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Bentley RET, Hindmarch CCT, Dunham-Snary KJ, Snetsinger B, Mewburn JD, Thébaud A, Lima PDA, Thébaud B, Archer SL. The molecular mechanisms of oxygen-sensing in human ductus arteriosus smooth muscle cells: A comprehensive transcriptome profile reveals a central role for mitochondria. Genomics 2021; 113:3128-3140. [PMID: 34245829 PMCID: PMC10659099 DOI: 10.1016/j.ygeno.2021.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/23/2021] [Accepted: 07/04/2021] [Indexed: 01/22/2023]
Abstract
The ductus arteriosus (DA) connects the fetal pulmonary artery and aorta, diverting placentally oxygenated blood from the developing lungs to the systemic circulation. The DA constricts in response to increases in oxygen (O2) with the first breaths, resulting in functional DA closure, with anatomic closure occurring within the first days of life. Failure of DA closure results in persistent patent ductus arteriosus (PDA), a common complication of extreme preterm birth. The DA's response to O2, though modulated by the endothelium, is intrinsic to the DA smooth muscle cells (DASMC). DA constriction is mediated by mitochondrial-derived reactive oxygen species, which increase in proportion to arterial partial pressure of oxygen (PaO2). The resulting redox changes inhibit voltage-gated potassium channels (Kv) leading to cell depolarization, calcium influx and DASMC constriction. To date, there has not been an unbiased assessment of the human DA O2-sensors using transcriptomics, nor are there known molecular mechanisms which characterize DA closure. DASMCs were isolated from DAs obtained from 10 term infants at the time of congenital heart surgery. Cells were purified by flow cytometry, negatively sorting using CD90 and CD31 to eliminate fibroblasts or endothelial cells, respectively. The purity of the DASMC population was confirmed by positive staining for α-smooth muscle actin, smoothelin B and caldesmon. Cells were grown for 96 h in hypoxia (2.5% O2) or normoxia (19% O2) and confocal imaging with Cal-520 was used to determine oxygen responsiveness. An oxygen-induced increase in intracellular calcium of 18.1% ± 4.4% and SMC constriction (-27% ± 1.5% shortening) occurred in all cell lines within five minutes. RNA sequencing of the cells grown in hypoxia and normoxia revealed significant regulation of 1344 genes (corrected p < 0.05). We examined these genes using Gene Ontology (GO). This unbiased assessment of altered gene expression indicated significant enrichment of the following GOterms: mitochondria, cellular respiration and transcription. The top regulated biologic process was generation of precursor metabolites and energy. The top regulated cellular component was mitochondrial matrix. The top regulated molecular function was transcription coactivator activity. Multiple members of the NADH-ubiquinone oxidoreductase (NDUF) family are upregulated in human DASMC (hDASMC) following normoxia. Several of our differentially regulated transcripts are encoded by genes that have been associated with genetic syndromes that have an increased incidence of PDA (Crebb binding protein and Histone Acetyltransferase P300). This first examination of the effects of O2 on human DA transcriptomics supports a putative role for mitochondria as oxygen sensors.
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Affiliation(s)
| | - Charles C T Hindmarch
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; QCPU, Queen's Cardiopulmonary Unit, Translational Institute of Medicine (TIME), Department of Medicine, Queen's University, Canada
| | - Kimberly J Dunham-Snary
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; Department of Biomedical and Molecular Science, Queen's University, Canada
| | - Brooke Snetsinger
- QCPU, Queen's Cardiopulmonary Unit, Translational Institute of Medicine (TIME), Department of Medicine, Queen's University, Canada
| | - Jeffrey D Mewburn
- Department of Biomedical and Molecular Science, Queen's University, Canada
| | - Arthur Thébaud
- Department of Kinesiology and Health Studies, Queen's University, Canada
| | - Patricia D A Lima
- QCPU, Queen's Cardiopulmonary Unit, Translational Institute of Medicine (TIME), Department of Medicine, Queen's University, Canada
| | - Bernard Thébaud
- Ottawa Hospital Research Institute, Regenerative Medicine Program, Ottawa, Ontario, Canada; Department of Pediatrics, Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada; Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada; QCPU, Queen's Cardiopulmonary Unit, Translational Institute of Medicine (TIME), Department of Medicine, Queen's University, Canada.
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Ovalı F. Molecular and Mechanical Mechanisms Regulating Ductus Arteriosus Closure in Preterm Infants. Front Pediatr 2020; 8:516. [PMID: 32984222 PMCID: PMC7477801 DOI: 10.3389/fped.2020.00516] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022] Open
Abstract
Failure of ductus arteriosus closure after preterm birth is associated with significant morbidities. Ductal closure requires and is regulated by a complex interplay of molecular and mechanical mechanisms with underlying genetic factors. In utero patency of the ductus is maintained by low oxygen tension, high levels of prostaglandins, nitric oxide and carbon monoxide. After birth, ductal closure occurs first by functional closure, followed by anatomical remodeling. High oxygen tension and decreased prostaglandin levels mediated by numerous factors including potassium channels, endothelin-1, isoprostanes lead to the contraction of the ductus. Bradykinin and corticosteroids also induce ductal constriction by attenuating the sensitivity of the ductus to PGE2. Smooth muscle cells of the ductus can sense oxygen through a mitochondrial network by the role of Rho-kinase pathway which ends up with increased intracellular calcium levels and contraction of myosin light chains. Anatomical closure of the ductus is also complex with various mechanisms such as migration and proliferation of smooth muscle cells, extracellular matrix production, endothelial cell proliferation which mediate cushion formation with the interaction of blood cells. Regulation of vessel walls is affected by retinoic acid, TGF-β1, notch signaling, hyaluronan, fibronectin, chondroitin sulfate, elastin, and vascular endothelial cell growth factor (VEGF). Formation of the platelet plug facilitates luminal remodeling by the obstruction of the constricted ductal lumen. Vasa vasorum are more pronounced in the term ductus but are less active in the preterm ductus. More than 100 genes are effective in the prostaglandin pathway or in vascular smooth muscle development and structure may affect the patency of ductus. Hemodynamic changes after birth including fluid load and flow characteristics as well as shear forces within the ductus also stimulate closure. Current pharmacological treatment for the closure of a patent ductus is based on the blockage of the prostaglandin pathway mainly through COX or POX inhibition, albeit with some limitations and side effects. Further research for new agents aiming ductal closure should focus on a clear understanding of vascular biology of the ductus.
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Affiliation(s)
- Fahri Ovalı
- Division of Neonatology, Department of Pediatrics, Istanbul Medeniyet University, Istanbul, Turkey
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Louis D, Wong C, Ye XY, McNamara PJ, Jain A. Factors associated with non-response to second course indomethacin for PDA treatment in preterm neonates. J Matern Fetal Neonatal Med 2017; 31:1407-1411. [PMID: 28391737 DOI: 10.1080/14767058.2017.1317736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Failure of first course of indomethacin (FCI) for patent ductus arteriosus (PDA) treatment in preterm neonates often prompts clinicians to consider a second course (SCI). OBJECTIVE To identify factors including baseline characteristics and response to FCI that are associated with non-response to SCI for PDA treatment in preterm neonates. METHODS In this retrospective observational study, neonates ≤32 weeks admitted to a tertiary NICU over 5 years who received two indomethacin courses for PDA treatment were reviewed. Only neonates with echocardiograms (ECHO) immediately before and after receipt of each indomethacin course were included. Primary outcome was non-response to SCI. Baseline characteristics and response to FCI were compared between responders and non-responders of SCI. RESULTS Of the 98 neonates enrolled, 47 (48%) had non-response to SCI. Of them, 27 patients (57%) had prior non-response to FCI, while of the 51 neonates who responded to SCI, 24 neonates (47%) had prior non-response to FCI. The adjusted risk of non-response to SCI in patients who had non-response to FCI was 37% higher (relative risk = 1.37, 95%CI: 0.87-1.80; p = .07) compared to those who had response to FCI. Multivariable analysis showed that increasing gestational age (AOR: 1.6, 95%CI: 1.1-2.3, p = .03) was associated with a higher odds of non-response to SCI while the odds of non-response to SCI increased by 90% in patients with non-response to FCI (AOR: 1.9, 95%CI: 0.8-4.5; p = .15) compared to those with success of FCI, although no statistical significance was observed. CONCLUSIONS Advanced gestational age was the predictor of non-response to SCI in preterm neonates.
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Affiliation(s)
- Deepak Louis
- a Department of Pediatrics , University of Toronto , Toronto , Canada
| | - Cindy Wong
- b Mount Sinai Hospital , Toronto , Canada
| | - Xiang Y Ye
- c MiCare Research Center, Mount Sinai Hospital , Toronto , Canada
| | - Patrick J McNamara
- d Division of Neonatology, Department of Pediatrics , The Hospital for Sick Children, University of Toronto , Toronto , Canada
| | - Amish Jain
- e Department of Pediatrics , Mount Sinai Hospital, University of Toronto , Toronto , Canada
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Batlivala SP, Glatz AC, Gillespie MJ, Dori Y, Rome JJ. Ductal spasm during performance of transcatheter ductal occlusion. Catheter Cardiovasc Interv 2013; 83:762-7. [PMID: 23832584 DOI: 10.1002/ccd.25120] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 06/30/2013] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Transcatheter patent ductus arteriosus (PDA) occlusion is a staple of pediatric catheterization laboratories. We present the phenomenon of significant PDA spasm to prevent failure to occlude a hemodynamically significant duct. BACKGROUND Transcatheter techniques have evolved, allowing safe and effective occlusion of PDAs in younger and smaller patients. Neonatal care is evolving with increasing survival at younger gestational ages. Premature infants often have PDAs, so the proportion of formerly premature children referred for transcatheter ductal occlusion will likely rise. METHODS We reviewed all transcatheter PDA occlusions performed at our institution since 2001 (N = 331). Retrospective data included: gestational age, age at catheterization, precatheterization echocardiographic parameters, PDA size (after spasm relief), device specifications, and most recent follow-up data. RESULTS Seven cases were identified. Median age was 12 months, median gestational age was 28 weeks. All were born prematurely. All PDAs were restrictive and six had left-heart volume overload. All patients were examined by the interventional cardiologist and had ductal murmurs. When reauscultated (three of seven), murmurs were absent during spasm. Once spasm relieved, PDA diameters ranged from 1.5 to 8 (median 2) mm. All patients accommodated a 6-mm-or larger-Amplatzer device. No significant complications occurred and all patients were well at follow-up. CONCLUSIONS Ductal spasm occurs during transcatheter occlusion and may be an unrecognized cause of procedural failure. The phenomenon seems to occur in children born prematurely, and can occur after infancy. Loss of a continuous murmur confirms the diagnosis. Care should be taken to avoid device under-sizing when spasm occurs.
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Affiliation(s)
- Sarosh P Batlivala
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania; Division of Cardiology, Batson Children's Hospital, Jackson, MS; Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS
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5
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Cotton RB, Shah LP, Poole SD, Ehinger NJ, Brown N, Shelton EL, Slaughter JC, Baldwin HS, Paria BC, Reese J. Cimetidine-associated patent ductus arteriosus is mediated via a cytochrome P450 mechanism independent of H2 receptor antagonism. J Mol Cell Cardiol 2013; 59:86-94. [PMID: 23454087 DOI: 10.1016/j.yjmcc.2013.02.010] [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] [Received: 11/26/2012] [Revised: 02/02/2013] [Accepted: 02/18/2013] [Indexed: 01/13/2023]
Abstract
Persistent patency of the ductus arteriosus (PDA) is a common problem in preterm infants. The antacid cimetidine is a potent antagonist of the H2 histamine receptor but it also inhibits certain cytochrome P450 enzymes (CYPs), which may affect DA patency. We examined whether cimetidine contributes to PDA and is mediated by CYP inhibition rather than H2 blockade. Analysis of a clinical trial to prevent lung injury in premature infants revealed a significant association between cimetidine treatment and PDA. Cimetidine and ranitidine, both CYP inhibitors as well as H2 blockers, caused relaxation of the term and preterm mouse DA. CYP enzymes that are inhibited by cimetidine were expressed in DA subendothelial smooth muscle. The selective CYP3A inhibitor ketoconazole induced greater DA relaxation than cimetidine, whereas famotidine and other H2 antagonists with less CYP inhibitory effects caused less dilation. Histamine receptors were developmentally regulated and localized in DA smooth muscle. However, cimetidine caused DA relaxation in histamine-deficient mice, consistent with CYP inhibition, not H2 antagonism, as the mechanism for PDA. Oxygen-induced DA constriction was inhibited by both cimetidine and famotidine. These studies show that antacids and other compounds with CYP inhibitory properties pose a significant and previously unrecognized risk for PDA in critically ill newborn infants.
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Affiliation(s)
- Robert B Cotton
- Department of Pediatrics, Vanderbilt University School of Medicine and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232, USA
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6
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Leppänen O, Ekstrand M, Bräsen JH, Levin M. Bioluminescence imaging of energy depletion in vascular pathology: patent ductus arteriosus and atherosclerosis. JOURNAL OF BIOPHOTONICS 2012; 5:336-344. [PMID: 22134948 DOI: 10.1002/jbio.201100096] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 11/11/2011] [Accepted: 11/12/2011] [Indexed: 05/31/2023]
Abstract
The artery wall may develop energy depletion due to insufficient nutritional supply. However, until recently it has not been possible to validate this hypothesis because no available technology has allowed assessment of energy metabolism with sufficient spatial resolution. We use high resolution bioluminescence metabolic imaging to study energy metabolism in two mechanistically different vascular pathologies: patent ductus arteriosus and atherosclerosis. Physiological energy depletion in postnatally constricting ductus arteriosus promotes permanent closure. Insufficient ductus energy depletion, common in preterm infants, is associated with persistent patent ductus arteriosus, a condition with significantly increased morbidity and mortality. In contrast, in atherosclerosis, energy depletion in the macrophage-rich lesion core promotes cell death contributing to lesion instability and disease progression.
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Affiliation(s)
- Olli Leppänen
- Centre for R&D, Uppsala University/County Council of Gävleborg, Gävle, Sweden
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7
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Clyman RI, Couto J, Murphy GM. Patent ductus arteriosus: are current neonatal treatment options better or worse than no treatment at all? Semin Perinatol 2012; 36:123-9. [PMID: 22414883 PMCID: PMC3305915 DOI: 10.1053/j.semperi.2011.09.022] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Although a moderate-sized patent ductus arteriosus (PDA) needs to be closed by the time a child is 1-2 years old, there is great uncertainty about whether it needs to be closed during the neonatal period. Although 95% of neonatologists believe that a moderate-sized PDA should be closed if it persists in infants (born before 28 weeks) who still require mechanical ventilation, the number of neonatologists who treat a PDA when it occurs in infants who do not require mechanical ventilation varies widely. Both the high likelihood of spontaneous ductus closure and the absence of randomized controlled trials, specifically addressing the risks and benefits of neonatal ductus closure, add to the current uncertainty. New information suggests that early pharmacologic treatment has several important short-term benefits for the preterm newborn. By contrast, ductus ligation, while eliminating the detrimental effects of a PDA on lung development, may create its own set of morbidities that counteract many of the benefits derived from ductus closure.
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MESH Headings
- Cardiovascular Agents/therapeutic use
- Ductus Arteriosus, Patent/drug therapy
- Ductus Arteriosus, Patent/physiopathology
- Ductus Arteriosus, Patent/surgery
- Ductus Arteriosus, Patent/therapy
- Female
- Humans
- Indomethacin/therapeutic use
- Infant, Newborn
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/physiopathology
- Infant, Premature, Diseases/surgery
- Ligation
- Male
- Pregnancy
- Respiration, Artificial
- Unnecessary Procedures
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Affiliation(s)
- Ronald I Clyman
- Department of Pediatrics, Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143, USA.
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8
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Waleh N, Seidner S, McCurnin D, Giavedoni L, Hodara V, Goelz S, Liu BM, Roman C, Clyman RI. Anatomic closure of the premature patent ductus arteriosus: The role of CD14+/CD163+ mononuclear cells and VEGF in neointimal mound formation. Pediatr Res 2011; 70:332-8. [PMID: 21691249 PMCID: PMC3166370 DOI: 10.1203/pdr.0b013e3182294471] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Permanent closure of the newborn ductus arteriosus requires the development of neointimal mounds to completely occlude its lumen. VEGF is required for neointimal mound formation. The size of the neointimal mounds (composed of proliferating endothelial and migrating smooth muscle cells) is directly related to the number of VLA4 mononuclear cells that adhere to the ductus lumen after birth. We hypothesized that VEGF plays a crucial role in attracting CD14/CD163 mononuclear cells (expressing VLA4) to the ductus lumen and that CD14/CD163 cell adhesion to the ductus lumen is important for neointimal growth. We used neutralizing antibodies against VEGF and VLA-4 to determine their respective roles in remodeling the ductus of premature newborn baboons. Anti-VEGF treatment blocked CD14/CD163 cell adhesion to the ductus lumen and prevented neointimal growth. Anti-VLA-4 treatment blocked CD14/CD163 cell adhesion to the ductus lumen, decreased the expression of PDGF-B (which promotes smooth muscle migration), and blocked smooth muscle influx into the neointimal subendothelial space (despite the presence of increased VEGF in the ductus wall). We conclude that VEGF is necessary for CD14/CD163 cell adhesion to the ductus lumen and that CD14/CD163 cell adhesion is essential for VEGF-induced expansion of the neointimal subendothelial zone.
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MESH Headings
- Animals
- Animals, Newborn
- Antibodies, Neutralizing/metabolism
- Antigens, CD/metabolism
- Antigens, Differentiation, Myelomonocytic/metabolism
- Cell Adhesion/physiology
- Cell Movement/physiology
- Ductus Arteriosus, Patent/metabolism
- Ductus Arteriosus, Patent/pathology
- Female
- Humans
- Hypoxia-Inducible Factor 1, alpha Subunit/genetics
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Infant, Newborn
- Integrin alpha4beta1/metabolism
- Leukocytes, Mononuclear/metabolism
- Lipopolysaccharide Receptors/metabolism
- Neointima
- Nitric Oxide Synthase Type III/metabolism
- Papio
- Receptors, Cell Surface/metabolism
- Vascular Cell Adhesion Molecule-1/metabolism
- Vascular Endothelial Growth Factor A/metabolism
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Affiliation(s)
- Nahid Waleh
- Pharmaceutical Discovery Division, SRI International, Menlo Park, California 94025, USA
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9
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Common signatures for gene expression in postnatal patients with patent arterial ducts and stented arteries. Cardiol Young 2009; 19:352-9. [PMID: 19538825 DOI: 10.1017/s1047951109004260] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The detailed molecular processes associated with postnatal remodelling of blood vessels are presently not understood. To characterize the response of the patients undergoing stenting of the patent arterial duct, we harvested samples of vascular tissue during surgical repair. Histological analysis of explanted ducts confirmed the patency of the ducts immediately after birth. As expected, a previously unstented duct that was examined 7 months after birth had become closed and ligamentous. Whole genome expression profiling of these samples showed that a large fraction, over 10%, of the gene sequences examined were expressed differentially between the samples taken from patients with open as opposed to the ligamentous duct. Interestingly, in 2 patients in whom closure was prevented by insertion of stents, one showed an expression profile that was similar to that of the patient initially having an unstented open duct, whereas the other was more closely related to the profile of the patient with a duct that had become ligamentous. Moreover, in 2 specimens obtained from patients with stented pulmonary arteries, a large fraction of the genes that were differentially expressed were identical to the pattern seen in the samples from the patients with open ducts. The gene regulation appeared to be independent of the nature of the respective malformations, and the site of implantation of the stents. These findings suggest that a set of differentially expressed genes are indicative for a transcriptional programme in neonatal remodelling of the arterial duct, which may also take place in patients in whom ductal closure is prevented by stents, or in those with stented pulmonary arteries. The differentially expressed genes included a significant number of extracellular matrix synthetic genes, and could therefore be predictive for vascular remodelling and neointimal formation.
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10
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Reese J, Waleh N, Poole SD, Brown N, Roman C, Clyman RI. Chronic in utero cyclooxygenase inhibition alters PGE2-regulated ductus arteriosus contractile pathways and prevents postnatal closure. Pediatr Res 2009; 66:155-61. [PMID: 19390487 PMCID: PMC3066019 DOI: 10.1203/pdr.0b013e3181aa07eb] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although prostaglandin E2 (PGE2) vasodilates the ductus arteriosus, tocolysis with cyclooxygenase (COX) inhibitors delays postnatal ductus arteriosus closure. We used fetal mice and sheep to determine whether PGE2 has a role in the development of ductus contractility that is distinct from its function as a vasodilator. Prolonged exposure of fetal ductus to PGE2 in vitro increased the expression of CaL- and K+-channel genes (CaLalpha1c, CaLbeta2, Kir6.1, and Kv1.5, which regulate oxygen-induced constriction) without affecting the genes that regulate Rho-kinase-mediated calcium sensitization. Conversely, chronic exposure to COX inhibitors in utero decreased expression of CaL- and K+-channel genes, without affecting Rho-kinase-associated genes. Chronic COX inhibition in utero decreased the ductus' in vitro contractile response to stimuli that use CaL- and K+-channels (like O2 and K+), whereas the response to stimuli that act through Rho-kinase-mediated pathways (like U46619) was not significantly affected. Phosphodiesterase expression, which decreases the ductus' sensitivity to cAMP- or cGMP-dependent vasodilators, was increased by PGE2 exposure and decreased by COX inhibition, respectively. These studies identify potential downstream effectors of a PGE2-mediated, developmental program, regulating oxygen-induced ductus closure. Alterations in these effectors may explain the increased risk of patent ductus arteriosus (PDA) after in utero COX inhibition.
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Affiliation(s)
- Jeff Reese
- Department of Pediatrics, Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee 37232, USA
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11
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Kim EK, Kim DH, Choi CW, Kim HS, Kim BI, Choi JH, Kim JE, Kim WH. Insufficient intimal thickening and scarcity of cell deaths may play a significant role in the pathogenesis of the persistently patent ductus arteriosus in the preterm infant. Early Hum Dev 2009; 85:181-6. [PMID: 18986784 DOI: 10.1016/j.earlhumdev.2008.09.413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Revised: 09/26/2008] [Accepted: 09/30/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Functional closure and subsequent remodeling of the ductus arteriosus (DA) are essential for postnatal adaptation. Very preterm infants often fail to accomplish this process spontaneously. Histologic studies on human DA have shown that the closing ductus exhibits progressive intimal thickening and cell death of muscle media, which was verified by recent animal studies. AIMS To analyze the histologic findings of preterm infants' DA in relation to their clinical parameters and to investigate the histologic difference between preterm and term DAs. METHODS Histology of 14 preterm DAs and 13 term DAs obtained from surgery was analyzed. We examined hematoxylin and eosin staining and van Gieson staining for the elastic tissue. Cell death was determined with the in situ apoptosis detection technique. RESULTS The histologic findings of preterm DAs showed apparent correlations with clinical parameters, especially birth weight. Preterm DA histology was significantly different from that of term DAs in the extent and degree of intimal thickening. Cytolytic necrosis where TUNEL-positive cell deaths were prominent was observed mainly in term DAs. CONCLUSIONS The results of this study indicate that insufficient intimal thickening and scarcity of cell deaths in the DA may play a significant role in the pathogenesis of the persistently patent DA in preterm infants.
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Affiliation(s)
- Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
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12
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Weber SC, Rheinlaender C, Sarioglu N, Peiser C, Rüdiger M, Obladen M, Koehne PS. The expression of VEGF and its receptors in the human ductus arteriosus. Pediatr Res 2008; 64:340-5. [PMID: 18535490 DOI: 10.1203/pdr.0b013e318180a375] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Programmed proliferative degeneration of the human fetal ductus arteriosus (DA) preceding definite postnatal closure has a large developmental variability and is controlled by several signaling pathways. Among these vascular endothelial growth factor (VEGF) and its receptors (VEGF-Rs) play an important role. Until now, gestational age dependent expression of VEGF and its receptors has not been investigated in a large number of human DA tissue specimens. We examined protein expression of VEGF and the three VEGF-Rs immunohistochemically in 63 human fetal autopsy DA specimens of 11-38 wk gestation. Specimens were classified into different maturity stages according to their histologic appearance. VEGF and VEGF-Rs-staining was detected in all maturity stages. VEGF-staining was localized perinuclearly in all vascular layers and did not change during development. VEGF-R1 and VEGF-R3 expression was marked in the endothelium in early maturity stages and decreased during development. In contrast, -R2 predominated in the media in later developmental stages. Our results emphasize the importance of VEGF as a mediator during programmed proliferative degeneration of fetal DA and support the hypothesis that VEGF-R1 and VEGF-R3 are required for normal blood vessel development during embryogenesis. In contrast, VEGF-R2 is the predominant receptor in later angiogenic signaling.
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Affiliation(s)
- Sven C Weber
- Department of Neonatology, Humboldt University, 13353 Berlin, Germany
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13
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Jegatheesan P, Ianus V, Buchh B, Yoon G, Chorne N, Ewig A, Lin E, Fields S, Moon-Grady A, Tacy T, Milstein J, Schreiber M, Padbury J, Clyman R. Increased indomethacin dosing for persistent patent ductus arteriosus in preterm infants: a multicenter, randomized, controlled trial. J Pediatr 2008; 153:183-9. [PMID: 18534218 DOI: 10.1016/j.jpeds.2008.01.031] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Revised: 12/19/2007] [Accepted: 01/24/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We conducted a multicenter, randomized, controlled trial to determine whether higher doses of indomethacin would improve the rate of patent ductus arteriosus (PDA) closure. STUDY DESIGN Infants (<28 weeks gestation) who received a conventional, prophylactic 3-dose course of indomethacin were eligible if they had continued evidence of persistent ductus patency on an echocardiogram obtained before the third prophylactic indomethacin dose. Infants (n = 105) were randomized to receive an extended 3-day course of either low-dose (0.1 mg/kg/d) or higher-dose (0.2 or 0.5 mg/kg/d) indomethacin. An echocardiogram was obtained 24 hours after the last dose of study drug. RESULTS Despite increasing serum indomethacin concentrations by 2.9-fold in the higher-dose group, we failed to detect a significant decrease in the rate of persistent PDA (low = 52%; higher = 45%, P = .50). The higher-dose group had a significantly higher occurrence of serum creatinine >2 mg/100 mL (low = 6%, higher = 19%, P < .05) and moderate/severe retinopathy of prematurity (ROP) (low = 15%, higher = 36%, P < .025). The incidence of moderate/severe ROP was directly related to the poststudy indomethacin concentrations (odds ratio = 1.75, confidence interval: 1.15-2.68, P < .01). CONCLUSION Increasing indomethacin concentrations above the levels achieved with a conventional dosing regimen had little effect on the rate of PDA closure but was associated with higher rates of moderate/severe ROP and renal compromise.
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Affiliation(s)
- Priya Jegatheesan
- Cardiovascular Research Institute and Department of Pediatrics, University of California, San Francisco, California 94143-0544, USA
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Abstract
Patent ductus arteriosus (PDA) is one of the most common congenital heart defects, accounting for 5%-10% of all congenital heart disease in term infants. The occurrence of PDA is inversely related to gestational age and weight, with an even greater incidence in preterm infants. The maintenance of ductal patency is essential for the normal development of the fetus. In the neonate, however, persistent patency of the ductus arteriosus (DA) is associated with significant morbidity and mortality. Normally, at birth, the DA constricts, resulting in intraluminal ischemic hypoxia, which eventually leads to closure and remodeling of the ductus. PDA in term infants is usually associated with a functional defect, whereas in preterm infants it is associated with immaturity. Normal physiologic mechanisms contributing to closure - oxygen tension and decreased prostaglandins-are altered in prematurity. Clinical signs of ductal patency include murmur, tachycardia, bounding peripheral pulses, and congestive heart failure and associated symptoms. Symptoms are not always present; therefore, diagnostic imaging is critical if a PDA is suspected on clinical grounds. Three management strategies are currently available for PDA: fluid restriction and diuretics (as clinically appropriate), medical intervention, and surgical ligation. Pharmacologic closure can be achieved via administration of intravenous indomethacin or ibuprofen lysine. While both agents have shown similar efficacy, ibuprofen lysine has demonstrated an improved safety profile, particularly in terms of renal effects, compared to indomethacin.
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Affiliation(s)
- James E Dice
- Department of Pharmacy, Children's Hospital of the King's Daughters, Norfolk, Virginia
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15
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Abstract
Patent ductus arteriosus (PDA) is one of the most common congenital heart defects, accounting for 5%-10% of all congenital heart disease in term infants. The occurrence of PDA is inversely related to gestational age and weight, with an even greater incidence in preterm infants. The maintenance of ductal patency is essential for the normal development of the fetus. In the neonate, however, persistent patency of the ductus arteriosus (DA) is associated with significant morbidity and mortality. Normally, at birth, the DA constricts, resulting in intraluminal ischemic hypoxia, which eventually leads to closure and remodeling of the ductus. PDA in term infants is usually associated with a functional defect, whereas in preterm infants it is associated with immaturity. Normal physiologic mechanisms contributing to closure - oxygen tension and decreased prostaglandins-are altered in prematurity. Clinical signs of ductal patency include murmur, tachycardia, bounding peripheral pulses, and congestive heart failure and associated symptoms. Symptoms are not always present; therefore, diagnostic imaging is critical if a PDA is suspected on clinical grounds. Three management strategies are currently available for PDA: fluid restriction and diuretics (as clinically appropriate), medical intervention, and surgical ligation. Pharmacologic closure can be achieved via administration of intravenous indomethacin or ibuprofen lysine. While both agents have shown similar efficacy, ibuprofen lysine has demonstrated an improved safety profile, particularly in terms of renal effects, compared to indomethacin.
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Affiliation(s)
- James E. Dice
- Department of Pharmacy, Children's Hospital of the King's Daughters, Norfolk, Virginia
| | - Jatinder Bhatia
- Section of Neonatology, Medical College of Georgia, Augusta, Georgia
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Asikainen TM, Chang LY, Coalson JJ, Schneider BK, Waleh NS, Ikegami M, Shannon JM, Winter VT, Grubb P, Clyman RI, Yoder BA, Crapo JD, White CW. Improved lung growth and function through hypoxia-inducible factor in primate chronic lung disease of prematurity. FASEB J 2006; 20:1698-700. [PMID: 16807366 DOI: 10.1096/fj.06-5887fje] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Bronchopulmonary dysplasia (BPD), a chronic lung disease affecting preterm neonates, is associated with significant childhood and adult health problems. Histopathologic features of BPD include impaired vascular and distal airway development. We previously showed that activation of hypoxia-inducible factors (HIFs) by inhibition of prolyl hydroxylase domain-containing proteins (PHDs) is feasible and that it stimulates vascular endothelial growth factor (VEGF)-dependent angiogenesis in vitro. We tested the hypothesis that enhancement of angiogenesis by activation of HIFs improves lung growth and function in prematurely born neonates in vivo. Preterm baboons (125 day+14 day pro re nata O2 model, corresponding to 27 human gestational weeks) were treated for 14 days with intravenous (i.v.) FG-4095, a PHD inhibitor. Notably, 77% of diminished total alveolar surface area in untreated controls was recovered by FG-4095 treatment. Functional significance of the structural changes was indicated by improved oxygenation and lung compliance in FG-4095-treated newborns. Surfactant proteins B and C and saturated phosphatidylcholine were unchanged. Incidence of spontaneous ductus arteriosus closure was increased, likely contributing to lower ratio of pulmonary to systemic blood flow in FG-4095 group. These findings indicate that HIF stimulation by PHD inhibition ameliorates pathological and physiological consequences of BPD.
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Affiliation(s)
- Tiina M Asikainen
- Department of Pediatrics, National Jewish Medical and Research Center, 1400 Jackson St., Rm. J-318, Denver, Colorado 80206, USA
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Hermes-DeSantis ER, Clyman RI. Patent ductus arteriosus: pathophysiology and management. J Perinatol 2006; 26 Suppl 1:S14-8; discussion S22-3. [PMID: 16625216 DOI: 10.1038/sj.jp.7211465] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patent ductus arteriosus (PDA) in preterm newborns prior to 28 weeks of gestation has led to many challenges regarding the type and timing of treatment regimens. A PDA results in increased pulmonary blood flow and redistribution of flow to other organs. Several co-morbidities (i.e., necrotizing enterocolitis, intracranial hemorrhage, pulmonary edema/hemorrhage, bronchopulmonary dysplasia, and retinopathy) are associated with the presence of a PDA, but whether or not a PDA is responsible for their development is still unclear. The prostaglandin inhibitor, indomethacin, is effective in the treatment of PDA. Questions regarding the optimal timing of the intervention--early prophylaxis or treatment, once signs and symptoms become evident--have challenged physicians for decades. Both evidence and experience are explored in this article. Comparative physiology between the full-term and preterm newborn and the barriers preventing the necessary cascade of events leading to permanent constriction of the PDA are reviewed.
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Affiliation(s)
- E R Hermes-DeSantis
- Drug Information Service, Robert Wood Johnson University Hospital, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, New Jersey, USA
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