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Xueyuan L, Yanping X, Jiaoqiong G, Yuehui Y. Autonomic nervous modulation: early treatment for pulmonary artery hypertension. ESC Heart Fail 2024; 11:619-627. [PMID: 38108098 DOI: 10.1002/ehf2.14616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 11/09/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
Pulmonary artery hypertension (PAH) is a chronic vascular disease defined by the elevation of pulmonary vascular resistance and mean pulmonary artery pressure, which arises due to pulmonary vascular remodelling. Prior research has already established a link between the autonomic nervous system (ANS) and PAH. Therefore, the rebalancing of the ANS offers a promising approach for the treatment of PAH. The process of rebalancing involves two key aspects: inhibiting an overactive sympathetic nervous system and fortifying the impaired parasympathetic nervous system through pharmacological or interventional procedures. However, the understanding of the precise mechanisms involved in neuromodulation, whether achieved through medication or intervention, remains insufficient. This limited understanding hinders our ability to determine the appropriate timing and scope of such treatment. This review aims to integrate the findings from clinical and mechanistic studies on ANS rebalancing as a treatment approach for PAH, with the ultimate goal of identifying a path to enhance the safety and efficacy of neuromodulation therapy and improve the prognosis of PAH.
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Affiliation(s)
- Liu Xueyuan
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xu Yanping
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guan Jiaoqiong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yin Yuehui
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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2
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Sandeep B, Cheng H, Yan Y, Huang X, Wu Q, Gao K, Xiao Z. Right ventricle-pulmonary artery coupling in pulmonary artery hypertension its measurement and pharmacotherapy. Curr Probl Cardiol 2024; 49:102425. [PMID: 38311275 DOI: 10.1016/j.cpcardiol.2024.102425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 01/29/2024] [Indexed: 02/09/2024]
Abstract
The right ventricular (RV) function correlates with prognosis in severe pulmonary artery hypertension (PAH) but which metric of it is most clinically relevant is still uncertain. Clinical methods to estimate RV function from simplified pressure volume loops correlate with disease severity but the clinical relevance has not been assessed. Evaluation of right ventricle pulmonary artery coupling in pulmonary hypertensive patients may help to elucidate the mechanisms of right ventricular failure and may also help to identify patients at risk or guide the timing of therapeutic interventions in pulmonary hypertension. Complete evaluation of RV failure requires echocardiographic or magnetic resonance imaging, and right heart catheterization measurements. Treatment of RV failure in PAH relies on decreasing afterload with drugs targeting pulmonary circulation; fluid management to optimize ventricular diastolic interactions; and inotropic interventions to reverse cardiogenic shock. The ability to relate quantitative metrics of RV function in pulmonary artery hypertension to clinical outcomes can provide a powerful tool for management. Such metrics could also be utilized in the future as surrogate endpoints for outcomes and evaluation of response to therapies. This review of literature gives an insight on RV-PA coupling associated with PAH, its types of measurement and pharmacological treatment.
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Affiliation(s)
- Bhushan Sandeep
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
| | - Han Cheng
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
| | - Yifan Yan
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
| | - Xin Huang
- Department of Anesthesiology, West China Hospital of Medicine, Sichuan University, Sichuan 610017, China
| | - Qinghui Wu
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
| | - Ke Gao
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China.
| | - Zongwei Xiao
- Department of Cardio-Thoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan 610017, China
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3
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Wang J, Chen J, Shu L, Zhang R, Dai M, Fang X, Hu Z, Xiao L, Xi Z, Zhang J, Bao M. Carotid Baroreceptor Stimulation Improves Pulmonary Arterial Remodeling and Right Ventricular Dysfunction in Pulmonary Arterial Hypertension. JACC Basic Transl Sci 2024; 9:475-492. [PMID: 38680958 PMCID: PMC11055206 DOI: 10.1016/j.jacbts.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 05/01/2024]
Abstract
Autonomic nervous system imbalance is intricately associated with the severity and prognosis of pulmonary arterial hypertension (PAH). Carotid baroreceptor stimulation (CBS) is a nonpharmaceutical intervention for autonomic neuromodulation. The effects of CBS on monocrotaline-induced PAH were investigated in this study, and its underlying mechanisms were elucidated. The results indicated that CBS improved pulmonary hemodynamic status and alleviated right ventricular dysfunction, improving pulmonary arterial remodeling and right ventricular remodeling, thus enhancing the survival rate of monocrotaline-induced PAH rats. The beneficial effects of CBS treatment on PAH might be mediated through the inhibition of sympathetic overactivation and inflammatory immune signaling pathways.
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Affiliation(s)
- Jing Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Chen
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
- Japan Friendship Hospital (Institute of Clinical Medical Sciences), Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ling Shu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Ruoliu Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Mingyan Dai
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Xuesheng Fang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Zhiling Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Lingling Xiao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Zhaoqing Xi
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Junxia Zhang
- Department of Endocrinology, Taikang Tongji (Wuhan) Hospital, Wuhan, China
| | - Mingwei Bao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
- Cardiovascular Research Institute, Wuhan University, Wuhan, China
- Hubei Key Laboratory of Cardiology, Wuhan, China
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Jasińska-Stroschein M. An updated review of experimental rodent models of pulmonary hypertension and left heart disease. Front Pharmacol 2024; 14:1308095. [PMID: 38259266 PMCID: PMC10800974 DOI: 10.3389/fphar.2023.1308095] [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: 10/05/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Left heart disease (LHD) is the leading cause of pulmonary hypertension (PH). Its recent growth has not been matched by the design of therapeutic agents directly targeting the disease. Effective therapies approved for pulmonary arterial hypertension (PAH) have been shown to be inefficient in patients with PH-LHD. Hence, there is a need for an animal model that would closely mimic PH-LHD in preclinical experiments. The current study describes and compares a number of rodent models of left ventricular failure and their potential to induce PH. It also evaluates whether, and to what extent, common PH models could develop LV failure. Articles were identified in the Pubmed/Medline and Web of Science online electronic databases following the PRISMA Protocol between 1992 and 2022. Quality assessment was carried out using the SYRCLE risk-of-bias tool for animal studies. Publication bias across studies using Egger's regression test statistic, was performed together with sensitivity analysis. A wide spectrum of protocols-135 studies and 207 interventions, was examined, including systemic hypertensive models, pressure-overload-induced HF, model of ischemic heart failure, and metabolic approaches based on high fat diet or metabolic syndrome. The most pronounced alterations in PH-related parameters were demonstrated for the common PH models, but were also seen in animals with LV failure induced by ischemic conditions, pressure overload or metabolic conditions. Models based on aortic banding, transverse aortic constriction (TAC), or with myocardial infarction (MI) caused by coronary artery ligation, demonstrated more pronounced worsening in PH due to LV failure; however, they also demonstrated poor survival, especially the ischemic-HF model. Common PH models, excluding prolonged exposure to monocrotaline, do not promote LV hypertrophy. Prolonged exposure to a high-fat diet, or a two-hit model of an obese ZSF1 rat combined with SU5416-induced pulmonary endothelial impairment (a VEGF receptor antagonist) worsened PH and impaired diastolic dysfunction. Due to the limited number of protocols, further trials are needed to confirm the utility of such approaches for modeling PH in subjects with metabolic syndrome. This would provide a clearer insight into the complexity of LHD, PH and metabolic disorders in PH-LHD, and thus accelerate the development of new therapies in clinical trials.
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de Man FS, Vonk Noordegraaf A. The right ventricle tamed. Eur Respir J 2023; 61:61/5/2300509. [PMID: 37208035 DOI: 10.1183/13993003.00509-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 03/25/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Frances S de Man
- Amsterdam UMC location Vrije Universiteit Amsterdam, PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Amsterdam UMC location Vrije Universiteit Amsterdam, PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
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Hirono K, Imamura T, Tsuboi K, Takarada S, Okabe M, Nakaoka H, Ibuki K, Ozawa S. Optimal Heart Rate May Improve Systolic and Diastolic Function in Patients with Fontan Circulation. J Clin Med 2023; 12:jcm12083033. [PMID: 37109372 PMCID: PMC10146582 DOI: 10.3390/jcm12083033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/07/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
(1) Background: The optimal heart rate, at which the E-wave and A-wave stand adjacent without any overlaps in the Doppler transmitral flow echocardiography, is associated with maximum cardiac output and favorable clinical outcomes in adult patients with systolic heart failure. However, the clinical implication of the echocardiographic overlap length in patients with Fontan circulation remains unknown. We investigated the relationship between heart rate (HR) and hemodynamics in Fontan surgery patients with and without beta-blockers. (2) Methods and Results: A total of 26 patients (median age 1.8 years, 13 males) were enrolled. At baseline, the plasma N-terminal pro-B-type natriuretic peptide was 2439 ± 3483 pg/mL, the fraction area change was 33.5 ± 11.4%, the cardiac index was 3.55 ± 0.90 L/min/m2, and the overlap length was 45.2 ± 59.0 msec. Overlap length was importantly decreased after the one-year follow-up (7.60 ± 78.57 msec, p = 0.0069). Positive correlations were noted between the overlap length and A-wave and E/A ratio (p = 0.0021 and p = 0.0046, respectively). Ventricular end-diastolic pressure was significantly correlated with the overlap length in non-beta-blocker patients (p = 0.0483). (3) Conclusion: Overlap length may reflect the status of ventricular dysfunction. Hemodynamic preservation at lower HR could be critical for cardiac reverse remodeling.
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Affiliation(s)
- Keiichi Hirono
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Teruhiko Imamura
- Second Internal Medicine, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Kaori Tsuboi
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Shinya Takarada
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Mako Okabe
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Hideyuki Nakaoka
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Keijiro Ibuki
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Sayaka Ozawa
- Department of Pediatrics, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
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New Drugs and Therapies in Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24065850. [PMID: 36982922 PMCID: PMC10058689 DOI: 10.3390/ijms24065850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2023] Open
Abstract
Pulmonary arterial hypertension is a chronic, progressive disorder of the pulmonary vasculature with associated pulmonary and cardiac remodeling. PAH was a uniformly fatal disease until the late 1970s, but with the advent of targeted therapies, the life expectancy of patients with PAH has now considerably improved. Despite these advances, PAH inevitably remains a progressive disease with significant morbidity and mortality. Thus, there is still an unmet need for the development of new drugs and other interventional therapies for the treatment of PAH. One shortcoming of currently approved vasodilator therapies is that they do not target or reverse the underlying pathogenesis of the disease process itself. A large body of evidence has evolved in the past two decades clarifying the role of genetics, dysregulation of growth factors, inflammatory pathways, mitochondrial dysfunction, DNA damage, sex hormones, neurohormonal pathways, and iron deficiency in the pathogenesis of PAH. This review focuses on newer targets and drugs that modify these pathways as well as novel interventional therapies in PAH.
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8
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Bekedam FT, Goumans MJ, Bogaard HJ, de Man FS, Llucià-Valldeperas A. Molecular mechanisms and targets of right ventricular fibrosis in pulmonary hypertension. Pharmacol Ther 2023; 244:108389. [PMID: 36940790 DOI: 10.1016/j.pharmthera.2023.108389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/19/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Abstract
Right ventricular fibrosis is a stress response, predominantly mediated by cardiac fibroblasts. This cell population is sensitive to increased levels of pro-inflammatory cytokines, pro-fibrotic growth factors and mechanical stimulation. Activation of fibroblasts results in the induction of various molecular signaling pathways, most notably the mitogen-activated protein kinase cassettes, leading to increased synthesis and remodeling of the extracellular matrix. While fibrosis confers structural protection in response to damage induced by ischemia or (pressure and volume) overload, it simultaneously contributes to increased myocardial stiffness and right ventricular dysfunction. Here, we review state-of-the-art knowledge of the development of right ventricular fibrosis in response to pressure overload and provide an overview of all published preclinical and clinical studies in which right ventricular fibrosis was targeted to improve cardiac function.
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Affiliation(s)
- F T Bekedam
- Amsterdam UMC location Vrije Universiteit Amsterdam, PHEniX laboratory, Department of Pulmonary Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - M J Goumans
- Department of Cell and Chemical Biology, Leiden UMC, 2300 RC Leiden, the Netherlands
| | - H J Bogaard
- Amsterdam UMC location Vrije Universiteit Amsterdam, PHEniX laboratory, Department of Pulmonary Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - F S de Man
- Amsterdam UMC location Vrije Universiteit Amsterdam, PHEniX laboratory, Department of Pulmonary Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands.
| | - A Llucià-Valldeperas
- Amsterdam UMC location Vrije Universiteit Amsterdam, PHEniX laboratory, Department of Pulmonary Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands.
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Soares LL, Leite LB, Ervilha LOG, Silva BAFD, Freitas MOD, Portes AMO, Rezende LMT, Drummond FR, Carneiro MA, Neves MM, Reis ECC, Natali AJ. O Treinamento Físico Resistido Atenua as Disfunções Ventriculares Esquerdas em Modelo de Hipertensão Arterial Pulmonar. Arq Bras Cardiol 2022; 119:574-584. [PMID: 36074480 PMCID: PMC9563884 DOI: 10.36660/abc.20210681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Fundamento A hipertrofia e a dilatação do ventrículo direito observadas na hipertensão arterial pulmonar (HAP) prejudicam a dinâmica do ventrículo esquerdo (VE) achatando o septo interventricular. Objetivo Investigar se o treinamento físico resistido (TFR) de intensidade baixa a moderada é benéfico para funções contráteis do VE e de cardiomiócitos em ratos durante o desenvolvimento de HAP induzida por monocrotalina (MCT). Métodos Foram usados ratos Wistar machos (Peso corporal: ~ 200 g). Para avaliar o tempo até o possível surgimento de insuficiência cardíaca (ou seja, ponto de desfecho), os ratos foram divididos em dois grupos, hipertensão com sedentarismo até a insuficiência (HSI, n=6) e hipertensão com treinamento até a insuficiência (HTI, n=6). Para testar os efeitos do TFR, os ratos foram divididos entre grupos de controle sedentários (CS, n=7), hipertensão com sedentarismo (HS, n=7) e hipertensão com treinamento (HT, n=7). A HAP foi induzida por duas injeções de MCT (20 mg/kg, com um intervalo de 7 dias). Os grupos com treinamento foram submetidos a um protocolo de TFR (subir escadas; 55-65% da máxima carga carregada), 5 dias por semana. A significância estatística foi definida em p <0,05. Resultados O TFR prolongou o ponto de desfecho (~25%), melhorou a tolerância ao esforço físico (~55%) e atenuou as disfunções de contratilidade de VE e de cardiomiócitos promovidas pela MCT preservando a fração de ejeção e o encurtamento fracional, a amplitude do encurtamento, e as velocidades de contração e relaxamento nos cardiomiócitos. O TFR também preveniu os aumentos de fibrose e colágeno tipo I no ventrículo esquerdo causados pela MCT, além de manter as dimensões de miócitos e colágeno tipo III reduzidas por MCT. Conclusão O TFR de intensidade baixa a moderada é benéfico para funções contráteis de VE e cardiomiócitos em ratos durante o desenvolvimento de HAP induzida por MCT.
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Badagliacca R, Mercurio V, Romeo E, Correale M, Masarone D, Papa S, Tocchetti C, Agostoni P. Beta-blockers in pulmonary arterial hypertension: Time for a second thought? Vascul Pharmacol 2022; 144:106974. [DOI: 10.1016/j.vph.2022.106974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/19/2022] [Accepted: 02/26/2022] [Indexed: 11/29/2022]
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Ciccarelli M, Dawson D, Falcao-Pires I, Giacca M, Hamdani N, Heymans S, Hooghiemstra A, Leeuwis A, Hermkens D, Tocchetti CG, van der Velden J, Zacchigna S, Thum T. Reciprocal organ interactions during heart failure: a position paper from the ESC Working Group on Myocardial Function. Cardiovasc Res 2021; 117:2416-2433. [PMID: 33483724 PMCID: PMC8562335 DOI: 10.1093/cvr/cvab009] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/20/2021] [Accepted: 01/08/2021] [Indexed: 12/13/2022] Open
Abstract
Heart failure-either with reduced or preserved ejection fraction (HFrEF/HFpEF)-is a clinical syndrome of multifactorial and gender-dependent aetiology, indicating the insufficiency of the heart to pump blood adequately to maintain blood flow to meet the body's needs. Typical symptoms commonly include shortness of breath, excessive fatigue with impaired exercise capacity, and peripheral oedema, thereby alluding to the fact that heart failure is a syndrome that affects multiple organ systems. Patients suffering from progressed heart failure have a very limited life expectancy, lower than that of numerous cancer types. In this position paper, we provide an overview regarding interactions between the heart and other organ systems, the clinical evidence, underlying mechanisms, potential available or yet-to-establish animal models to study such interactions and finally discuss potential new drug interventions to be developed in the future. Our working group suggests that more experimental research is required to understand the individual molecular mechanisms underlying heart failure and reinforces the urgency for tailored therapeutic interventions that target not only the heart but also other related affected organ systems to effectively treat heart failure as a clinical syndrome that affects and involves multiple organs.
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Affiliation(s)
- Michele Ciccarelli
- University of Salerno, Department of Medicine, Surgery and Dentistry, Via S. Allende 1, 84081, Baronissi(Salerno), Italy
| | - Dana Dawson
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen AB25 2DZ, UK
| | - Inês Falcao-Pires
- Department of Surgery and Physiology, Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Mauro Giacca
- King’s College London, Molecular Medicine Laboratory, 125 Caldharbour Lane, London WC2R2LS, United Kingdom
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Padriciano, 99, 34149 Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume, 447, 34129 Trieste, Italy
| | - Nazha Hamdani
- Department of Clinical Pharmacology and Molecular Cardiology, Institute of Physiology, Ruhr University Bochum, Universitätsstraße 150, D-44801 Bochum, Germany
- Department of Cardiology, St. Josef-Hospital, Ruhr University Bochum, Universitätsstraße 150, D-44801 Bochum, Germany
| | - Stéphane Heymans
- Centre for Molecular and Vascular Biology, KU Leuven, Herestraat 49, Bus 911, 3000 Leuven, Belgium
- Department of Cardiology, Maastricht University, CARIM School for Cardiovascular Diseases, Universiteitssingel 50, 6229 ER Maastricht, the Netherlands
- ICIN-Netherlands Heart Institute, Holland Heart House, Moreelsepark 1, 3511 EP Utrecht, the Netherlands
| | - Astrid Hooghiemstra
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam UMC, Location VUmc, De Boelelaan 1089a, 1081HV, Amsterdam, The Netherlands
| | - Annebet Leeuwis
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081HZ, Amsterdam, The Netherlands
| | - Dorien Hermkens
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105AZ, Amsterdam, the Netherlands
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center of Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | - Jolanda van der Velden
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081HZ Amsterdam, the Netherlands
| | - Serena Zacchigna
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Strada di Fiume, 447, 34129 Trieste, Italy
- Cardiovascular Biology Laboratory, International Centre for Genetic Engineering and Biotechnology (ICGEB), Padriciano, 99, 34149 Trieste, Italy
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
- REBIRTH Center for Translational Regenerative Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine, Nicolai-Fuchs-Str. 1, D-30625 Hannover, Germany
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Kwan ED, Vélez-Rendón D, Zhang X, Mu H, Patel M, Pursell E, Stowe J, Valdez-Jasso D. Distinct time courses and mechanics of right ventricular hypertrophy and diastolic stiffening in a male rat model of pulmonary arterial hypertension. Am J Physiol Heart Circ Physiol 2021; 321:H702-H715. [PMID: 34448637 PMCID: PMC8794227 DOI: 10.1152/ajpheart.00046.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/30/2021] [Accepted: 08/17/2021] [Indexed: 11/22/2022]
Abstract
Although pulmonary arterial hypertension (PAH) leads to right ventricle (RV) hypertrophy and structural remodeling, the relative contributions of changes in myocardial geometric and mechanical properties to systolic and diastolic chamber dysfunction and their time courses remain unknown. Using measurements of RV hemodynamic and morphological changes over 10 wk in a male rat model of PAH and a mathematical model of RV mechanics, we discriminated the contributions of RV geometric remodeling and alterations of myocardial material properties to changes in systolic and diastolic chamber function. Significant and rapid RV hypertrophic wall thickening was sufficient to stabilize ejection fraction in response to increased pulmonary arterial pressure by week 4 without significant changes in systolic myofilament activation. After week 4, RV end-diastolic pressure increased significantly with no corresponding changes in end-diastolic volume. Significant RV diastolic chamber stiffening by week 5 was not explained by RV hypertrophy. Instead, model analysis showed that the increases in RV end-diastolic chamber stiffness were entirely attributable to increased resting myocardial material stiffness that was not associated with significant myocardial fibrosis or changes in myocardial collagen content or type. These findings suggest that whereas systolic volume in this model of RV pressure overload is stabilized by early RV hypertrophy, diastolic dilation is prevented by subsequent resting myocardial stiffening.NEW & NOTEWORTHY Using a novel combination of hemodynamic and morphological measurements over 10 wk in a male rat model of PAH and a mathematical model of RV mechanics, we found that compensated systolic function was almost entirely explained by RV hypertrophy, but subsequently altered RV end-diastolic mechanics were primarily explained by passive myocardial stiffening that was not associated with significant collagen extracellular matrix accumulation.
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MESH Headings
- Animals
- Biomechanical Phenomena
- Diastole
- Disease Models, Animal
- Fibrosis
- Heart Ventricles/pathology
- Heart Ventricles/physiopathology
- Hypertrophy, Right Ventricular/etiology
- Hypertrophy, Right Ventricular/pathology
- Hypertrophy, Right Ventricular/physiopathology
- Male
- Models, Cardiovascular
- Myocardium/pathology
- Pulmonary Arterial Hypertension/complications
- Pulmonary Arterial Hypertension/physiopathology
- Rats, Sprague-Dawley
- Systole
- Time Factors
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/pathology
- Ventricular Dysfunction, Right/physiopathology
- Ventricular Function, Right
- Ventricular Remodeling
- Rats
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Affiliation(s)
- Ethan D Kwan
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Daniela Vélez-Rendón
- Department of Bioengineering, University of Illinois at Chicago, Chicago, Illinois
| | - Xiaoyan Zhang
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Hao Mu
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Megh Patel
- College of Medicine, Texas A&M University, College Station, Texas
| | - Erica Pursell
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Jennifer Stowe
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | - Daniela Valdez-Jasso
- Department of Bioengineering, University of California San Diego, La Jolla, California
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13
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Zolty R. Novel Experimental Therapies for Treatment of Pulmonary Arterial Hypertension. J Exp Pharmacol 2021; 13:817-857. [PMID: 34429666 PMCID: PMC8380049 DOI: 10.2147/jep.s236743] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 07/07/2021] [Indexed: 12/18/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive and devastating disease characterized by pulmonary artery vasoconstriction and vascular remodeling leading to vascular rarefaction with elevation of pulmonary arterial pressures and pulmonary vascular resistance. Often PAH will cause death from right heart failure. Current PAH-targeted therapies improve functional capacity, pulmonary hemodynamics and reduce hospitalization. Nevertheless, today PAH still remains incurable and is often refractory to medical therapy, underscoring the need for further research. Over the last three decades, PAH has evolved from a disease of unknown pathogenesis devoid of effective therapy to a condition whose cellular, genetic and molecular underpinnings are unfolding. This article provides an update on current knowledge and summarizes the progression in recent advances in pharmacological therapy in PAH.
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Affiliation(s)
- Ronald Zolty
- Pulmonary Hypertension Program, University of Nebraska Medical Center, Lied Transplant Center, Omaha, NE, USA
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14
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Spyropoulos F, Michael Z, Finander B, Vitali S, Kosmas K, Zymaris P, Kalish BT, Kourembanas S, Christou H. Acetazolamide Improves Right Ventricular Function and Metabolic Gene Dysregulation in Experimental Pulmonary Arterial Hypertension. Front Cardiovasc Med 2021; 8:662870. [PMID: 34222363 PMCID: PMC8247952 DOI: 10.3389/fcvm.2021.662870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/19/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Right ventricular (RV) performance is a key determinant of mortality in pulmonary arterial hypertension (PAH). RV failure is characterized by metabolic dysregulation with unbalanced anaerobic glycolysis, oxidative phosphorylation, and fatty acid oxidation (FAO). We previously found that acetazolamide (ACTZ) treatment modulates the pulmonary inflammatory response and ameliorates experimental PAH. Objective: To evaluate the effect of ACTZ treatment on RV function and metabolic profile in experimental PAH. Design/Methods: In the Sugen 5416/hypoxia (SuHx) rat model of severe PAH, RV transcriptomic analysis was performed by RNA-seq, and top metabolic targets were validated by RT-PCR. We assessed the effect of therapeutic administration of ACTZ in the drinking water on hemodynamics by catheterization [right and left ventricular systolic pressure (RVSP and LVSP, respectively)] and echocardiography [pulmonary artery acceleration time (PAAT), RV wall thickness in diastole (RVWT), RV end-diastolic diameter (RVEDD), tricuspid annular plane systolic excursion (TAPSE)] and on RV hypertrophy (RVH) by Fulton's index (FI) and RV-to-body weight (BW) ratio (RV/BW). We also examined myocardial histopathology and expression of metabolic markers in RV tissues. Results: There was a distinct transcriptomic signature of RVH in the SuHx model of PAH, with significant downregulation of metabolic enzymes involved in fatty acid transport, beta oxidation, and glucose oxidation compared to controls. Treatment with ACTZ led to a pattern of gene expression suggestive of restored metabolic balance in the RV with significantly increased beta oxidation transcripts. In addition, the FAO transcription factor peroxisome proliferator-activated receptor gamma coactivator 1-alpha (Pgc-1α) was significantly downregulated in untreated SuHx rats compared to controls, and ACTZ treatment restored its expression levels. These metabolic changes were associated with amelioration of the hemodynamic and echocardiographic markers of RVH in the ACTZ-treated SuHx animals and attenuation of cardiomyocyte hypertrophy and RV fibrosis. Conclusion: Acetazolamide treatment prevents the development of PAH, RVH, and fibrosis in the SuHx rat model of severe PAH, improves RV function, and restores the RV metabolic profile.
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Affiliation(s)
- Fotios Spyropoulos
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Zoe Michael
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Benjamin Finander
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Department of Neurobiology, Harvard Medical School, Boston, MA, United States
| | - Sally Vitali
- Harvard Medical School, Boston, MA, United States.,Department of Anesthesia and Critical Care Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Kosmas Kosmas
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Panagiotis Zymaris
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Brian T Kalish
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Department of Neurobiology, Harvard Medical School, Boston, MA, United States
| | - Stella Kourembanas
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Helen Christou
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
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15
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Reddy SA, Nethercott SL, Khialani BV, Grace AA, Martin CA. Management of arrhythmias in pulmonary hypertension. J Interv Card Electrophysiol 2021; 62:219-229. [DOI: 10.1007/s10840-021-00988-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/28/2021] [Indexed: 12/24/2022]
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16
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Zelt JGE, Schock S, deKemp RA, Stewart DJ, Staines WA, Ahmadi A, Beanlands R, Mielniczuk LM. [ 11C]meta-hydroxyephedrine PET evaluation in experimental pulmonary arterial hypertension: Effects of carvedilol of right ventricular sympathetic function. J Nucl Cardiol 2021; 28:407-422. [PMID: 33501547 DOI: 10.1007/s12350-020-02494-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Little is known about the sequelae of chronic sympathetic nervous system (SNS) activation in patients with pulmonary arterial hypertension (PAH) and right heart failure (RHF). We aimed to, (1) validate the use of [11C]-meta-hydroxyephedrine (HED) for assessing right ventricular (RV) SNS integrity, and (2) determine the effects of β-receptor blockade on ventricular function and myocardial SNS activity in a PAH rat model. METHODS PAH was induced in male Sprague-Dawley rats (N = 36) using the Sugen+chronic hypoxia model. At week 5 post-injection, PAH rats were randomized to carvedilol (15 mg·kg-1·day-1 oral; N = 16) or vehicle (N = 16) for 4 weeks. Myocardial SNS function was assessed with HED positron emission tomography(PET). RESULTS With increasing PAH disease severity, immunohistochemistry confirmed selective sympathetic denervation within the RV and sparing of parasympathetic nerves. These findings were confirmed on PET with a significant negative relationship between HED volume of distribution(DV) and right ventricular systolic pressure (RVSP) in the RV (r = -0.90, p = 0.0003). Carvedilol did not reduce hemodynamic severity compared to vehicle. RV ejection fraction (EF) was lower in both PAH groups compared to control (p < 0.05), and was not further reduced by carvedilol. Carvedilol improved SNS function in the LV with significant increases in the HED DV, and decreased tracer washout in the LV (p < 0.05) but not RV. CONCLUSIONS PAH disease severity correlated with a reduction in HED DV in the RV. This was associated with selective sympathetic denervation. Late carvedilol treatment did not lead to recovery of RV function. These results support the role of HED imaging in assessing SNS innervation in a failing right ventricle.
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Affiliation(s)
- Jason G E Zelt
- Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada.
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada.
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Canada.
| | - Sarah Schock
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Robert A deKemp
- Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Duncan J Stewart
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Canada
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, Canada
| | - William A Staines
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Ali Ahmadi
- Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Rob Beanlands
- Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Canada
| | - Lisa M Mielniczuk
- Molecular Function and Imaging Program, The National Cardiac PET Centre, Division of Cardiology, Department of Medicine and the Cardiac Research Methods Centre, University of Ottawa Heart Institute and University of Ottawa, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Division of Cardiology, University of Ottawa Heart Institute and University of Ottawa, Ottawa, Canada
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17
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Peters EL, Bogaard HJ, Vonk Noordegraaf A, de Man FS. Neurohormonal modulation in pulmonary arterial hypertension. Eur Respir J 2021; 58:13993003.04633-2020. [PMID: 33766951 PMCID: PMC8551560 DOI: 10.1183/13993003.04633-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 03/13/2021] [Indexed: 12/15/2022]
Abstract
Pulmonary hypertension is a fatal condition of elevated pulmonary pressures, complicated by right heart failure. Pulmonary hypertension appears in various forms; one of those is pulmonary arterial hypertension (PAH) and is particularly characterised by progressive remodelling and obstruction of the smaller pulmonary vessels. Neurohormonal imbalance in PAH patients is associated with worse prognosis and survival. In this back-to-basics article on neurohormonal modulation in PAH, we provide an overview of the pharmacological and nonpharmacological strategies that have been tested pre-clinically and clinically. The benefit of neurohormonal modulation strategies in PAH patients has been limited by lack of insight into how the neurohormonal system is changed throughout the disease and difficulties in translation from animal models to human trials. We propose that longitudinal and individual assessments of neurohormonal status are required to improve the timing and specificity of neurohormonal modulation strategies. Ongoing developments in imaging techniques such as positron emission tomography may become helpful to determine neurohormonal status in PAH patients in different disease stages and optimise individual treatment responses.
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Affiliation(s)
- Eva L Peters
- Dept of Pulmonology, Amsterdam UMC, Amsterdam, The Netherlands.,Dept of Physiology, Amsterdam UMC, Amsterdam, The Netherlands
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18
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Dignam JP, Scott TE, Kemp-Harper BK, Hobbs AJ. Animal models of pulmonary hypertension: Getting to the heart of the problem. Br J Pharmacol 2021; 179:811-837. [PMID: 33724447 DOI: 10.1111/bph.15444] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 03/06/2021] [Indexed: 12/12/2022] Open
Abstract
Despite recent therapeutic advances, pulmonary hypertension (PH) remains a fatal disease due to the development of right ventricular (RV) failure. At present, no treatments targeted at the right ventricle are available, and RV function is not widely considered in the preclinical assessment of new therapeutics. Several small animal models are used in the study of PH, including the classic models of exposure to either hypoxia or monocrotaline, newer combinational and genetic models, and pulmonary artery banding, a surgical model of pure RV pressure overload. These models reproduce selected features of the structural remodelling and functional decline seen in patients and have provided valuable insight into the pathophysiology of RV failure. However, significant reversal of remodelling and improvement in RV function remains a therapeutic obstacle. Emerging animal models will provide a deeper understanding of the mechanisms governing the transition from adaptive remodelling to a failing right ventricle, aiding the hunt for druggable molecular targets.
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Affiliation(s)
- Joshua P Dignam
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Tara E Scott
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia.,Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University Parkville Campus, Parkville, Victoria, Australia
| | - Barbara K Kemp-Harper
- Department of Pharmacology, Cardiovascular Disease Program, Biomedicine Discovery Institute, Monash University Clayton Campus, Clayton, Victoria, Australia
| | - Adrian J Hobbs
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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19
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Yamasaki Y, Abe K, Kamitani T, Sagiyama K, Hida T, Hosokawa K, Matsuura Y, Hioki K, Nagao M, Yabuuchi H, Ishigami K. Right Ventricular Extracellular Volume with Dual-Layer Spectral Detector CT: Value in Chronic Thromboembolic Pulmonary Hypertension. Radiology 2021; 298:589-596. [PMID: 33497315 DOI: 10.1148/radiol.2020203719] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Right ventricular (RV) extracellular volumes (ECVs), as a surrogate for histologic fibrosis, have not been sufficiently investigated. Purpose To evaluate and compare RV and left ventricular (LV) ECVs obtained with dual-layer spectral detector CT (DLCT) in chronic thromboembolic pulmonary hypertension (CTEPH) and investigate the clinical importance of RV ECV. Materials and Methods Retrospective analysis was performed on data from 31 patients with CTEPH (17 were not treated with pulmonary endarterectomy [PEA] or balloon pulmonary angioplasty [BPA] and 14 were) and eight control subjects who underwent myocardial delayed enhancement (MDE) DLCT from January 2019 to June 2020. The ECVs in the RV and LV walls were calculated by using iodine density as derived from spectral data pertaining to MDE. Statistical analyses were performed with one-way repeated analysis of variance with the Tukey post hoc test or the Kruskal-Wallis test with the Steel-Dwass test and linear regression analysis. Results The PEA- and BPA-naive group showed significantly higher ECVs than the PEA- or BPA-treated group and control group in the septum (28.2% ± 2.9 vs 24.3% ± 3.6, P = .005), anterior right ventricular insertion point (RVIP) (32.9% ± 4.6 vs 25.3% ± 3.6, P < .001), posterior RVIP (35.2% ± 5.2 vs 27.3% ± 4.2, P < .001), mean RVIP (34.0% ± 4.2 vs 26.3% ± 3.4, P < .001), RV free wall (29.5% ± 3.3 vs 25.9% ± 4.1, P = .036), and mean RV wall (29.1% ± 3.0 vs 26.1% ± 3.1, P = .029). There were no significant differences between the PEA- or BPA-treated group and control subjects in these segments (septum, P = .93; anterior RVIP, P = .38; posterior RVIP, P = .52; mean RVIP, P = .36; RV free wall, P = .97; and mean RV, P = .33). There were significant correlations between ECV and mean pulmonary artery pressure (PAP) or brain natriuretic peptide (BNP) in the mean RVIP (mean PAP: R = 0.66, P < .001; BNP: R = 0.44, P = .014) and the mean RV (mean PAP: R = 0.49, P = .005; BNP: R = 0.44, P = .013). Conclusion Right ventricular and right ventricular insertion point extracellular volumes could be noninvasive surrogate markers of disease severity and reverse tissue remodeling in chronic thromboembolic pulmonary hypertension. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Sandfort and Bluemke in this issue.
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Affiliation(s)
- Yuzo Yamasaki
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Kohtaro Abe
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Takeshi Kamitani
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Koji Sagiyama
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Tomoyuki Hida
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Kazuya Hosokawa
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Yuko Matsuura
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Kazuhito Hioki
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Michinobu Nagao
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Hidetake Yabuuchi
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
| | - Kousei Ishigami
- From the Departments of Clinical Radiology (Y.Y., T.K., K.S., T.H., Y.M., K.I.), Cardiovascular Medicine (K.A., K. Hosokawa), and Health Sciences (H.Y.), Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi Higashi-ku, Fukuoka 812-8582, Japan; Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan (K. Hioki); and Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan (M.N.)
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20
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Kearney K, Kotlyar E, Lau EMT. Pulmonary Vascular Disease as a Systemic and Multisystem Disease. Clin Chest Med 2021; 42:167-177. [PMID: 33541610 DOI: 10.1016/j.ccm.2020.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a disease of progressive pulmonary vascular remodeling due to abnormal proliferation of pulmonary vascular endothelial and smooth muscle cells and endothelial dysfunction. PAH is a multisystem disease with systemic manifestations and complications. This article covers the chronic heart failure syndrome, including the systemic consequences of right ventricle-pulmonary artery uncoupling and neurohormonal activation, skeletal and respiratory muscle effects, systemic endothelial dysfunction and coronary artery disease, systemic inflammation and infection, endocrine and metabolic changes, the liver and gut axis, sleep, neurologic complications, and skin and iron metabolic changes.
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Affiliation(s)
- Katherine Kearney
- Cardiology Department, St Vincent's Hospital, 394 Victoria Street, Darlinghurst, New South Wales 2010, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| | - Eugene Kotlyar
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia; Heart Transplant Unit, St Vincent's Hospital, 394 Victoria Street, Darlinghurst, New South Wales 2010, Australia
| | - Edmund M T Lau
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia; Sydney Medical School, University of Sydney, Camperdown, Australia.
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21
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Ishii R, Okumura K, Akazawa Y, Malhi M, Ebata R, Sun M, Fujioka T, Kato H, Honjo O, Kabir G, Kuebler WM, Connelly K, Maynes JT, Friedberg MK. Heart Rate Reduction Improves Right Ventricular Function and Fibrosis in Pulmonary Hypertension. Am J Respir Cell Mol Biol 2021; 63:843-855. [PMID: 32915674 DOI: 10.1165/rcmb.2019-0317oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The potential benefit of heart rate reduction (HRR), independent of β-blockade, on right ventricular (RV) function in pulmonary hypertension (PH) remains undecided. We studied HRR effects on RV fibrosis and function in PH and RV pressure-loading models. Adult rats were randomized to 1) sham controls, 2) monocrotaline (MCT)-induced PH, 3) SU5416 + hypoxia (SUHX)-induced PH, or 4) pulmonary artery banding (PAB). Ivabradine (IVA) (10 mg/kg/d) was administered from 2 weeks after PH induction or PAB. Exercise tolerance, echocardiography, and pressure-volume hemodynamics were obtained at a terminal experiment 3 weeks later. RV myocardial samples were analyzed for putative mechanisms of HRR effects through fibrosis, profibrotic molecular signaling, and Ca++ handling. The effects of IVA versus carvedilol on human induced pluripotent stem cell-derived cardiomyocytes beat rate and relaxation properties were evaluated in vitro. Despite unabated severely elevated RV systolic pressures, IVA improved RV systolic and diastolic function, profibrotic signaling, and RV fibrosis in PH/PAB rats. RV systolic-elastance (control, 121 ± 116; MCT, 49 ± 36 vs. MCT+IVA, 120 ± 54; PAB, 70 ± 20 vs. PAB+IVA, 168 ± 76; SUHX, 86 ± 56 vs. SUHX +IVA, 218 ± 111; all P < 0.05), the time constant of RV relaxation, echo indices of RV function, and fibrosis (fibrosis: control, 4.6 ± 1%; MCT, 13.4 ± 6.5 vs. MCT+IVA, 6.7 ± 2.6%; PAB, 11.4 ± 4.5 vs. PAB+IVA, 6.4 ± 5.1%; SUHX, 10 ± 4.6 vs. SUHX+IVA, 3.9 ± 2.2%; all P < 0.001) were improved by IVA versus controls. IVA had a dose-response effect on induced pluripotent stem cell-derived cardiomyocytes beat rate by delaying Ca++ loss from the cytoplasm. In experimental PH or RV pressure loading, HRR improves RV fibrosis, function, and exercise endurance independent of β-blockade. The balance between adverse tachycardia and bradycardia requires further study, but judicious HRR may provide a promising strategy to improve RV function in clinical PH.
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Affiliation(s)
- Ryo Ishii
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Kenichi Okumura
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Yohei Akazawa
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Manpreet Malhi
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Canada
| | - Ryota Ebata
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Mei Sun
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Tao Fujioka
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Hideyuki Kato
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Osami Honjo
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Golam Kabir
- The Keenan Research Center for Biomedical Research of St. Michael's Hospital, Toronto, Canada; and
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Kim Connelly
- The Keenan Research Center for Biomedical Research of St. Michael's Hospital, Toronto, Canada; and
| | - Jason T Maynes
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Canada
| | - Mark K Friedberg
- The Labatt Family Heart Center, Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children and University of Toronto, Toronto, Canada
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22
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Zheng W, Wang Z, Jiang X, Zhao Q, Shen J. Targeted Drugs for Treatment of Pulmonary Arterial Hypertension: Past, Present, and Future Perspectives. J Med Chem 2020; 63:15153-15186. [PMID: 33314936 DOI: 10.1021/acs.jmedchem.0c01093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a devastating disease that can lead to right ventricular failure and premature death. Although approved drugs have been shown to be safe and effective, PAH remains a severe clinical condition, and the long-term survival of patients with PAH is still suboptimal. Thus, potential therapeutic targets and new agents to treat PAH are urgently needed. In recent years, a variety of related pathways and potential therapeutic targets have been found, which brings new hope for PAH therapy. In this perspective, not only are the marketed drugs used to treat PAH summarized but also the recently developed novel pharmaceutical therapies currently in clinical trials are discussed. Furthermore, the advances in natural products as potential treatment for PAH are also updated.
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Affiliation(s)
- Wei Zheng
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China.,School of Pharmacy, University of the Chinese Academy of Sciences, Beijing 100049, China
| | - Zhen Wang
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Xiangrui Jiang
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Qingjie Zhao
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Jingshan Shen
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China.,School of Pharmacy, University of the Chinese Academy of Sciences, Beijing 100049, China
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23
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Neurohormonal Modulation as a Therapeutic Target in Pulmonary Hypertension. Cells 2020; 9:cells9112521. [PMID: 33266371 PMCID: PMC7700466 DOI: 10.3390/cells9112521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022] Open
Abstract
The autonomic nervous system (ANS) and renin-angiotensin-aldosterone system (RAAS) are involved in many cardiovascular disorders, including pulmonary hypertension (PH). The current review focuses on the role of the ANS and RAAS activation in PH and updated evidence of potential therapies targeting both systems in this condition, particularly in Groups 1 and 2. State of the art knowledge in preclinical and clinical use of pharmacologic drugs (beta-blockers, beta-three adrenoceptor agonists, or renin-angiotensin-aldosterone signaling drugs) and invasive procedures, such as pulmonary artery denervation, is provided.
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24
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Klinke A, Schubert T, Müller M, Legchenko E, Zelt JGE, Shimauchi T, Napp LC, Rothman AMK, Bonnet S, Stewart DJ, Hansmann G, Rudolph V. Emerging therapies for right ventricular dysfunction and failure. Cardiovasc Diagn Ther 2020; 10:1735-1767. [PMID: 33224787 PMCID: PMC7666928 DOI: 10.21037/cdt-20-592] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022]
Abstract
Therapeutic options for right ventricular (RV) dysfunction and failure are strongly limited. Right heart failure (RHF) has been mostly addressed in the context of pulmonary arterial hypertension (PAH), where it is not possible to discern pulmonary vascular- and RV-directed effects of therapeutic approaches. In part, opposing pathomechanisms in RV and pulmonary vasculature, i.e., regarding apoptosis, angiogenesis and proliferation, complicate addressing RHF in PAH. Therapy effective for left heart failure is not applicable to RHF, e.g., inhibition of adrenoceptor signaling and of the renin-angiotensin system had no or only limited success. A number of experimental studies employing animal models for PAH or RV dysfunction or failure have identified beneficial effects of novel pharmacological agents, with most promising results obtained with modulators of metabolism and reactive oxygen species or inflammation, respectively. In addition, established PAH agents, in particular phosphodiesterase-5 inhibitors and soluble guanylate cyclase stimulators, may directly address RV integrity. Promising results are furthermore derived with microRNA (miRNA) and long non-coding RNA (lncRNA) blocking or mimetic strategies, which can target microvascular rarefaction, inflammation, metabolism or fibrotic and hypertrophic remodeling in the dysfunctional RV. Likewise, pre-clinical data demonstrate that cell-based therapies using stem or progenitor cells have beneficial effects on the RV, mainly by improving the microvascular system, however clinical success will largely depend on delivery routes. A particular option for PAH is targeted denervation of the pulmonary vasculature, given the sympathetic overdrive in PAH patients. Finally, acute and durable mechanical circulatory support are available for the right heart, which however has been tested mostly in RHF with concomitant left heart disease. Here, we aim to review current pharmacological, RNA- and cell-based therapeutic options and their potential to directly target the RV and to review available data for pulmonary artery denervation and mechanical circulatory support.
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Affiliation(s)
- Anna Klinke
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Torben Schubert
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Marion Müller
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ekaterina Legchenko
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Jason G. E. Zelt
- Division of Cardiology, University of Ottawa Heart Institute and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Tsukasa Shimauchi
- Pulmonary Hypertension Research Group, Centre de recherche de IUCPQ/Laval University, Quebec, Canada
| | - L. Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Centre de recherche de IUCPQ/Laval University, Quebec, Canada
| | - Duncan J. Stewart
- Division of Cardiology, University of Ottawa Heart Institute and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Volker Rudolph
- Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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25
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Kojonazarov B. Heart Rate Reduction by Ivabradine: Slowly but Surely? Am J Respir Cell Mol Biol 2020; 63:725-726. [PMID: 32946268 PMCID: PMC7790139 DOI: 10.1165/rcmb.2020-0364ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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26
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Galves R, Da Costa A, Pierrard R, Bayard G, Guichard JB, Isaaz K. Impact of β-blocker therapy on right ventricular function in heart failure patients with reduced ejection fraction. A prospective evaluation. Echocardiography 2020; 37:1392-1398. [PMID: 32815195 DOI: 10.1111/echo.14813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Beta-blocker (β-blocker) therapy has been shown to improve mortality and reduce hospitalizations in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Although the physiological action mechanisms of β-blockers are well described, their effects on right ventricular (RV) function have not been prospectively studied. OBJECTIVE This prospective study aimed to (a) evaluate whether β-blocker therapy impacts RV remodeling based on echo parameters and (b) determine the predictive echo factors of β-blocker therapy response. METHODS From September 2017 to September 2018, HF patients were prospectively enrolled using CIBIS criteria: Class II, III, or IV HF; left ventricular ejection fraction (LVEF) of ≤40%; hospitalized for HF within the previous 12 months. Echo evaluation was performed before initiating β-blocker therapy and 3 months after optimal dose adjustment. Based on previous studies, patients with (absolute) LVEF ≥ 5% improvement were considered significant β-blocker therapy responders. RESULTS Overall, 40 patients (pts) completed the study, characterized as follows by age: 70 ± 10 years; gender: 10 women; cardiomyopathy etiology: idiopathic in 24 and ischemic in 16; NYHA Class: II in 22 and III in 10; LVEF: 32 ± 5%; and NTProBNP: 2665 ± 2400 pg/mL. The final population comprised 32 pts (79%), with eight (21%) excluded: two because of β-blocker therapy intolerance, one lost to follow-up, and five withdrew from the study. Under β-blocker therapy, several echo parameters significantly improved: LVEF from 31.7 ± 9 to 40.5 ± 9 (P < .0001); LV end-diastolic volume (EDV) from 154 ± 54 to 143 ± 45 mL (P = .06); LV end-systolic volume (ESV) from 107 ± 49 to 88 ± 37 mL (P = .0006); LV ES from 46 ± 11 to 64 ± 13 mL (P = .008); LV end-diastolic diameter (EDD) from 57 ± 9 to 54 ± 6 mm (P = .04); LV end-systolic diameter (ESD) from 48 ± 10 to 44 ± 7 mm (P = .007); and right ventricular systolic pressure (RV SP) from 39 ± 10 to 32 ± 8 mm Hg (P = .0001). Significant modifications were observed in terms of RV echo parameters: right ventricular (RV) size decreased from 30 ± 4 to 27 ± 5 mm (P = .03), while RV systolic function significantly improved based on tricuspid annular plane systolic excursion (TAPSE) (16.5 ± 4 vs. 19 ± 4 mm; 0.0006); DTI-derived tricuspid lateral annular systolic velocity wave (S') (10 ± 2 vs. 11.3 ± 3 cm/s; P = .03); and RIMP (Tei index) (0.5 ± 0.1 vs 0.46 ± 0.1; P = .04). RV 2D fractional area change (%) did not significantly differ despite a clear improvement tendency (35 ± 6 vs. 37 ± 4%; P = .1). No significant modifications were observed concerning LV diastolic parameters. Overall, β-blocker echo responders (n = 23/32; 72%) exhibited the same left and right echo parameters. No echo variables predicted the β-blocker response. CONCLUSIONS In HFrEF pts, β-blocker therapy significantly improves LV and RV systolic remodeling. Accordingly, β-blocker therapy could be applied as soon as possible in HFrEF patients with right ventricular dysfunction so as to limit RV remodeling.
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Affiliation(s)
- Rémi Galves
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
| | - Antoine Da Costa
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
| | - Romain Pierrard
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
| | - Geoffrey Bayard
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
| | | | - Karl Isaaz
- Division of Cardiology CHU Saint Etienne, Jean Monnet University, Saint-Etienne, France
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27
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Omura J, Habbout K, Shimauchi T, Wu WH, Breuils-Bonnet S, Tremblay E, Martineau S, Nadeau V, Gagnon K, Mazoyer F, Perron J, Potus F, Lin JH, Zafar H, Kiely DG, Lawrie A, Archer SL, Paulin R, Provencher S, Boucherat O, Bonnet S. Identification of Long Noncoding RNA H19 as a New Biomarker and Therapeutic Target in Right Ventricular Failure in Pulmonary Arterial Hypertension. Circulation 2020; 142:1464-1484. [PMID: 32698630 DOI: 10.1161/circulationaha.120.047626] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Right ventricular (RV) function is the major determinant for both functional capacity and survival in patients with pulmonary arterial hypertension (PAH). Despite the recognized clinical importance of preserving RV function, the subcellular mechanisms that govern the transition from a compensated to a decompensated state remain poorly understood and as a consequence there are no clinically established treatments for RV failure and a paucity of clinically useful biomarkers. Accumulating evidence indicates that long noncoding RNAs are powerful regulators of cardiac development and disease. Nonetheless, their implication in adverse RV remodeling in PAH is unknown. METHODS Expression of the long noncoding RNA H19 was assessed by quantitative PCR in plasma and RV from patients categorized as control RV, compensated RV or decompensated RV based on clinical history and cardiac index. The impact of H19 suppression using GapmeR was explored in 2 rat models mimicking RV failure, namely the monocrotaline and pulmonary artery banding. Echocardiographic, hemodynamic, histological, and biochemical analyses were conducted. In vitro gain- and loss-of-function experiments were performed in rat cardiomyocytes. RESULTS We demonstrated that H19 is upregulated in decompensated RV from PAH patients and correlates with RV hypertrophy and fibrosis. Similar findings were observed in monocrotaline and pulmonary artery banding rats. We found that silencing H19 limits pathological RV hypertrophy, fibrosis and capillary rarefaction, thus preserving RV function in monocrotaline and pulmonary artery banding rats without affecting pulmonary vascular remodeling. This cardioprotective effect was accompanied by E2F transcription factor 1-mediated upregulation of enhancer of zeste homolog 2. In vitro, knockdown of H19 suppressed cardiomyocyte hypertrophy induced by phenylephrine, while its overexpression has the opposite effect. Finally, we demonstrated that circulating H19 levels in plasma discriminate PAH patients from controls, correlate with RV function and predict long-term survival in 2 independent idiopathic PAH cohorts. Moreover, H19 levels delineate subgroups of patients with differentiated prognosis when combined with the NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels or the risk score proposed by both REVEAL (Registry to Evaluate Early and Long-Term PAH Disease Management) and the 2015 European Pulmonary Hypertension Guidelines. CONCLUSIONS Our findings identify H19 as a new therapeutic target to impede the development of maladaptive RV remodeling and a promising biomarker of PAH severity and prognosis.
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Affiliation(s)
- Junichi Omura
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Karima Habbout
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Tsukasa Shimauchi
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Wen-Hui Wu
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.).,Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, China (W-H.W.)
| | - Sandra Breuils-Bonnet
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Eve Tremblay
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Sandra Martineau
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Valérie Nadeau
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Kassandra Gagnon
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Florence Mazoyer
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Jean Perron
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.)
| | - Francois Potus
- Department of Medicine, Queen's University, Kingston, ON, Canada (F.P., S.L.A.)
| | - Jian-Hui Lin
- Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, UK (J-H.L., H.Z., D.G.K., A.L.)
| | - Hamza Zafar
- Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, UK (J-H.L., H.Z., D.G.K., A.L.).,Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, UK (H.Z., D.G.K.)
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, UK (J-H.L., H.Z., D.G.K., A.L.).,Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, UK (H.Z., D.G.K.)
| | - Allan Lawrie
- Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, UK (J-H.L., H.Z., D.G.K., A.L.)
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, ON, Canada (F.P., S.L.A.)
| | - Roxane Paulin
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.).,Department of Medicine, Université Laval, Québec, QC, Canada (R.P., S.P., O.B., S.B.)
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.).,Department of Medicine, Université Laval, Québec, QC, Canada (R.P., S.P., O.B., S.B.)
| | - Olivier Boucherat
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.).,Department of Medicine, Université Laval, Québec, QC, Canada (R.P., S.P., O.B., S.B.)
| | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Center de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada (J.O., K.H., T.S., W-H.W., S.B-B., E.T., S.M., V.N., K.G., F.M., J.P., R.P., S.P., O.B., S.B.).,Department of Medicine, Université Laval, Québec, QC, Canada (R.P., S.P., O.B., S.B.)
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28
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Chen J, Luo J, Yang X, Ouyang M, Zhu T, Li Y, Luo P, Chen Y, Li Z, Li J. Expression of ApoA5 and its function in the right ventricular failing and remodeling secondary to pulmonary hypertension. J Cell Physiol 2020; 236:1013-1024. [PMID: 32602585 DOI: 10.1002/jcp.29911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/15/2020] [Indexed: 11/08/2022]
Abstract
Right heart failure and right ventricular (RV) remodeling were the main reason for mortality of pulmonary hypertension (PH) patients. Apolipoprotein AV (ApoA5) is a key regulator of plasma triglyceride and have multifunction in several target organs. We detected decreased ApoA5 in serum of patients with PH and both in serum and RV of monocrotaline-induced PH model. Exogenously, overexpression ApoA5 by adenovirus showed protective effects on RV failure and RV fibrosis secondary to PH. In addition, in vitro experiments showed ApoA5 attenuated the activation of fibroblast induced by transforming growth factor β1 and synthesis and secretion of extracellular matrix by inhibiting focal adhesion kinase-c-Jun N-terminal kinase-Smad3 pathway. Finally, we suggest that ApoA5 may potentially be a pivotal target for RV failure and fibrosis secondary of PH.
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Affiliation(s)
- Jingyuan Chen
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jun Luo
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xiaojie Yang
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Minzhi Ouyang
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China.,Department of Ultrasound, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Tengteng Zhu
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yuanchang Li
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Peng Luo
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yusi Chen
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zilu Li
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jiang Li
- Department of Cardiovascular Medicine, Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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Taverne YJHJ, Sadeghi A, Bartelds B, Bogers AJJC, Merkus D. Right ventricular phenotype, function, and failure: a journey from evolution to clinics. Heart Fail Rev 2020; 26:1447-1466. [PMID: 32556672 PMCID: PMC8510935 DOI: 10.1007/s10741-020-09982-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The right ventricle has long been perceived as the "low pressure bystander" of the left ventricle. Although the structure consists of, at first glance, the same cardiomyocytes as the left ventricle, it is in fact derived from a different set of precursor cells and has a complex three-dimensional anatomy and a very distinct contraction pattern. Mechanisms of right ventricular failure, its detection and follow-up, and more specific different responses to pressure versus volume overload are still incompletely understood. In order to fully comprehend right ventricular form and function, evolutionary biological entities that have led to the specifics of right ventricular physiology and morphology need to be addressed. Processes responsible for cardiac formation are based on very ancient cardiac lineages and within the first few weeks of fetal life, the human heart seems to repeat cardiac evolution. Furthermore, it appears that most cardiogenic signal pathways (if not all) act in combination with tissue-specific transcriptional cofactors to exert inductive responses reflecting an important expansion of ancestral regulatory genes throughout evolution and eventually cardiac complexity. Such molecular entities result in specific biomechanics of the RV that differs from that of the left ventricle. It is clear that sole descriptions of right ventricular contraction patterns (and LV contraction patterns for that matter) are futile and need to be addressed into a bigger multilayer three-dimensional picture. Therefore, we aim to present a complete picture from evolution, formation, and clinical presentation of right ventricular (mal)adaptation and failure on a molecular, cellular, biomechanical, and (patho)anatomical basis.
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Affiliation(s)
- Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Room Rg627, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands. .,Division of Experimental Cardiology, Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands. .,Unit for Cardiac Morphology and Translational Electrophysiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Amir Sadeghi
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Room Rg627, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Beatrijs Bartelds
- Division of Pediatrics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Room Rg627, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Daphne Merkus
- Division of Experimental Cardiology, Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Razee A, Umar S. Editorial Commentary: Pulmonary Artery Denervation for Pulmonary Hypertension: Recent Updates and Future Perspectives. Trends Cardiovasc Med 2020; 31:261-263. [PMID: 32434044 DOI: 10.1016/j.tcm.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 05/03/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Asif Razee
- Department of Anesthesiology and Perioperative medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Soban Umar
- Department of Anesthesiology and Perioperative medicine, Division of Molecular Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
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31
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Pulmonary artery denervation for pulmonary arterial hypertension. Trends Cardiovasc Med 2020; 31:252-260. [PMID: 32413394 DOI: 10.1016/j.tcm.2020.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 01/18/2023]
Abstract
Pulmonary arterial hypertension remains a progressive, life-limiting disease despite optimal medical therapy. Pulmonary artery denervation has arisen as a novel intervention in the treatment of pulmonary arterial hypertension, and other forms of pulmonary hypertension, with the aim of reducing the sympathetic activity of the pulmonary circulation. Pre-clinical studies and initial clinical trials have demonstrated that the technique can be performed safely with some positive effects on clinical, haemodynamic and echocardiographic markers of disease. The scope of the technique in current practice remains limited given the absence of well-designed, large-scale, international randomised controlled clinical trials. This review provides an overview of this exciting new treatment modality, including pathophysiology, technical innovations and recent trial results.
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Rothman AMK, Vachiery JL, Howard LS, Mikhail GW, Lang IM, Jonas M, Kiely DG, Shav D, Shabtay O, Avriel A, Lewis GD, Rosenzweig EB, Kirtane AJ, Kim NH, Mahmud E, McLaughlain VV, Chetcuti S, Leon MB, Ben-Yehuda O, Rubin LJ. Intravascular Ultrasound Pulmonary Artery Denervation to Treat Pulmonary Arterial Hypertension (TROPHY1): Multicenter, Early Feasibility Study. JACC Cardiovasc Interv 2020; 13:989-999. [PMID: 32327095 DOI: 10.1016/j.jcin.2019.12.027] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 11/25/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to investigate whether therapeutic intravascular ultrasound pulmonary artery denervation (PDN) is safe and reduces pulmonary vascular resistance (PVR) in patients with pulmonary arterial hypertension (PAH) on a minimum of dual oral therapy. BACKGROUND Early studies have suggested that PDN can reduce PVR in patients with PAH. METHODS TROPHY1 (Treatment of Pulmonary Hypertension 1) was a multicenter, international, open-label trial undertaken at 8 specialist centers. Patients 18 to 75 years of age with PAH were eligible if taking dual oral or triple nonparenteral therapy and not responsive to acute vasodilator testing. Eligible patients underwent PDN (TIVUS System). The primary safety endpoint was procedure-related adverse events at 30 days. Secondary endpoints included procedure-related adverse events, disease worsening and death to 12 months, and efficacy endpoints that included change in pulmonary hemodynamic status, 6-min walk distance, and quality of life from baseline to 4 or 6 months. Patients were to remain on disease-specific medication for the duration of the study. RESULTS Twenty-three patients underwent PDN, with no procedure-related serious adverse events reported. The reduction in PVR at 4- or 6-month follow-up was 94 ± 151 dyn·s·cm-5 (p = 0.001) or 17.8%, which was associated with a 42 ± 63 m (p = 0.02) increase in 6-min walk distance and a 671 ± 1,555 step (p = 0.04) increase in daily activity. CONCLUSIONS In this multicenter early feasibility study, PDN with an intravascular ultrasound catheter was performed without procedure-related adverse events and was associated with a reduction in PVR and increases in 6-min walk distance and daily activity in patients with PAH on background dual or triple therapy.
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Affiliation(s)
- Alexander M K Rothman
- University of Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom.
| | - Jean-Luc Vachiery
- Cliniques Universitaires de Bruxelles, Erasme Hospital, Brussels, Belgium
| | - Luke S Howard
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ghada W Mikhail
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | - David G Kiely
- University of Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | | | | | | | | | - Erika B Rosenzweig
- University of Columbia Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Ajay J Kirtane
- University of Columbia Medical Center, NewYork-Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Nick H Kim
- University of California, San Diego, San Diego, California
| | | | | | | | - Martin B Leon
- University of Columbia Medical Center, NewYork-Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | | | - Lewis J Rubin
- University of California, San Diego, San Diego, California
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Rijnierse MT, Groeneveldt JA, van Campen JSJA, de Boer K, van der Bruggen CEE, Harms HJ, Raijmakers PG, Lammertsma AA, Knaapen P, Bogaard HJ, Westerhof BE, Vonk Noordegraaf A, Allaart CP, de Man FS. Bisoprolol therapy does not reduce right ventricular sympathetic activity in pulmonary arterial hypertension patients. Pulm Circ 2020; 10:2045894019873548. [PMID: 32363028 PMCID: PMC7187746 DOI: 10.1177/2045894019873548] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/29/2019] [Indexed: 11/27/2022] Open
Abstract
Right ventricular (RV) function and autonomic dysfunction are important
determinants of morbidity and mortality in patients with pulmonary arterial
hypertension (PAH). Although successful in animal studies, effects of
beta-blocker therapy on RV function in clinical trials were disappointing. To
understand this discrepancy, we studied whether beta-blocker therapy changes RV
sympathetic activity. Idiopathic PAH (IPAH) patients received beta-blocker
therapy (uptitrated to a maximal tolerated dose) and underwent cardiac magnetic
resonance imaging, right heart catheterization, and a
[11C]-hydroxyephedrine positron emission tomography
([11C]HED PET) scan at baseline to determine, respectively, RV
ejection fraction (RVEF), RV pressures, and sympathetic activity.
[11C]HED, a norepinephrine analogue, allows determination of
sympathetic innervation of the RV. [11C]HED retention index reflects
norepinephrine transporter activity. As a consequence of excessive catecholamine
levels in the synaptic cleft, this transporter may be downregulated. Therefore,
low [11C]HED retention index indicates high sympathetic activity. 13
IPAH patients underwent [11C]HED PET scans at baseline and after
bisoprolol treatment. Although heart rate was reduced, systemic modulation of
autonomic activity by bisoprolol did not affect local RV sympathetic nerve
activity, RV function, or RV wall tension. In PAH patients, RV
[11C]HED retention index was lower compared to LV tracer uptake
(p<0.01) and was related to systolic wall tension (R2 = 0.4731,
p<0.01) and RV function (R2 = 0.44, p = 0.01). In RV failure, the
tolerated dosage of bisoprolol did not result in an improvement of RV function
nor in a reduction in RV sympathetic activity.
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Affiliation(s)
- Mischa T Rijnierse
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Joanne A Groeneveldt
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jasmijn S J A van Campen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Karin de Boer
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cathelijne E E van der Bruggen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Hendrik J Harms
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Pieter G Raijmakers
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Adriaan A Lammertsma
- Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Paul Knaapen
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Harm Jan Bogaard
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Berend E Westerhof
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Medical Biology, Section of Systems Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Cornelis P Allaart
- Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Frances S de Man
- Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Dang Z, Su S, Jin G, Nan X, Ma L, Li Z, Lu D, Ge R. Tsantan Sumtang attenuated chronic hypoxia-induced right ventricular structure remodeling and fibrosis by equilibrating local ACE-AngII-AT1R/ACE2-Ang1-7-Mas axis in rat. JOURNAL OF ETHNOPHARMACOLOGY 2020; 250:112470. [PMID: 31862407 DOI: 10.1016/j.jep.2019.112470] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 12/02/2019] [Accepted: 12/09/2019] [Indexed: 06/10/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Tsantan Sumtang, which consists of Choerospondias axillaris (Roxb.) Burtt et Hill, Myristica fragrans Houtt and Santalum album L, is a traditional and common prescription of Tibetan medicine. Tsantan Sumtang originates from Four Tantra with properties of nourishing heart and has been used as a folk medicine for cardiovascular diseases and heart failure in Qinghai, Tibet and Inner Mongolia. Our previous studies found that Tsantan Sumtang showed beneficial effects on right ventricular structure in hypoxia rats, while the underling mechanism remains unclear. AIM OF THE STUDY To elucidate the underlying mechanisms of Tsantan Sumtang attenuated right ventricular (RV) remodeling and fibrosis of chronic hypoxia-induced pulmonary arterial hypertension (HPAH) rats. MATERIALS AND METHODS Fifty male Sprague Dawley (SD) rats (170 ± 20 g) were randomly divided into control group, hypoxia group, and hypoxia + Tsantan Sumtang groups (1.0 g· kg-1·day-1, 1.25 g· kg-1·day-1, 1.5 g ·kg-1·day-1). Rats in the hypoxia group and hypoxia + Tsantan Sumtang groups were maintained in a hypobaric chamber by adjusting the inner pressure and oxygen content to simulate an altitude of 4500 m for 28 days. The mean pulmonary arterial pressure (mPAP), right ventricle hypertrophy index (RVHI), the ratio of RV weight to tibia length (TL) (RV/TL), heart rate (HR) and RV systolic pressure (RVSP) was determined. Histomorphological assay of RV structure was evaluated by hematoxylin and eosin (HE) staining. RV tissue fibrosis was assessed by collagen proportion area (CPA), collagen I, collagen III and hydroxyproline content. CPA was obtained by picro-sirius red staining (PSR). The expression of collagen I and collagen III were detected by immunohistochemistry and western blotting. The hydroxyproline content was detected by alkaline hydrolysis. In addition, the level of angiotensin II (AngII) and angiotensin 1-7 (Ang1-7) in RV tissue was tested by enzyme-linked immune sorbent assay (ELISA). Protein expression of angiotensin-converting enzyme (ACE), AngII, AngII type 1 receptor (AT1R), angiotensin-converting enzyme 2 (ACE2), Mas receptor (Mas) were determined by immunohistochemistry and western blotting. mRNA level of ACE, AT1R, ACE2, Mas were tested by qPCR. The chemical profile of Tsantan Sumtang was revealed by UHPLC-Q-Exactive hybrid quadrupole-orbitrap mass analysis. RESULTS Our results showed that RVHI, RV/TL and RVSP were significantly increased in HPAH rat. Furthermore, levels of collagen I, collagen III and hydroxyproline were up-regulated in RV tissue under hypoxia. We found that RV hypertrophy and fibrosis were associated with increased expression of ACE, AngII, AT1R as well as decreased expression of ACE2, Ang1-7 and Mas. RV remodeling and fibrosis were attenuated after Tsantan Sumtang administration by up-regulating ACE2 and Mas level as well as down-regulating ACE, AngII and AT1R levels in RV tissue. 35 constituents in Tsantan Sumtang were identified. CONCLUSION Tsantan Sumtang attenuated RV remodeling and fibrosis in rat exposed to chronic hypoxia. The pharmacological effect of Tsantan Sumtang was based on equilibrating ACE-AngII-AT1R and ACE2-Ang1-7-Mas axis of RV tissue in HPAH rat.
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Affiliation(s)
- Zhancui Dang
- Research Center for High Altitude Medicine, Qinghai University, Xining, 810001, China; Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Xining, 810001, China; Medical College, Qinghai University, Xining, 810001, China
| | - Shanshan Su
- Technical Center of Xining Customs District, Key Laboratory of Food Safety Research in Qinghai Province, Xining, 810003, China
| | - Guoen Jin
- Research Center for High Altitude Medicine, Qinghai University, Xining, 810001, China; Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Xining, 810001, China
| | - Xingmei Nan
- Medical College, Qinghai University, Xining, 810001, China
| | - Lan Ma
- Research Center for High Altitude Medicine, Qinghai University, Xining, 810001, China; Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Xining, 810001, China
| | - Zhanqiang Li
- Research Center for High Altitude Medicine, Qinghai University, Xining, 810001, China; Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Xining, 810001, China.
| | - Dianxiang Lu
- Research Center for High Altitude Medicine, Qinghai University, Xining, 810001, China; Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Xining, 810001, China.
| | - Rili Ge
- Research Center for High Altitude Medicine, Qinghai University, Xining, 810001, China; Key Laboratory of Application and Foundation for High Altitude Medicine Research in Qinghai Province (Qinghai-Utah Joint Research Key Lab for High Altitude Medicine), Xining, 810001, China.
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Maron BA, Leopold JA, Hemnes AR. Metabolic syndrome, neurohumoral modulation, and pulmonary arterial hypertension. Br J Pharmacol 2020; 177:1457-1471. [PMID: 31881099 DOI: 10.1111/bph.14968] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
Abstract
Pulmonary vascular disease, including pulmonary arterial hypertension (PAH), is increasingly recognized to be affected by systemic alterations including up-regulation of the renin-angiotensin-aldosterone system and perturbations to metabolic pathways, particularly glucose and fat metabolism. There is increasing preclinical and clinical data that each of these pathways can promote pulmonary vascular disease and right heart failure and are not simply disease markers. More recently, trials of therapeutics aimed at neurohormonal activation or metabolic dysfunction are beginning to shed light on how interventions in these pathways may affect patients with PAH. This review will focus on underlying mechanistic data that supports neurohormonal activation and metabolic dysfunction in the pathogenesis of PAH and right heart failure as well as discussing early translational data in patients with PAH.
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Affiliation(s)
- Bradley A Maron
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jane A Leopold
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Pulmonary Artery Denervation as an Innovative Treatment for Pulmonary Hypertension With and Without Heart Failure. Cardiol Rev 2020; 29:89-95. [PMID: 32032132 DOI: 10.1097/crd.0000000000000299] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pulmonary hypertension (PH) is categorized into 5 groups based on etiology. The 2 most prevalent forms are pulmonary arterial hypertension (PAH) and PH due to left heart disease (PH-LHD). Therapeutic options do exist for PAH to decrease symptoms and improve functional capacity; however, the mortality rate remains high and clinical improvements are limited. PH-LHD is the most common cause of PH; however, no treatment exists and the use of PAH-therapies is discouraged. Pulmonary artery denervation (PADN) is an innovative catheter-based ablation technique targeting the afferent and efferent fibers of a baroreceptor reflex in the main pulmonary artery (PA) trunk and its bifurcation. This reflex is involved in the elevation of the PA pressure seen in PH. Since 2013, both animal trials and human trials have shown the efficacy of PADN in improving PAH, including improved hemodynamic parameters, increased functional capacity, decreased PA remodeling, and much more. PADN has been shown to decrease the rate of rehospitalization, PH-related complications, and death, and is an overall safe procedure. PADN has also been shown to be effective for PH-LHD. Additional therapeutic mechanisms and benefits of PADN are discussed along with new PADN techniques. PADN has shown efficacy and safety as a potential treatment option for PH.
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Prins KW, Thenappan T, Weir EK, Kalra R, Pritzker M, Archer SL. Repurposing Medications for Treatment of Pulmonary Arterial Hypertension: What's Old Is New Again. J Am Heart Assoc 2020; 8:e011343. [PMID: 30590974 PMCID: PMC6405714 DOI: 10.1161/jaha.118.011343] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Kurt W Prins
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Thenappan Thenappan
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - E Kenneth Weir
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Rajat Kalra
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
| | - Marc Pritzker
- 1 Cardiovascular Division University of Minnesota Medical School Minneapolis MN
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Antigny F, Mercier O, Humbert M, Sabourin J. Excitation-contraction coupling and relaxation alteration in right ventricular remodelling caused by pulmonary arterial hypertension. Arch Cardiovasc Dis 2020; 113:70-84. [DOI: 10.1016/j.acvd.2019.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/18/2019] [Accepted: 10/23/2019] [Indexed: 02/09/2023]
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Tello K, Seeger W, Naeije R, Vanderpool R, Ghofrani HA, Richter M, Tedford RJ, Bogaard HJ. Right heart failure in pulmonary hypertension: Diagnosis and new perspectives on vascular and direct right ventricular treatment. Br J Pharmacol 2019; 178:90-107. [PMID: 31517994 DOI: 10.1111/bph.14866] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/15/2019] [Accepted: 09/04/2019] [Indexed: 12/18/2022] Open
Abstract
Adaptation of right ventricular (RV) function to increased afterload-known as RV-arterial coupling-is a key determinant of prognosis in pulmonary hypertension. However, measurement of RV-arterial coupling is a complex, invasive process involving analysis of the RV pressure-volume relationship during preload reduction over multiple cardiac cycles. Simplified methods have therefore been proposed, including echocardiographic and cardiac MRI approaches. This review describes the available methods for assessment of RV function and RV-arterial coupling and the effects of pharmacotherapy on these variables. Overall, pharmacotherapies for pulmonary hypertension have shown beneficial effects on various measures of RV function, but it is often unclear if these are direct RV effects or indirect results of afterload reduction. Studies of the effects of pharmacotherapies on RV-arterial coupling are limited and mostly restricted to experimental models. Simplified methods to assess RV-arterial coupling should be validated and incorporated into routine clinical follow-up and future clinical trials. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.1/issuetoc.
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Affiliation(s)
- Khodr Tello
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Robert Naeije
- Physiology, Erasme University Hospital, Brussels, Belgium
| | | | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Manuel Richter
- Department of Internal Medicine, Justus-Liebig-University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Harm J Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Ntiloudi D, Qanud K, Tomaio JN, Giannakoulas G, Al-Abed Y, Zanos S. Pulmonary arterial hypertension: the case for a bioelectronic treatment. Bioelectron Med 2019; 5:20. [PMID: 32232109 PMCID: PMC7098229 DOI: 10.1186/s42234-019-0036-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/08/2019] [Indexed: 12/16/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease of unknown etiology that progresses to right ventricular failure. It has a complex pathophysiology, which involves an imbalance between vasoconstrictive and vasodilative processes in the pulmonary circulation, pulmonary vasoconstriction, vascular and right ventricular remodeling, systemic inflammation, and autonomic imbalance, with a reduced parasympathetic and increased sympathetic tone. Current pharmacological treatments for PAH include several classes of drugs that target signaling pathways in vascular biology and cardiovascular physiology, but they can have severe unwanted effects and they do not typically stop the progression of the disease. Pulmonary artery denervation has been tested clinically as a method to suppress sympathetic overactivation, however it is a nonspecific and irreversible intervention. Bioelectronic medicine, in particular vagus nerve stimulation (VNS), has been used in cardiovascular disorders like arrhythmias, heart failure and arterial hypertension and could, in principle, be tested as a treatment in PAH. VNS can produce pulmonary vasodilation and renormalize right ventricular function, via activation of pulmonary and cardiac vagal fibers. It can suppress systemic inflammation, via activation of fibers that innervate the spleen. Finally, VNS can gradually restore the balance between parasympathetic and sympathetic tone by regulating autonomic reflexes. Preclinical studies support the feasibility of using VNS in PAH. However, there are challenges with such an approach, arising from the need to affect a relatively small number of relevant vagal fibers, and the potential for unwanted cardiac and noncardiac effects of VNS in this sensitive patient population.
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Affiliation(s)
- Despοina Ntiloudi
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA.,2Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
| | - Khaled Qanud
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | - Jacquelyn-Nicole Tomaio
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | | | - Yousef Al-Abed
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
| | - Stavros Zanos
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY 11030 USA
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41
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Kaley VR, Aregullin EO, Samuel BP, Vettukattil JJ. Trends in the off-label use of β-blockers in pediatric patients. Pediatr Int 2019; 61:1071-1080. [PMID: 31571355 DOI: 10.1111/ped.14015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 06/10/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
The use of US Food and Drug Administration (FDA)-approved drugs for the treatment of an unapproved indication or in an unapproved age group, or at doses or route of administration not indicated on the label is known as off-label use. Off-label use may be beneficial in circumstances when the standard-of-care treatment has failed, and/or no other FDA-approved medications are available for a particular condition. In pediatric patients, off-label use may increase the risk of adverse events as pharmacokinetic and pharmacodynamic data are limited in children. Approximately 73% of off-label drugs currently prescribed for various conditions do not have sufficient scientific evidence for safety and efficacy. For example, β-blockers are a class of drugs with FDA-approval for very few indications in pediatrics but are commonly used for various off-label indications. Interestingly, the proportion of off-label use of β-blockers in adults is at about 52% (66.2 million) of the total number of β-blockers prescribed. The frequency of off-label use of β-blockers in children is also high with limited data on the indications as well as safety and efficacy. We present trends in off-label use of β-blockers in children to discuss drug safety and efficacy and include recommendations for pediatric providers.
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Affiliation(s)
- Vishal R Kaley
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - E Oliver Aregullin
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA.,College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Bennett P Samuel
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Joseph J Vettukattil
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA.,College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
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Abstract
The role of right ventricular (RV) fibrosis in pulmonary hypertension (PH) remains a subject of ongoing discussion. Alterations of the collagen network of the extracellular matrix may help prevent ventricular dilatation in the pressure-overloaded RV. At the same time, fibrosis impairs cardiac function, and a growing body of experimental data suggests that fibrosis plays a crucial role in the development of RV failure. In idiopathic pulmonary arterial hypertension and chronic thromboembolic PH, the RV is exposed to a ≈5 times increased afterload, which makes these conditions excellent models for studying the impact of pressure overload on RV structure. With this review, we present clinical evidence of RV fibrosis in idiopathic pulmonary arterial hypertension and chronic thromboembolic PH, explore the correlation between fibrosis and RV function, and discuss the clinical relevance of RV fibrosis in patients with PH. We postulate that RV fibrosis has a dual role in patients with pressure-overloaded RVs of idiopathic pulmonary arterial hypertension and chronic thromboembolic PH: as part of an adaptive response to prevent cardiomyocyte overstretch and to maintain RV shape for optimal function, and as part of a maladaptive response that increases diastolic stiffness, perturbs cardiomyocyte excitation-contraction coupling, and disrupts the coordination of myocardial contraction. Finally, we discuss potential novel therapeutic strategies and describe more sensitive techniques to quantify RV fibrosis, which may be used to clarify the causal relation between RV fibrosis and RV function in future research.
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Affiliation(s)
| | | | | | - Frances S de Man
- Amsterdam UMC, Vrije Universiteit, The Netherlands (A.V.N., F.S.d.M)
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43
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Rothman A, Jonas M, Castel D, Tzafriri AR, Traxler H, Shav D, Leon MB, Ben-Yehuda O, Rubin L. Pulmonary artery denervation using catheter-based ultrasonic energy. EUROINTERVENTION 2019; 15:722-730. [PMID: 31062694 DOI: 10.4244/eij-d-18-01082] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
AIMS Pulmonary arterial hypertension is a devastating disease characterised by pulmonary vascular remodelling and right heart failure. Radio-frequency pulmonary artery denervation (PDN) has improved pulmonary haemodynamics in preclinical and early clinical studies; however, denervation depth is limited. High-frequency non-focused ultrasound can deliver energy to the vessel adventitia, sparing the intima and media. We therefore aimed to investigate the feasibility, safety and efficacy of ultrasound PDN. METHODS AND RESULTS Histological examination demonstrated that innervation of human pulmonary arteries is predominantly sympathetic (71%), with >40% of nerves at a depth of >4 mm. Finite element analysis of ultrasound energy distribution and ex vivo studies demonstrated generation of temperatures >47ºC to a depth of 10 mm. In domestic swine, PDN reduced mean pulmonary artery pressure induced by thromboxane A2 in comparison to sham. No adverse events were observed up to 95 days. Histological examination identified structural and immunohistological changes of nerves in PDN-treated animals, with sparing of the intima and media and reduced tyrosine hydroxylase staining 95 days post procedure, indicating persistent alteration of the structure of sympathetic nerves. CONCLUSIONS Ultrasound PDN is safe and effective in the preclinical setting, with energy delivery to a depth that would permit targeting sympathetic nerves in humans.
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Affiliation(s)
- Alex Rothman
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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Abstract
PURPOSE OF REVIEW Right ventricular (RV) function is an important determinant of morbidity and mortality in patients with pulmonary arterial hypertension (PAH). Although substantial progress has been made in understanding the development of RV failure in the last decennia, this has not yet resulted in the development of RV selective therapies. In this review, we will discuss the current status on the treatment of RV failure and potential novel therapeutic strategies that are currently being investigated in clinical trials. RECENT FINDINGS Increased afterload results in elevated wall tension. Consequences of increased wall tension include autonomic disbalance, metabolic shift and inflammation, negatively affecting RV contractility. Compromised RV systolic function and low cardiac output activate renin-angiotensin aldosterone system, which leads to fluid retention and further increase in RV wall tension. This vicious circle can be interrupted by directly targeting the determinants of RV wall tension; preload and afterload by PAH-medications and diuretics, but is also possibly by restoring neurohormonal and metabolic disbalance, and inhibiting maladaptive inflammation. A variety of RV selective drugs are currently being studied in clinical trials. SUMMARY Nowadays, afterload reduction is still the cornerstone in treatment of PAH. New treatments targeting important pathobiological determinants of RV failure directly are emerging.
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Affiliation(s)
- Joanne A. Groeneveldt
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
| | - Frances S. de Man
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
| | - Berend E. Westerhof
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam
- Section of Systems Physiology, Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Mercurio V, Pellegrino T, Bosso G, Campi G, Parrella P, Piscopo V, Tocchetti CG, Hassoun PM, Petretta M, Cuocolo A, Bonaduce D. EXPRESS: Cardiac Sympathetic Dysfunction in Pulmonary Arterial Hypertension: Lesson from Left-sided Heart Failure. Pulm Circ 2019; 9:2045894019868620. [PMID: 31328636 PMCID: PMC6689920 DOI: 10.1177/2045894019868620] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/18/2019] [Indexed: 12/22/2022] Open
Abstract
Sympathetic nervous system hyperactivity has a well-recognized role in the pathophysiology of heart failure with reduced left ventricular ejection fraction. Alterations in sympathetic nervous system have been related to the pathophysiology of pulmonary arterial hypertension, but it is unclear whether cardiac sympathetic nervous system is impaired and how sympathetic dysfunction correlates with hemodynamics and clinical status in pulmonary arterial hypertension patients. The aim of this study was to evaluate the cardiac sympathetic nervous system activity by means of 123Iodine-metaiodobenzylguanidine nuclear imaging in pulmonary arterial hypertension patients and to explore its possible correlation with markers of disease severity. Twelve consecutive pulmonary arterial hypertension patients (nine women, median age 56.5 (17.8), eight idiopathic and four connective tissue-associated pulmonary arterial hypertension) underwent cardiac 123Iodine-metaiodobenzylguanidine scintigraphy. The results were compared with those of 12 subjects with a negative history of cardiovascular or pulmonary disease who underwent the same nuclear imaging test because of a suspected paraganglioma or pheochromocytoma, with a negative result (controls), and 12 patients with heart failure with reduced left ventricular ejection fraction. Hemodynamics, echocardiography, six-minute walking distance, cardiopulmonary exercise testing, and N-terminal pro brain natriuretic peptide were collected in pulmonary arterial hypertension patients within one week from 123Iodine-metaiodobenzylguanidine scintigraphy. Cardiac 123Iodine-metaiodobenzylguanidine uptake, assessed as early and late heart-to-mediastinum ratio, was significantly lower in pulmonary arterial hypertension compared to controls (p = 0.001), but similar to heart failure with reduced left ventricular ejection fraction. Myocardial 123Iodine-metaiodobenzylguanidine turnover, expressed as washout rate, was similar in pulmonary arterial hypertension and heart failure with reduced left ventricular ejection fraction and significantly higher compared to controls (p = 0.016). In the pulmonary arterial hypertension group, both early and late heart-to-mediastinum ratios and washout rate correlated with parameters of pulmonary arterial hypertension severity including pulmonary vascular resistance, right atrial pressure, tricuspid annular plane systolic excursion, N-terminal pro brain natriuretic peptide, and peak VO2. Although we evaluated a small number of subjects, our study showed a significant impairment in cardiac sympathetic nervous system in pulmonary arterial hypertension, similarly to that observed in heart failure with reduced left ventricular ejection fraction. This impairment correlated with indices of pulmonary arterial hypertension severity. Cardiac sympathetic dysfunction may be a contributing factor to the development of right-sided heart failure in pulmonary arterial hypertension.
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Affiliation(s)
- Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | - Teresa Pellegrino
- Referral Cancer Center of Basilicata, Scientific Institute for Hospitalization and Care, Rionero in Vulture, Italy
| | - Giorgio Bosso
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Giacomo Campi
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Paolo Parrella
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Valentina Piscopo
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy
| | - Carlo G. Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Paul M. Hassoun
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | - Mario Petretta
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Science, Federico II University, Naples, Italy
| | - Domenico Bonaduce
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
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Zelt JG, Chaudhary KR, Cadete VJ, Mielniczuk LM, Stewart DJ. Medical Therapy for Heart Failure Associated With Pulmonary Hypertension. Circ Res 2019; 124:1551-1567. [DOI: 10.1161/circresaha.118.313650] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Jason G.E. Zelt
- From the Division of Cardiology, University of Ottawa Heart Institute (J.G.E.Z., L.M.M., D.J.S.), University of Ottawa, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
| | - Ketul R. Chaudhary
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Canada (K.R.C., V.J.C., D.J.S.)
| | - Virgilio J. Cadete
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Canada (K.R.C., V.J.C., D.J.S.)
| | - Lisa M. Mielniczuk
- From the Division of Cardiology, University of Ottawa Heart Institute (J.G.E.Z., L.M.M., D.J.S.), University of Ottawa, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
| | - Duncan J. Stewart
- From the Division of Cardiology, University of Ottawa Heart Institute (J.G.E.Z., L.M.M., D.J.S.), University of Ottawa, Canada
- Department of Cellular and Molecular Medicine, Faculty of Medicine (J.G.E.Z., K.R.C., V.J.C., L.M.M., D.J.S.), University of Ottawa, Canada
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Canada (K.R.C., V.J.C., D.J.S.)
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Right ventricular systolic to diastolic duration ratio: A novel predictor of outcome in adult idiopathic pulmonary arterial hypertension. Int J Cardiol 2019; 293:218-222. [PMID: 31126734 DOI: 10.1016/j.ijcard.2019.05.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/17/2019] [Accepted: 05/06/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND The systolic to diastolic (SD) duration ratio reflects global RV performance in pulmonary arterial hypertension (PAH) yet limited data exists on its application to adult non-congenital PAH. We measured SD ratios on echocardiogram in idiopathic PAH (IPAH) to establish its response to pulmonary vasodilator therapy and prognostic value at diagnosis and follow up. METHODS Incident patients with IPAH undergoing echocardiogram, haemodynamic and exercise assessments were identified within our centre between 2005 and 2018. SD ratios were adjusted for heart rate at diagnosis and follow up. RESULTS In 98 patients at diagnosis, the mean SD ratio was 1.03 ± 0.37 decreasing to 0.85 ± 0.25, p < 0.001 at follow-up echocardiogram performed at a median interval of 9.0 months. The SD ratio at diagnosis correlated weakly with RV basal diameter (r = 0.24, p = 0.04) and 6MWD (r = 0.23, p = 0.04). At follow up, the mean SD ratio was lower in those receiving combination vs monotherapy pulmonary vasodilator treatment (71 ± 25 vs 92 ± 22% baseline respectively, p < 0.001). After a median follow-up of 4.8 years, 3 patients were transplanted and 23 patients died. The SD ratio at diagnosis and follow up predicted an increased risk of death/transplantation (HR 2.41 (1.09-5.29), p = 0.03; HR 5.02 (1.27-19.77), p = 0.02 respectively), retaining its predictive value at diagnosis in bivariate models with 6MWD (HR 2.18 (1.06-4.08)), WHO Functional Class (HR 2.33 (1.04-5.21)) and TAPSE (HR 2.36 (1.07-5.19)), all p < 0.05. CONCLUSIONS The SD ratio carries prognostic value at diagnosis and follow up in IPAH. Its further evaluation alongside current PAH risk stratification parameters should be considered.
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Fowler ED, Hauton D, Boyle J, Egginton S, Steele DS, White E. Energy Metabolism in the Failing Right Ventricle: Limitations of Oxygen Delivery and the Creatine Kinase System. Int J Mol Sci 2019; 20:E1805. [PMID: 31013688 PMCID: PMC6514649 DOI: 10.3390/ijms20081805] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/08/2019] [Accepted: 04/10/2019] [Indexed: 12/15/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) results in hypertrophic remodeling of the right ventricle (RV) to overcome increased pulmonary pressure. This increases the O2 consumption of the myocardium, and without a concomitant increase in energy generation, a mismatch with demand may occur. Eventually, RV function can no longer be sustained, and RV failure occurs. Beta-adrenergic blockers (BB) are thought to improve survival in left heart failure, in part by reducing energy expenditure and hypertrophy, however they are not currently a therapy for PAH. The monocrotaline (MCT) rat model of PAH was used to investigate the consequence of RV failure on myocardial oxygenation and mitochondrial function. A second group of MCT rats was treated daily with the beta-1 blocker metoprolol (MCT + BB). Histology confirmed reduced capillary density and increased capillary supply area without indications of capillary rarefaction in MCT rats. A computer model of O2 flux was applied to the experimentally recorded capillary locations and predicted a reduction in mean tissue PO2 in MCT rats. The fraction of hypoxic tissue (defined as PO2 < 0.5 mmHg) was reduced following beta-1 blocker (BB) treatment. The functionality of the creatine kinase (CK) energy shuttle was measured in permeabilized RV myocytes by sequential ADP titrations in the presence and absence of creatine. Creatine significantly decreased the KmADP in cells from saline-injected control (CON) rats, but not MCT rats. The difference in KmADP with or without creatine was not different in MCT + BB cells compared to CON or MCT cells. Improved myocardial energetics could contribute to improved survival of PAH with chronic BB treatment.
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Affiliation(s)
- Ewan D Fowler
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds LS2 9JT, UK.
- Cardiac Research Laboratories, School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol BS8 1TD, UK.
| | - David Hauton
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds LS2 9JT, UK.
- Metabolomics Research Group, Chemistry Research Laboratory, University of Oxford, Oxford OX1 3TA, UK.
| | - John Boyle
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds LS2 9JT, UK.
| | - Stuart Egginton
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds LS2 9JT, UK.
| | - Derek S Steele
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds LS2 9JT, UK.
| | - Ed White
- Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds LS2 9JT, UK.
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Power AS, Norman R, Jones TLM, Hickey AJ, Ward ML. Mitochondrial function remains impaired in the hypertrophied right ventricle of pulmonary hypertensive rats following short duration metoprolol treatment. PLoS One 2019; 14:e0214740. [PMID: 30964911 PMCID: PMC6456253 DOI: 10.1371/journal.pone.0214740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/19/2019] [Indexed: 12/16/2022] Open
Abstract
Pulmonary hypertension (PH) increases the work of the right ventricle (RV) and causes right-sided heart failure. This study examined RV mitochondrial function and ADP transfer in PH animals advancing to right heart failure, and investigated a potential therapy with the specific β1-adrenergic-blocker metoprolol. Adult Wistar rats (317 ± 4 g) were injected either with monocrotaline (MCT, 60 mg kg-1) to induce PH, or with an equivalent volume of saline for controls (CON). At three weeks post-injection the MCT rats began oral metoprolol (10 mg kg-1 day-1-) or placebo treatment until heart failure was observed in the MCT group. Mitochondrial function was then measured using high-resolution respirometry from permeabilised RV fibres. Relative to controls, MCT animals had impaired mitochondrial function but maintained coupling between myofibrillar ATPases and mitochondria, despite an increase in ADP diffusion distances. Cardiomyocytes from the RV of MCT rats were enlarged, primarily due to an increase in myofibrillar protein. The ratio of mitochondria per myofilament area was decreased in both MCT groups (p ≤ 0.05) in comparison to control (CON: 1.03 ± 0.04; MCT: 0.74 ± 0.04; MCT + BB: 0.74 ± 0.03). This not only implicates impaired energy production in PH, but also increases the diffusion distance for metabolites within the MCT cardiomyocytes, adding an additional hindrance to energy supply. Together, these changes may limit energy supply in MCT rat hearts, particularly at high cardiac workloads. Metoprolol treatment did not delay the onset of heart failure symptoms, improve mitochondrial function, or regress RV hypertrophy.
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Affiliation(s)
- Amelia S. Power
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
- * E-mail: (M-L W); (ASP)
| | - Ruth Norman
- School of Biological Sciences, University of Leeds, Leeds, United Kingdom
| | - Timothy L. M. Jones
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
| | - Anthony J. Hickey
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Marie-Louise Ward
- Department of Physiology, School of Medical Sciences, University of Auckland, Auckland, New Zealand
- * E-mail: (M-L W); (ASP)
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Affiliation(s)
- Anna R Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine (A.R.H.)
| | - Evan L Brittain
- Division of Cardiovascular Medicine (E.L.B.), Vanderbilt University Medical Center, Nashville, TN
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