regulation of RIP3 attenuated the p55γ- or IPC-induced inhibition of necroptosis in vivo. Importantly, p55γ directly bound and degraded RIP3 in a ubiquitin-dependent manner. We identified MG53 as the E3 ligase that mediated the p55γ-induced degradation of RIP3. In addition, we also found that p55γ activated the RISK pathway during IPC. CONCLUSIONS Our findings reveal that activation of the MG53-RIP3 signal pathway by p55γ protects the heart against I/R-induced necroptosis and underlies IPC-induced cardioprotection.
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Affiliation(s)
- Zhenyan Li
- Laboratory of Cardiovascular Science, Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China
- Department of Physiology, Capital Institute of Pediatrics, 2 Yabao Road, Chaoyang District, Beijing 100020, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, 9 Dongdansantiao, Dongcheng District, Beijing 100730, China
| | - Rilei Dai
- Laboratory of Cardiovascular Science, Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China
| | - Min Chen
- Department of Physiology, Capital Institute of Pediatrics, 2 Yabao Road, Chaoyang District, Beijing 100020, China
| | - Lixuan Huang
- Department of Dermatology, The Fourth Hospital of Hebei Medical University, Hebei Medical University, 361 Zhongshan East Road, Shijiazhuang 050017, China
| | - Kun Zhu
- Laboratory of Cardiovascular Science, Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China
| | - Mingyang Li
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China
| | - Wenting Zhu
- Laboratory of Cardiovascular Science, Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China
| | - Yang Li
- Laboratory of Cardiovascular Science, Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China
| | - Ning Xie
- Institute of Molecular Medicine, Peking University, 5 Yiheyuan Road, Haidian District, Beijing 100871, China
| | - Jingchen Li
- Laboratory of Cardiovascular Science, Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China
| | - Li Wang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Feng Lan
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Xicheng District, Beijing 100037, China
| | - Chun-Mei Cao
- Laboratory of Cardiovascular Science, Beijing Clinical Research Institute, Beijing Friendship Hospital, Capital Medical University, 95 Yongan Road, Xicheng District, Beijing 100050, China
- Department of Physiology, Capital Institute of Pediatrics, 2 Yabao Road, Chaoyang District, Beijing 100020, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, 9 Dongdansantiao, Dongcheng District, Beijing 100730, China
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Ughetto A, Roubille F, Molina A, Battistella P, Gaudard P, Demaria R, Guihaire J, Lacampagne A, Delmas C. Heart graft preservation technics and limits: an update and perspectives. Front Cardiovasc Med 2023; 10:1248606. [PMID: 38028479 PMCID: PMC10657826 DOI: 10.3389/fcvm.2023.1248606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Heart transplantation, the gold standard treatment for end-stage heart failure, is limited by heart graft shortage, justifying expansion of the donor pool. Currently, static cold storage (SCS) of hearts from donations after brainstem death remains the standard practice, but it is usually limited to 240 min. Prolonged cold ischemia and ischemia-reperfusion injury (IRI) have been recognized as major causes of post-transplant graft failure. Continuous ex situ perfusion is a new approach for donor organ management to expand the donor pool and/or increase the utilization rate. Continuous ex situ machine perfusion (MP) can satisfy the metabolic needs of the myocardium, minimizing irreversible ischemic cell damage and cell death. Several hypothermic or normothermic MP methods have been developed and studied, particularly in the preclinical setting, but whether MP is superior to SCS remains controversial. Other approaches seem to be interesting for extending the pool of heart graft donors, such as blocking the paths of apoptosis and necrosis, extracellular vesicle therapy, or donor heart-specific gene therapy. In this systematic review, we summarize the mechanisms involved in IRI during heart transplantation and existing targeting therapies. We also critically evaluate all available data on continuous ex situ perfusion devices for adult donor hearts, highlighting its therapeutic potential and current limitations and shortcomings.
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Affiliation(s)
- Aurore Ughetto
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - François Roubille
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Cardiology Department, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - Adrien Molina
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Cardio-thoracic and Vascular Surgery Department, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - Pascal Battistella
- Cardio-thoracic and Vascular Surgery Department, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - Philippe Gaudard
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Roland Demaria
- Cardio-thoracic and Vascular Surgery Department, CHU de Montpellier, University of Montpellier, Montpellier, France
| | - Julien Guihaire
- Cardiac and Vascular Surgery, Marie Lanelongue Hospital, Paris Saclay University, Le Plessis Robinson, France
| | - Alain Lacampagne
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
| | - Clément Delmas
- Phymedexp INSERM, CNRS, University of Montpellier, CHRU Montpellier, Montpellier, France
- Intensive Cardiac Care Unit, Cardiology Department, Rangueil University Hospital, Toulouse, France
- REICATRA, Institut Saint Jacques, CHU de Toulouse, Toulouse, France
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Li Y, Gao Y, Li G. Preclinical multi-target strategies for myocardial ischemia-reperfusion injury. Front Cardiovasc Med 2022; 9:967115. [PMID: 36072870 PMCID: PMC9444048 DOI: 10.3389/fcvm.2022.967115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
Despite promising breakthroughs in diagnosing and treating acute coronary syndromes, cardiovascular disease’s high global mortality rate remains indisputable. Nearly half of these patients died of ischemic heart disease. Primary percutaneous coronary intervention (PCI) and coronary artery bypass grafting can rapidly restore interrupted blood flow and become the most effective method for salvaging viable myocardium. However, restoring blood flow could increase the risk of other complications and myocardial cell death attributed to myocardial ischemia-reperfusion injury (IRI). How to reduce the damage of blood reperfusion to ischemic myocardium has become an urgent problem to be solved. In preclinical experiments, many treatments have substantial cardioprotective effects against myocardial IRI. However, the transition from these cardioprotective therapies to clinically beneficial therapies for patients with acute myocardial infarction remains elusive. The reasons for the failure of the clinical translation may be multi-faceted, and three points are summarized here: (1) Our understanding of the complex pathophysiological mechanisms of myocardial IRI is far from enough, and the classification of specific therapeutic targets is not rigorous, and not clear enough; (2) Most of the clinical patients have comorbidities, and single cardioprotective strategies including ischemia regulation strategies cannot exert their due cardioprotective effects under conditions of hyperglycemia, hypertension, hyperlipidemia, and aging; (3) Most preclinical experimental results are based on adult, healthy animal models. However, most clinical patients had comorbidities and received multiple drug treatments before reperfusion therapy. In 2019, COST Action proposed a multi-target drug combination initiative for prospective myocardial IRI; the optimal cardioprotective strategy may be a combination of additive or synergistic multi-target therapy, which we support. By establishing more reasonable preclinical models, screening multi-target drug combinations more in line with clinical practice will benefit the translation of clinical treatment strategies.
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Lv Z, Luo X, Hong B, Ye Q, Liu J, Hu Y. CBL knockdown protects cardiomyocytes against hypoxia‑reoxygenation injury by downregulating GRB2 expression. Exp Ther Med 2022; 23:188. [PMID: 35069869 PMCID: PMC8764905 DOI: 10.3892/etm.2022.11111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/27/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Zhengbing Lv
- Department of Cardiology, The Second People's Hospital of Chengdu, Chengdu, Sichuan 610017, P.R. China
| | - Xiaojia Luo
- Department of Cardiology, The Second People's Hospital of Chengdu, Chengdu, Sichuan 610017, P.R. China
| | - Biying Hong
- Department of Cardiology, The Second People's Hospital of Chengdu, Chengdu, Sichuan 610017, P.R. China
| | - Qiran Ye
- Department of Biotechnology, College of Life Science Sichuan University, Chengdu, Sichuan 610000, P.R. China
| | - Jianxiong Liu
- Department of Cardiology, The Second People's Hospital of Chengdu, Chengdu, Sichuan 610017, P.R. China
| | - Yongmei Hu
- Department of Cardiology, The Second People's Hospital of Chengdu, Chengdu, Sichuan 610017, P.R. China
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de Miranda DC, de Oliveira Faria G, Hermidorff MM, Dos Santos Silva FC, de Assis LVM, Isoldi MC. Pre- and Post-Conditioning of the Heart: An Overview of Cardioprotective Signaling Pathways. Curr Vasc Pharmacol 2020; 19:499-524. [PMID: 33222675 DOI: 10.2174/1570161119666201120160619] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 11/22/2022]
Abstract
Since the discovery of ischemic pre- and post-conditioning, more than 30 years ago, the knowledge about the mechanisms and signaling pathways involved in these processes has significantly increased. In clinical practice, on the other hand, such advancement has yet to be seen. This article provides an overview of ischemic pre-, post-, remote, and pharmacological conditioning related to the heart. In addition, we reviewed the cardioprotective signaling pathways and therapeutic agents involved in the above-mentioned processes, aiming to provide a comprehensive evaluation of the advancements in the field. The advancements made over the last decades cannot be ignored and with the exponential growth in techniques and applications. The future of pre- and post-conditioning is promising.
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Affiliation(s)
- Denise Coutinho de Miranda
- Laboratory of Cell Signaling, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
| | - Gabriela de Oliveira Faria
- Laboratory of Cell Signaling, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
| | - Milla Marques Hermidorff
- Laboratory of Cell Signaling, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
| | - Fernanda Cacilda Dos Santos Silva
- Laboratory of Cardiovascular Physiology, Department of Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
| | - Leonardo Vinícius Monteiro de Assis
- Laboratory of Comparative Physiology of Pigmentation, Department of Physiology, Institute of Biosciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Mauro César Isoldi
- Laboratory of Cell Signaling, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
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Ponnalagu D, Hussain AT, Thanawala R, Meka J, Bednarczyk P, Feng Y, Szewczyk A, GururajaRao S, Bopassa JC, Khan M, Singh H. Chloride channel blocker IAA-94 increases myocardial infarction by reducing calcium retention capacity of the cardiac mitochondria. Life Sci 2019; 235:116841. [PMID: 31494173 PMCID: PMC7664129 DOI: 10.1016/j.lfs.2019.116841] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 08/28/2019] [Accepted: 09/04/2019] [Indexed: 01/14/2023]
Abstract
Indanyloxyacetic acid-94 (IAA-94), an intracellular chloride channel blocker, is shown to ablate cardioprotection rendered by ischemic preconditioning (IPC), N (6)-2-(4-aminophenyl) ethyladenosine or the PKC activator phorbol 12-myristate 13-acetate and cyclosporin A (CsA) in both ex-vivo and in-vivo ischemia-reperfusion (IR) injury. Thus signifying the role of the IAA-94 sensitive chloride channels in mediating cardio-protection upon IR injury. Although IAA-94 sensitive chloride currents are recorded in cardiac mitoplast, there is still a lack of understanding of the mechanism by which IAA-94 increases myocardial infarction (MI) by IR injury. Mitochondria are the key arbitrators of cell life and death pathways. Both oxidative stress and calcium overload in the mitochondria, elicit pathways resulting in the opening of mitochondrial permeability transition pore (mPTP) leading to cell death. Therefore, in this study we explored the role of IAA-94 in MI and in maintaining calcium retention capacity (CRC) of cardiac mitochondria after IR. IAA-94 inhibited the CRC of the isolated cardiac mitochondria in a concentration-dependent manner as measured spectrofluorimetrically using calcium green-5 N. Interestingly, IAA-94 did not change the mitochondrial membrane potential. Further, CsA a blocker of mPTP opening could not override the effect of IAA-94. We also showed for the first time that IAA-94 perfusion after ischemic event augments MI by reducing the CRC of mitochondria. To conclude, our results demonstrate that the mechanism of IAA-94 mediated cardio-deleterious effects is via modulating the mitochondria CRC, thereby playing a role in mPTP opening. These findings highlight new pharmacological targets, which can mediate cardioprotection from IR injury.
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Affiliation(s)
- Devasena Ponnalagu
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, United States of America; Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH 43210, United States of America.
| | - Ahmed Tafsirul Hussain
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, United States of America
| | - Rushi Thanawala
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, United States of America
| | - Jahnavi Meka
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, United States of America
| | - Piotr Bednarczyk
- Department of Biophysics, Warsaw University of Life Sciences - SGGW, Poland
| | - Yansheng Feng
- Department of Cellular and Integrative Physiology, University of Texas Health Science Center, San Antonio, TX 78229, United States of America
| | - Adam Szewczyk
- Department of Biochemistry, Nencki Institute of Experimental Biology, Poland
| | - Shubha GururajaRao
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, United States of America; Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH 43210, United States of America
| | - Jean C Bopassa
- Department of Cellular and Integrative Physiology, University of Texas Health Science Center, San Antonio, TX 78229, United States of America
| | - Mahmood Khan
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH 43210, United States of America; Department of Emergency Medicine, The Ohio State University, Columbus, OH 43210, United States of America
| | - Harpreet Singh
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA 19102, United States of America; Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH 43210, United States of America.
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Liu D, Xu L, Zhang X, Shi C, Qiao S, Ma Z, Yuan J. Snapshot: Implications for mTOR in Aging-related Ischemia/Reperfusion Injury. Aging Dis 2019; 10:116-133. [PMID: 30705773 PMCID: PMC6345330 DOI: 10.14336/ad.2018.0501] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 05/01/2018] [Indexed: 12/15/2022] Open
Abstract
Aging may aggravate the damage and dysfunction of different components of multiorgan and thus increasing multiorgan ischemia/reperfusion (IR) injury. IR injury occurs in many organs and tissues, which is a major cause of morbidity and mortality worldwide. The kinase mammalian target of rapamycin (mTOR), an atypical serine/threonine protein kinase, involves in the pathophysiological process of IR injury. In this review, we first briefly introduce the molecular features of mTOR, the association between mTOR and aging, and especially its role on autophagy. Special focus is placed on the roles of mTOR during ischemic and IR injury. We then clarify the association between mTOR and conditioning phenomena. Following this background, we expand our discussion to potential future directions of research in this area. Collectively, information reviewed herein will serve as a comprehensive reference for the actions of mTOR in IR injury and may be significant for the design of future research and increase the potential of mTOR as a therapeutic target.
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Affiliation(s)
- Dong Liu
- 1State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Liqun Xu
- 1State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.,2Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, 1 Xinsi Road, Xi'an 710038, China.,3Cadet group 3, School of Basic Medical Sciences, The Fourth Military Medical University, Xi'an 710032, China.,4Laboratory Animal Center, The Fourth Military Medical University, Xi'an 710032, China
| | - Xiaoyan Zhang
- 2Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, 1 Xinsi Road, Xi'an 710038, China.,3Cadet group 3, School of Basic Medical Sciences, The Fourth Military Medical University, Xi'an 710032, China
| | - Changhong Shi
- 4Laboratory Animal Center, The Fourth Military Medical University, Xi'an 710032, China
| | - Shubin Qiao
- 1State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Zhiqiang Ma
- 1State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.,2Department of Thoracic Surgery, Tangdu Hospital, The Fourth Military Medical University, 1 Xinsi Road, Xi'an 710038, China
| | - Jiansong Yuan
- 1State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
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Xu Y, Yu Q, Yang J, Yuan F, Zhong Y, Zhou Z, Wang N. Acute Hemodynamic Effects of Remote Ischemic Preconditioning on Coronary Perfusion Pressure and Coronary Collateral Blood Flow in Coronary Heart Disease. ACTA CARDIOLOGICA SINICA 2018; 34:299-306. [PMID: 30065567 PMCID: PMC6066945 DOI: 10.6515/acs.201807_34(4).20180317a] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 03/17/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND The aim of this study was to assess the acute hemodynamic effects of remote ischemic preconditioning (RIPC) on coronary perfusion pressure and coronary collateral blood flow. METHODS A total of 17 patients with coronary heart disease with severe (70%-85%) stenosis in one or two vessels confirmed by angiography were enrolled into this study. They were randomly divided into the RIPC group (9 patients) and the control group (8 patients). Distal pressure of coronary artery stenosis before balloon dilation (non-occlusive pressure, Pn-occl) and distal coronary artery occlusive pressure (Poccl) during balloon dilation occlusion were measured in all patients. The patients in the RIPC group received three cycles of lower limb ischemia-reperfusion preconditioning (5 minutes inflation of a blood pressure cuff, followed by 5 minutes reperfusion). For controls, the cuff was not inflated. After this process, Pn-occl and Poccl were measured again in each patient. RESULTS There were no significant differences in angiographic characteristics between the two groups (all p > 0.05). Troponin I (TNI) levels after percutaneous coronary intervention (PCI) were lower in the RIPC group than in the control group (p = 0.004). In the RIPC group, mean Pn-occl and Poccl were significantly increased after RIPC compared to before RIPC [(72.78 ± 10.10) mmHg vs. (79.67 ± 9.79) mmHg, p = 0.002, (20.89 ± 8.61) mmHg vs. (26.78 ± 10.73) mmHg, p = 0.001, respectively]. CONCLUSIONS RIPC can improve distal coronary perfusion pressure and rapidly increase distal coronary occlusive pressure thereby improving coronary collateral blood flow.
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Affiliation(s)
- Yuansheng Xu
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Qinkai Yu
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Jianmin Yang
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Fang Yuan
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Yigang Zhong
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Zhanlin Zhou
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou First People's Hospital, Hangzhou, 310006, China
| | - Ningfu Wang
- Department of Cardiology, The Affiliated Hangzhou Hospital of Nanjing Medical University, Hangzhou First People's Hospital, Hangzhou, 310006, China
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Hentia C, Rizzato A, Camporesi E, Yang Z, Muntean DM, Săndesc D, Bosco G. An overview of protective strategies against ischemia/reperfusion injury: The role of hyperbaric oxygen preconditioning. Brain Behav 2018; 8:e00959. [PMID: 29761012 PMCID: PMC5943756 DOI: 10.1002/brb3.959] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 02/12/2018] [Accepted: 02/18/2018] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Ischemia/reperfusion (I/R) injury, such as myocardial infarction, stroke, and peripheral vascular disease, has been recognized as the most frequent causes of devastating disorders and death currently. Protective effect of various preconditioning stimuli, including hyperbaric oxygen (HBO), has been proposed in the management of I/R. METHODS In this study, we searched and reviewed up-to-date published papers to explore the pathophysiology of I/R injury and to understand the mechanisms underlying the protective effect of HBO as conditioning strategy. RESULTS Animal study and clinic observation support the notion that HBO therapy and conditioning provide beneficial effect against the deleterious effects of postischemic reperfusion. Several explanations have been proposed. The first likely mechanism may be that HBO counteracts hypoxia and reduces I/R injury by improving oxygen delivery to an area with diminished blood flow. Secondly, by reducing hypoxia-ischemia, HBO reduces all the pathological events as a consequence of hypoxia, including tissue edema, increased affective area permeability, postischemia derangement of tissue metabolism, and inflammation. Thirdly, HBO may directly affect cell apoptosis, signal transduction, and gene expression in those that are sensitive to oxygen or hypoxia. HBO provides a reservoir of oxygen at cellular level not only carried by blood, but also by diffusion from the interstitial tissue where it reaches high concentration that may last for several hours, improves endothelial function and rheology, and decreases local inflammation and edema. CONCLUSION Evidence suggests the benefits of HBO when used as a preconditioning stimulus in the setting of I/R injury. Translating the beneficial effects of HBO into current practice requires, as for the "conditioning strategies", a thorough consideration of risk factors, comorbidities, and comedications that could interfere with HBO-related protection.
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Affiliation(s)
- Ciprian Hentia
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy.,Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Alex Rizzato
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy
| | | | - Zhongjin Yang
- The Institute for Human Performance SUNY Upstate Medical University Syracuse NY USA
| | - Danina M Muntean
- Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania.,Center for Translational Research and Systems Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Dorel Săndesc
- Faculty of Medicine "Victor Babeș" University of Medicine and Pharmacy Timișoara Romania
| | - Gerardo Bosco
- Master II level in Hyperbaric Medicine Department of Biomedical Sciences University of Padova Padova Italy
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11
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Jung H. Kidney transplantation and ischemic conditioning: past, present and future perspectives. Anesth Pain Med (Seoul) 2018. [DOI: 10.17085/apm.2018.13.1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hoon Jung
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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12
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Abstract
Coronary artery disease (CAD) is a major cause of morbidity and mortality worldwide. Coronary artery bypass graft (CABG) surgery is the revascularisation strategy of choice in patients with diabetes mellitus and complex CAD. Owing to a number of factors, including the ageing population, the increased complexity of CAD being treated, concomitant valve and aortic surgery, and multiple comorbidities, higher-risk patients are being operated on, the result of which is an increased risk of sustaining perioperative myocardial injury (PMI) and poorer clinical outcomes. As such, new treatment strategies are required to protect the heart against PMI and improve clinical outcomes following cardiac surgery. In this regard, the heart can be endogenously protected from PMI by subjecting the myocardium to one or more brief cycles of ischaemia and reperfusion, a strategy called "ischaemic conditioning". However, this requires an intervention applied directly to the heart, which may be challenging to apply in the clinical setting. In this regard, the strategy of remote ischaemic conditioning (RIC) may be more attractive, as it allows the endogenous cardioprotective strategy to be applied away from the heart to the arm or leg by simply inflating and deflating a cuff on the upper arm or thigh to induce one or more brief cycles of ischaemia and reperfusion (termed "limb RIC"). Although a number of small clinical studies have demonstrated less PMI with limb RIC following cardiac surgery, three recently published large multicentre randomised clinical trials found no beneficial effects on short-term or long-term clinical outcomes, questioning the role of limb RIC in the setting of cardiac surgery. In this article, we review ischaemic conditioning as a therapeutic strategy for endogenous cardioprotection in patients undergoing cardiac surgery and discuss the potential reasons for the failure of limb RIC to improve clinical outcomes in this setting. Crucially, limb RIC still has the therapeutic potential to protect the heart in other clinical settings, such as acute myocardial infarction, and it may also protect other organs against acute ischaemia/reperfusion injury (such as the brain, kidney, and liver).
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Affiliation(s)
- Luciano Candilio
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, London, UK.,The National Institute of Health Research-University College London Hospitals Biomedical Research Centre, London, UK
| | - Derek Hausenloy
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, London, UK.,The National Institute of Health Research-University College London Hospitals Biomedical Research Centre, London, UK.,Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore, Singapore.,National Heart Research Institute Singapore, National Heart Centre, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
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13
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Caveolin-1/-3: therapeutic targets for myocardial ischemia/reperfusion injury. Basic Res Cardiol 2016; 111:45. [PMID: 27282376 DOI: 10.1007/s00395-016-0561-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/05/2016] [Accepted: 05/06/2016] [Indexed: 01/20/2023]
Abstract
Myocardial ischemia/reperfusion (I/R) injury is a major cause of morbidity and mortality worldwide. Caveolae, caveolin-1 (Cav-1), and caveolin-3 (Cav-3) are essential for the protective effects of conditioning against myocardial I/R injury. Caveolins are membrane-bound scaffolding proteins that compartmentalize and modulate signal transduction. In this review, we introduce caveolae and caveolins and briefly describe the interactions of caveolins in the cardiovascular diseases. We also review the roles of Cav-1/-3 in protection against myocardial ischemia and I/R injury, and in conditioning. Finally, we suggest several potential research avenues that may be of interest to clinicians and basic scientists. The information included, herein, is potentially useful for the design of future studies and should advance the investigation of caveolins as therapeutic targets.
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Ottani F, Latini R, Staszewsky L, La Vecchia L, Locuratolo N, Sicuro M, Masson S, Barlera S, Milani V, Lombardi M, Costalunga A, Mollichelli N, Santarelli A, De Cesare N, Sganzerla P, Boi A, Maggioni AP, Limbruno U. Cyclosporine A in Reperfused Myocardial Infarction: The Multicenter, Controlled, Open-Label CYCLE Trial. J Am Coll Cardiol 2016; 67:365-374. [PMID: 26821623 DOI: 10.1016/j.jacc.2015.10.081] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 10/23/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Whether cyclosporine A (CsA) has beneficial effects in reperfused myocardial infarction (MI) is debated. OBJECTIVES This study investigated whether CsA improved ST-segment resolution in a randomized, multicenter phase II study. METHODS The authors randomly assigned 410 patients from 31 cardiac care units, age 63 ± 12 years, with large ST-segment elevation MI within 6 h of symptom onset, Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 to 1 in the infarct-related artery, and committed to primary percutaneous coronary intervention, to 2.5 mg/kg intravenous CsA (n = 207) or control (n = 203) groups. The primary endpoint was incidence of ≥70% ST-segment resolution 60 min after TIMI flow grade 3. Secondary endpoints included high-sensitivity cardiac troponin T (hs-cTnT) on day 4, left ventricular (LV) remodeling, and clinical events at 6-month follow-up. RESULTS Time from symptom onset to first antegrade flow was 180 ± 67 min; a median of 5 electrocardiography leads showed ST-segment deviation (quartile [Q]1 to Q3: 4 to 6); 49.8% of MIs were anterior. ST-segment resolution ≥70% was found in 52.0% of CsA patients and 49.0% of controls (p = 0.55). Median hs-cTnT on day 4 was 2,160 (Q1 to Q3: 1,087 to 3,274) ng/l in CsA and 2,068 (1,117 to 3,690) ng/l in controls (p = 0.85). The 2 groups did not differ in LV ejection fraction on day 4 and at 6 months. Infarct site did not influence CsA efficacy. There were no acute allergic reactions or nonsignificant excesses of 6-month mortality (5.7% CsA vs. 3.2% controls, p = 0.17) or cardiogenic shock (2.4% CsA vs. 1.5% controls, p = 0.33). CONCLUSIONS In the CYCLE (CYCLosporinE A in Reperfused Acute Myocardial Infarction) trial, a single intravenous CsA bolus just before primary percutaneous coronary intervention had no effect on ST-segment resolution or hs-cTnT, and did not improve clinical outcomes or LV remodeling up to 6 months. (CYCLosporinE A in Reperfused Acute Myocardial Infarction [CYCLE]; NCT01650662; EudraCT number 2011-002876-18).
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Affiliation(s)
- Filippo Ottani
- Unità Operativa di Cardiologia, Ospedale GB Morgagni, Forlì, Italy
| | - Roberto Latini
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy.
| | - Lidia Staszewsky
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | | | | | - Marco Sicuro
- Cardiologia e UTIC, Ospedale Regionale Umberto Parini, Aosta, Italy
| | - Serge Masson
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Simona Barlera
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Valentina Milani
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Mario Lombardi
- Unità Operativa di Cardiologia, Ospedali Riuniti Villa Sofia, Palermo, Italy
| | | | | | | | | | - Paolo Sganzerla
- Cardiologia, Ospedale Treviglio-Caravaggio, Treviglio, Italy
| | - Alberto Boi
- Struttura Complessa di Emodinamica, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | | | - Ugo Limbruno
- Cardiologia, Ospedale delle Misericordie, Grosseto, Italy
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Eitel I, Stiermaier T, Rommel KP, Fuernau G, Sandri M, Mangner N, Linke A, Erbs S, Lurz P, Boudriot E, Mende M, Desch S, Schuler G, Thiele H. Cardioprotection by combined intrahospital remote ischaemic perconditioning and postconditioning in ST-elevation myocardial infarction: the randomized LIPSIA CONDITIONING trial. Eur Heart J 2015; 36:3049-57. [PMID: 26385956 DOI: 10.1093/eurheartj/ehv463] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/19/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Remote ischaemic conditioning (RIC) and postconditioning (PostC) are both potent activators of innate protection against ischaemia-reperfusion injury and have demonstrated cardioprotection in experimental and clinical ST-elevation myocardial infarction (STEMI) trials. However, their combined effects have not been studied in detail. The aim of this study was to evaluate if the co-application of intrahospital RIC and PostC has a more powerful effect on myocardial salvage compared with either PostC alone or control. METHODS AND RESULTS This prospective, controlled, single-centre study randomized 696 STEMI patients to one of the following three groups: (i) combined intrahospital RIC + PostC in addition to primary percutaneous coronary intervention (PCI); (ii) PostC in addition to PCI; and (iii) conventional PCI (control). The primary endpoint myocardial salvage index was assessed by cardiac magnetic resonance (CMR) imaging within 3 days after infarction. Secondary endpoints included infarct size and microvascular obstruction (MVO) assessed by CMR. The combined clinical endpoint consisted of death, reinfarction, and new congestive heart failure within 6 months. The primary endpoint myocardial salvage index was significantly greater in the combined RIC + PostC group when compared with the control group (49 [interquartile range 30-72] vs. 40 [interquartile range 16-68], P = 0.02). Postconditioning alone failed to improve myocardial salvage when compared with conventional PCI (P = 0.39). The secondary endpoints, including infarct size and MVO, showed no significant differences between groups. Clinical follow-up at 6 months revealed no differences in the combined clinical endpoint between groups (P = 0.44). CONCLUSION Combined intrahospital RIC + PostC in conjunction with PCI in STEMI significantly improves myocardial salvage in comparison with control and PostC. CLINICALTRIALSGOV NCT02158468.
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Affiliation(s)
- Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Thomas Stiermaier
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Karl P Rommel
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Georg Fuernau
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Marcus Sandri
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Norman Mangner
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Axel Linke
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Sandra Erbs
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Phillip Lurz
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Enno Boudriot
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Meinhard Mende
- Clinical Trial Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Steffen Desch
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Gerhard Schuler
- Department of Internal Medicine/Cardiology, University of Leipzig - Heart Center, Leipzig, Germany
| | - Holger Thiele
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23538 Lübeck, Germany German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
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