1
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Liu CH, Wen ZH, Huo YN, Lin CY, Yang HY, Tsai CS. Piscidin-1 regulates lipopolysaccharide-induced intracellular calcium, sodium dysregulation, and oxidative stress in atrial cardiomyocytes. Eur J Pharmacol 2024; 976:176695. [PMID: 38821161 DOI: 10.1016/j.ejphar.2024.176695] [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: 03/19/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024]
Abstract
Lipopolysaccharide (LPS) triggers an inflammatory response, causing impairment of cardiomyocyte Ca2+ and Na + regulation. This study aimed to determine whether piscidin-1 (PCD-1), an antimicrobial peptide, improves intracellular Ca2+ and Na + regulation in LPS-challenged atrial cardiomyocytes. Rabbit atrial cardiomyocytes were enzymatically isolated from the left atria. Patch-clamp ionic current recording, intracellular Ca2+ monitoring using Fluo-3, and detection of cytosolic reactive oxygen species production were conducted in control, LPS-challenged, and LPS + PCD-1-treated atrial cardiomyocytes. LPS-challenged cardiomyocytes showed shortened durations of action potential at their 50% and 90% repolarizations, which was reversed by PCD-1 treatment. LPS-challenged cardiomyocytes showed decreased L-type Ca2+ channel currents and larger Na+/Ca2+ exchange currents compared to controls. While LPS did not affect the sodium current, an enhanced late sodium current with increased cytosolic Na+ levels was observed in LPS-challenged cardiomyocytes. These LPS-induced alterations in the ionic current were ameliorated by PCD-1 treatment. LPS-challenged cardiomyocytes displayed lowered Ca2+ transient amplitudes and decreased Ca2+ stores and greater Ca2+ leakage in the sarcoplasmic reticulum compared to the control. Exposure to PCD-1 attenuated LPS-induced alterations in Ca2+ regulation. The elevated reactive oxygen species levels observed in LPS-challenged myocytes were suppressed after PCD-1 treatment. The protein levels of NF-κB and IL-6 increased following LPS treatment. Decreased sarcoplasmic/endoplasmic reticulum Ca2+ ATPase 2a protein levels were observed in LPS-challenged cardiomyocytes. PCD-1 modulates LPS-induced alterations in inflammatory and Ca2+ regulatory protein levels. Our results suggest that PCD-1 modulates LPS-induced alterations in intracellular Ca2+ and Na + homeostasis, reactive oxygen species production, and the NF-κB inflammatory pathway in atrial cardiomyocytes.
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Affiliation(s)
- Ching-Han Liu
- Department of Marine Biotechnology and Resources, National Sun Yat-Sen University, Kaohsiung, 804201, Taiwan; Division of Cardiology, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, 80284, Taiwan
| | - Zhi-Hong Wen
- Department of Marine Biotechnology and Resources, National Sun Yat-Sen University, Kaohsiung, 804201, Taiwan; Institute of BioPharmaceutical Sciences, National Sun Yat-Sen University, Kaohsiung, 804201, Taiwan
| | - Yen-Nien Huo
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Yuan Lin
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Hsiang-Yu Yang
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan.
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department and Graduate Institute of Pharmacology, National Defense Medical Center, Taipei, Taiwan
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2
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Na SJ, Ko RE, Chung CR, Yang JH, Oh DK, Lee SY, Park MH, Lee H, Lim CM, Suh GY. Early detection of low QRS voltage and its association with mortality in patients with sepsis. Sci Rep 2024; 14:16066. [PMID: 38992092 PMCID: PMC11239899 DOI: 10.1038/s41598-024-66612-x] [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: 02/11/2024] [Accepted: 07/02/2024] [Indexed: 07/13/2024] Open
Abstract
Various electrocardiographic changes occur during sepsis, but data on the clinical importance of a low QRS voltage in sepsis are still limited. We aimed to evaluate the association between low QRS voltage identified early in sepsis and mortality in patients with sepsis. Between September 2019 and December 2020, all consecutive adult patients diagnosed with sepsis in the emergency room or general ward at Samsung Medical Center were enrolled. Patients without a 12-lead electrocardiogram recorded within 48 h of recognition of sepsis were excluded. In 432 eligible patients, 12-lead electrocardiogram was recorded within the median of 24 min from the first recognition of sepsis, and low QRS voltage was identified in 115 (26.6%) patients. The low QRS group showed more severe organ dysfunction and had higher levels of N-terminal pro-brain natriuretic peptide. The hospital mortality was significantly higher in the low QRS voltage group than in the normal QRS voltage group (49.6% vs. 28.1%, p < 0.001). Similarly, among the 160 patients who required intensive care unit admission, significantly more patients in the low QRS group died in the intensive care unit (35.9% vs. 18.2%, p = 0.021). Low QRS voltage was associated with increased hospital mortality in patients with sepsis.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Yang
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Kyu Oh
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Su Yeon Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi Hyeon Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Haein Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Chae-Man Lim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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3
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Gunjan K, Modi M, Thakur A, Soni A, Saluja S. Echocardiographic characteristics in neonates with septic shock. Eur J Pediatr 2024; 183:1849-1855. [PMID: 38276999 DOI: 10.1007/s00431-024-05444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
Clinical parameters used for hemodynamic assessment and titration of vasopressor therapy in neonates with septic shock have several limitations. Functional echocardiography is an emerging tool for bedside assessment of cardiac function and may be useful for diagnosis of shock and assessing the response to therapy. Data regarding echocardiographic parameters in neonates with shock is lacking. This prospective observational study was conducted in a Level III NICU with the primary objective of comparing echocardiographic characteristics of neonates with septic shock at diagnosis, following fluid boluses, and after maximum inotropic support [A1]. Additionally, we compared these characteristics with those of healthy stable neonates who were gestation and postnatal age-matched. A total of 36 neonates with septic shock and 30 gestation and postnatal age-matched controls were enrolled. The mean (SD) gestation and birth weight of neonates with septic shock were 30.6 (4.0) weeks and 1538 (728) g, respectively. Gram-negative bacilli constituted 78.9% of all isolates. At presentation, there was no significant difference between neonates with shock and controls in terms of ventricular outputs, shortening fraction, ratio of early to late diastolic trans-mitral flow velocity, and myocardial performance indices. The distensibility index of inferior vena cava was higher in neonates with shock compared to controls, (17% vs 10%, (p < 0.01)). Left ventricular output was 209 (92) and 227 (102) ml/kg/min (p = 0.53) and right ventricular output was 427 (203) and 459 (227) ml/kg/min, (p = 0.03), respectively, before and after inotropic therapy. Conclusion: Echocardiographic parameters may not differentiate neonates with septic shock from hemodynamically stable neonates. Neonates with shock associated with predominantly gram-negative sepsis are not able to augment cardiac functions, either at the onset or after administration of inotropes. Trial registration: (CTRI/2017/12/010766). What is known: • For neonates with shock, echocardiography is becoming increasingly popular as an objective method of evaluating hemodynamics. • In healthy preterm neonate, cardiac output has been known to increase in response to altered hemodynamics during states of increased oxygen demand. What is new: • In the setting of septic shock induced by gram-negative organisms, echocardiographic parameters are less likely to assist in the assessment of the response to vasoactive agents. Cytokines, induced by gram-negative organisms, may alter adrenoreceptors in myocardium and vasculature.
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Affiliation(s)
- Kumari Gunjan
- Department of Neonatology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Manoj Modi
- Department of Neonatology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Anup Thakur
- Department of Neonatology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Arun Soni
- Department of Neonatology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Satish Saluja
- Department of Neonatology, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India.
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4
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Duignan SM, Lakshminrusimha S, Armstrong K, de Boode WP, El-Khuffash A, Franklin O, Molloy EJ. Neonatal sepsis and cardiovascular dysfunction I: mechanisms and pathophysiology. Pediatr Res 2024; 95:1207-1216. [PMID: 38044334 DOI: 10.1038/s41390-023-02926-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 12/05/2023]
Abstract
The highest incidence of sepsis across all age groups occurs in neonates leading to substantial mortality and morbidity. Cardiovascular dysfunction frequently complicates neonatal sepsis including biventricular systolic and/or diastolic dysfunction, vasoregulatory failure, and pulmonary arterial hypertension. The haemodynamic response in neonatal sepsis can be hyperdynamic or hypodynamic and the underlying pathophysiological mechanisms are heterogeneous. The diagnosis and definition of both neonatal sepsis and cardiovascular dysfunction complicating neonatal sepsis are challenging and not consensus-based. Future developments in neonatal sepsis management will be facilitated by common definitions and datasets especially in neonatal cardiovascular optimisation. IMPACT: Cardiovascular dysfunction is common in neonatal sepsis but there is no consensus-based definition, making calculating the incidence and designing clinical trials challenging. Neonatal cardiovascular dysfunction is related to the inflammatory response, which can directly target myocyte function and systemic haemodynamics.
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Affiliation(s)
- Sophie M Duignan
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | | | - Kathryn Armstrong
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC, Canada
| | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Afif El-Khuffash
- School of Medicine, Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
- Discipline of Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland
| | - Eleanor J Molloy
- Discipline of Paediatrics, Trinity College, The University of Dublin, Trinity Research in Childhood (TRiCC) & Trinity Translational Medicine Institute (TTMI), Dublin, Ireland.
- Department of Neonatology, Children's Health Ireland at Crumlin, Dublin, Ireland.
- Department of Neonatology, Coombe Women and Infants University Hospital, Dublin, Ireland.
- Paediatric Neurodisability, Children's Health Ireland at Tallaght, Dublin, Ireland.
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5
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Abele N, Münz F, Zink F, Gröger M, Hoffmann A, Wolfschmitt EM, Hogg M, Calzia E, Waller C, Radermacher P, Merz T. Relation of Plasma Catecholamine Concentrations and Myocardial Mitochondrial Respiratory Activity in Anesthetized and Mechanically Ventilated, Cardiovascular Healthy Swine. Int J Mol Sci 2023; 24:17293. [PMID: 38139121 PMCID: PMC10743631 DOI: 10.3390/ijms242417293] [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: 11/14/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Chronic heart failure is associated with reduced myocardial β-adrenergic receptor expression and mitochondrial function. Since these data coincide with increased plasma catecholamine levels, we investigated the relation between myocardial β-receptor expression and mitochondrial respiratory activity under conditions of physiological catecholamine concentrations. This post hoc analysis used material of a prospective randomized, controlled study on 12 sexually mature (age 20-24 weeks) Early Life Stress or control pigs (weaning at day 21 and 28-35 after birth, respectively) of either sex. Measurements in anesthetized, mechanically ventilated, and instrumented animals comprised serum catecholamine (liquid-chromatography/tandem-mass-spectrometry) and 8-isoprostane levels, whole blood superoxide anion concentrations (electron spin resonance), oxidative DNA strand breaks (tail moment in the "comet assay"), post mortem cardiac tissue mitochondrial respiration, and immunohistochemistry (β2-adrenoreceptor, mitochondrial respiration complex, and nitrotyrosine expression). Catecholamine concentrations were inversely related to myocardial mitochondrial respiratory activity and β2-adrenoceptor expression, whereas there was no relation to mitochondrial respiratory complex expression. Except for a significant, direct, non-linear relation between DNA damage and noradrenaline levels, catecholamine concentrations were unrelated to markers of oxidative stress. The present study suggests that physiological variations of the plasma catecholamine concentrations, e.g., due to physical and/or psychological stress, may affect cardiac β2-adrenoceptor expression and mitochondrial respiration.
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Affiliation(s)
- Nadja Abele
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
| | - Franziska Münz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
- Clinic for Anesthesiology and Intensive Care, Ulm University Medical Center, 89069 Ulm, Germany
| | - Fabian Zink
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
| | - Michael Gröger
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
| | - Andrea Hoffmann
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
| | - Eva-Maria Wolfschmitt
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
| | - Melanie Hogg
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
| | - Enrico Calzia
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
| | - Christiane Waller
- Clinic for Psychosomatic Medicine and Psychotherapy, Paracelsus Medical Private University, 90402 Nuremberg, Germany;
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89069 Ulm, Germany; (N.A.); (F.Z.); (M.G.); (A.H.); (E.-M.W.); (M.H.); (E.C.)
- Clinic for Anesthesiology and Intensive Care, Ulm University Medical Center, 89069 Ulm, Germany
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6
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Vintrych P, Al-Obeidallah M, Horák J, Chvojka J, Valešová L, Nalos L, Jarkovská D, Matějovič M, Štengl M. Modeling sepsis, with a special focus on large animal models of porcine peritonitis and bacteremia. Front Physiol 2023; 13:1094199. [PMID: 36703923 PMCID: PMC9871395 DOI: 10.3389/fphys.2022.1094199] [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: 11/09/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023] Open
Abstract
Infectious diseases, which often result in deadly sepsis or septic shock, represent a major global health problem. For understanding the pathophysiology of sepsis and developing new treatment strategies, reliable and clinically relevant animal models of the disease are necessary. In this review, two large animal (porcine) models of sepsis induced by either peritonitis or bacteremia are introduced and their strong and weak points are discussed in the context of clinical relevance and other animal models of sepsis, with a special focus on cardiovascular and immune systems, experimental design, and monitoring. Especially for testing new therapeutic strategies, the large animal (porcine) models represent a more clinically relevant alternative to small animal models, and the findings obtained in small animal (transgenic) models should be verified in these clinically relevant large animal models before translation to the clinical level.
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Affiliation(s)
- Pavel Vintrych
- Department of Cardiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Mahmoud Al-Obeidallah
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Jan Horák
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Jiří Chvojka
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Lenka Valešová
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Lukáš Nalos
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Dagmar Jarkovská
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Martin Matějovič
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia
| | - Milan Štengl
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Prague, Czechia,*Correspondence: Milan Štengl,
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7
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Gut microbiome diversity of porcine peritonitis model of sepsis. Sci Rep 2022; 12:17430. [PMID: 36261543 PMCID: PMC9581925 DOI: 10.1038/s41598-022-21079-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 09/22/2022] [Indexed: 01/12/2023] Open
Abstract
Animal models are essential in understanding of the mechanisms of sepsis moreover the development and the assessment of emerging therapies. In clinically relevant porcine model, however, a significant variability in the host response has been observed among animals. Thus, there is a strong demand to better understand the potential sources of this heterogeneity. In this study, we compared faecal microbiome composition of 12 animals. Three samples were collected at different time points from each animal. Bacteriome was subjected to 16S rDNA profiling. A significant difference in bacterial composition was associated with the season (p < 0.001) but not with the sex of the pig (p = 0.28), the timing of sample collection (p = 0.59), or interactions thereof (all p > 0.3). The season batch explained 55% of the total variance in the bacteriome diversity. The season term was highly significant from the high-resolution level of the bacterial amplicon sequencing variants up to the level of phylum. The diversity of the microbiome composition could significantly influence experimental model of sepsis, and studies are warranted to demonstrate the effects of gut microbiome diversity on the host-response. If confirmed, control of the gut microbiome should become a standard part of the pre-clinical sepsis experiments.
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Abstract
Objectives: Expound upon priorities for basic/translational science identified in a recent paper by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Data Sources: Original paper, search of the literature. Study Selection: By several members of the original task force with specific expertise in basic/translational science. Data Extraction: None. Data Synthesis: None. Conclusions: In the first of a series of follow-up reports to the original paper, several members of the original task force with specific expertise provided a more in-depth analysis of the five identified priorities directly related to basic/translational science. This analysis expounds on what is known about the question and what was identified as priorities for ongoing research. It is hoped that this analysis will aid the development of future research initiatives.
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Al-Obeidallah M, Jarkovská D, Valešová L, Horák J, Jedlička J, Nalos L, Chvojka J, Švíglerová J, Kuncová J, Beneš J, Matějovič M, Štengl M. SOFA Score, Hemodynamics and Body Temperature Allow Early Discrimination between Porcine Peritonitis-Induced Sepsis and Peritonitis-Induced Septic Shock. J Pers Med 2021; 11:jpm11030164. [PMID: 33670874 PMCID: PMC7997134 DOI: 10.3390/jpm11030164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 01/18/2023] Open
Abstract
Porcine model of peritonitis-induced sepsis is a well-established clinically relevant model of human disease. Interindividual variability of the response often complicates the interpretation of findings. To better understand the biological basis of the disease variability, the progression of the disease was compared between animals with sepsis and septic shock. Peritonitis was induced by inoculation of autologous feces in fifteen anesthetized, mechanically ventilated and surgically instrumented pigs and continued for 24 h. Cardiovascular and biochemical parameters were collected at baseline (just before peritonitis induction), 12 h, 18 h and 24 h (end of the experiment) after induction of peritonitis. Analysis of multiple parameters revealed the earliest significant differences between sepsis and septic shock groups in the sequential organ failure assessment (SOFA) score, systemic vascular resistance, partial pressure of oxygen in mixed venous blood and body temperature. Other significant functional differences developed later in the course of the disease. The data indicate that SOFA score, hemodynamical parameters and body temperature discriminate early between sepsis and septic shock in a clinically relevant porcine model. Early pronounced alterations of these parameters may herald a progression of the disease toward irreversible septic shock.
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Affiliation(s)
- Mahmoud Al-Obeidallah
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00 Pilsen, Czech Republic; (M.A.-O.); (D.J.); (J.J.); (L.N.); (J.Š.); (J.K.)
| | - Dagmar Jarkovská
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00 Pilsen, Czech Republic; (M.A.-O.); (D.J.); (J.J.); (L.N.); (J.Š.); (J.K.)
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
| | - Lenka Valešová
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
| | - Jan Horák
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Jan Jedlička
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00 Pilsen, Czech Republic; (M.A.-O.); (D.J.); (J.J.); (L.N.); (J.Š.); (J.K.)
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
| | - Lukáš Nalos
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00 Pilsen, Czech Republic; (M.A.-O.); (D.J.); (J.J.); (L.N.); (J.Š.); (J.K.)
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
| | - Jiří Chvojka
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
| | - Jitka Švíglerová
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00 Pilsen, Czech Republic; (M.A.-O.); (D.J.); (J.J.); (L.N.); (J.Š.); (J.K.)
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
| | - Jitka Kuncová
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00 Pilsen, Czech Republic; (M.A.-O.); (D.J.); (J.J.); (L.N.); (J.Š.); (J.K.)
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
| | - Jan Beneš
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
- Department of Aneshesiology and Intensive Care Medicine, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Martin Matějovič
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
- Department of Internal Medicine I, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 80, 304 60 Pilsen, Czech Republic
| | - Milan Štengl
- Department of Physiology, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 1655/76, 323 00 Pilsen, Czech Republic; (M.A.-O.); (D.J.); (J.J.); (L.N.); (J.Š.); (J.K.)
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Alej Svobody 76, 323 00 Pilsen, Czech Republic; (L.V.); (J.H.); (J.C.); (J.B.); (M.M.)
- Correspondence: ; Tel.: +420-377-593-341
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10
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Mitochondrial Function in the Kidney and Heart, but Not the Brain, is Mainly Altered in an Experimental Model of Endotoxaemia. Shock 2020; 52:e153-e162. [PMID: 30640252 DOI: 10.1097/shk.0000000000001315] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Significant impairments in mitochondrial function are associated with the development of multi-organ failure in sepsis/endotoxaemia, but the data on the dynamics of simultaneous mitochondrial impairment in multiple organs are limited. The aim of this study was to evaluate the changes in heart, brain and kidney mitochondrial function in an experimental model of lipopolysaccharide (LPS)-induced endotoxaemia.Samples were collected 4 and 24 h after single injection of LPS (10 mg/kg) in mice. Marked increases in inflammation-related gene expression were observed in all studied tissues 4 h after LPS administration. At 24 h post LPS administration, this expression of inflammation-related genes remained upregulated only in kidneys. Significantly increased concentrations of kidney function markers confirmed that kidneys were severely damaged. Echocardiographic measurements showed that the ejection fraction and fractional shortening were significantly reduced 4 h after LPS administration, whereas 24 h after LPS administration, the cardiac function was restored to baseline. A two-fold decrease in mitochondrial oxidative phosphorylation (OXPHOS) capacity in the kidney was observed 4 and 24 h after LPS administration. Significant decrease in mitochondrial fatty acid oxidation was observed in heart 4 h after LPS administration. Furthermore, 24 h after LPS administration, the respiration rates in cardiac fibers at OXPHOS and electron transport (ET) states were significantly increased, which resulted in increased ET coupling efficiency in the LPS-treated group, whereas four-fold increases in the H2O2 production rate and H2O2/O ratio were observed. The brain mitochondria demonstrated a slightly impaired mitochondrial functionality just 24 h after the induction of endotoxaemia.In conclusion, among studied tissues kidney mitochondria are the most sensitive to endotoxaemia and do not recover from LPS-induced damage, whereas in brain, mitochondrial function was not significantly altered. In heart, endotoxaemia induces a decrease in the mitochondrial fatty acid oxidation capacity, but during the phase of suppressed inflammatory response, the ET efficiency is improved despite the marked increase in reactive oxygen species production.
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11
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Deutschman CS, Hellman J, Roca RF, De Backer D, Coopersmith CM. The surviving sepsis campaign: basic/translational science research priorities. Intensive Care Med Exp 2020; 8:31. [PMID: 32676795 PMCID: PMC7365694 DOI: 10.1186/s40635-020-00312-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objectives Expound upon priorities for basic/translational science identified in a recent paper by a group of experts assigned by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Data sources Original paper, search of the literature. Study selection This study is selected by several members of the original task force with specific expertise in basic/translational science. Data extraction and data synthesis are not available. Conclusions In the first of a series of follow-up reports to the original paper, several members of the original task force with specific expertise provided a more in-depth analysis of the five identified priorities directly related to basic/translational science. This analysis expounds on what is known about the question and what was identified as priorities for ongoing research. It is hoped that this analysis will aid the development of future research initiatives.
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Affiliation(s)
- Clifford S Deutschman
- Department of Pediatrics, Hofstra/Northwell School of Medicine and the Feinstein Institute for Medical Research/Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA. .,Department of Molecular Medicine, Hofstra/Northwell School of Medicine and the Feinstein Institute for Medical Research/Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, USA.
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Ricard Ferrer Roca
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation (SODIR) Research Group, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Daniel De Backer
- Chirec Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University, Atlanta, GA, USA
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12
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Lado-Abeal J. Non-thyroidal illness syndrome, the hidden player in the septic shock induced myocardial contractile depression. Med Hypotheses 2020; 142:109775. [PMID: 32344285 DOI: 10.1016/j.mehy.2020.109775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/21/2020] [Indexed: 12/14/2022]
Abstract
Septic shock causes high mortality in hospitalized patients, especially in those that develop myocardial dysfunction as an early complication. The myocardial dysfunction of septic shock is characterized by a decrease in ventricular relaxation (diastolic dysfunction) and reduced ventricular ejection fraction (systolic dysfunction). Most patients with septic shock have low serum thyroid hormone levels, a condition known as non-thyroidal illness syndrome. Thyroid hormones sustain myocardial contractility and energy metabolism. Septic shock non-thyroidal illness syndrome causes myocardial hypothyroidism, and hypothyroidism causes myocardial dysfunction that resembles the myocardial depression of septic shock. We hypothesize that the myocardial hypothyroidism that occurs during septic shock has a causal role in the pathogenesis of septic shock-induced myocardial dysfunction. Thyroid hormones regulate the calcium cycle, the phenotype of contractile proteins, adrenergic response, and fatty acid transport and oxidation in the cardiomyocytes. Therefore, the administration of levothyroxine and liothyronine to normalize thyroid hormones level within the myocardium will improve the myocardial function. The hypothesis will be tested in humans with septic shock by performing a prospective, randomized, placebo-controlled study to compare the effect of thyroid hormone administration with placebo on myocardial function. The proposed hypothesis challenges the idea that non-thyroidal illness syndrome is a beneficial response of the thyroid hormone axis to illness and that thyroid hormone replacement is detrimental. The administration of thyroid hormone in order to prevent and reverse myocardial hypothyroidism during septic shock is a new theoretical concept on thyroid hormone metabolism and action at the tissue level during non-thyroidal illness syndrome. If the hypothesis is correct, clinicians should consider cardiac hypothyroidism as a central player in myocardial dysfunction caused by sepsis. Thyroid hormone replacement should be incorporated into the armamentarium of septic shock treatment.
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Affiliation(s)
- Joaquin Lado-Abeal
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Truman Medical Centers and University of Missouri Kansas City, MO, USA.
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13
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Vagus Nerve Stimulation Attenuates Multiple Organ Dysfunction in Resuscitated Porcine Progressive Sepsis. Crit Care Med 2020; 47:e461-e469. [PMID: 30908312 DOI: 10.1097/ccm.0000000000003714] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To investigate the potential benefits of vagus nerve stimulation in a clinically-relevant large animal model of progressive sepsis. DESIGN Prospective, controlled, randomized trial. SETTING University animal research laboratory. SUBJECTS Twenty-five domestic pigs were divided into three groups: 1) sepsis group (eight pigs), 2) sepsis + vagus nerve stimulation group (nine pigs), and 3) control sham group (eight pigs). INTERVENTIONS Sepsis was induced by cultivated autologous feces inoculation in anesthetized, mechanically ventilated, and surgically instrumented pigs and followed for 24 hours. Electrical stimulation of the cervical vagus nerve was initiated 6 hours after the induction of peritonitis and maintained throughout the experiment. MEASUREMENTS AND MAIN RESULTS Measurements of hemodynamics, electrocardiography, biochemistry, blood gases, cytokines, and blood cells were collected at baseline (just before peritonitis induction) and at the end of the in vivo experiment (24 hr after peritonitis induction). Subsequent in vitro analyses addressed cardiac contractility and calcium handling in isolated tissues and myocytes and analyzed mitochondrial function by ultrasensitive oxygraphy. Vagus nerve stimulation partially or completely prevented the development of hyperlactatemia, hyperdynamic circulation, cellular myocardial depression, shift in sympathovagal balance toward sympathetic dominance, and cardiac mitochondrial dysfunction, and reduced the number of activated monocytes. Sequential Organ Failure Assessment scores and vasopressor requirements significantly decreased after vagus nerve stimulation. CONCLUSIONS In a clinically-relevant large animal model of progressive sepsis, vagus nerve stimulation was associated with a number of beneficial effects that resulted in significantly attenuated multiple organ dysfunction and reduced vasopressor and fluid resuscitation requirements. This suggests that vagus nerve stimulation might provide a significant therapeutic potential that warrants further thorough investigation.
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14
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Park I, Lee JH, Jang DH, Kim D, Chang H, Kwon H, Kim S, Kim TS, Jo YH. Characterization of Fecal Peritonitis–Induced Sepsis in a Porcine Model. J Surg Res 2019; 244:492-501. [DOI: 10.1016/j.jss.2019.06.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/03/2019] [Accepted: 06/21/2019] [Indexed: 01/04/2023]
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15
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Vico TA, Marchini T, Ginart S, Lorenzetti MA, Adán Areán JS, Calabró V, Garcés M, Ferrero MC, Mazo T, D’Annunzio V, Gelpi RJ, Corach D, Evelson P, Vanasco V, Alvarez S. Mitochondrial bioenergetics links inflammation and cardiac contractility in endotoxemia. Basic Res Cardiol 2019; 114:38. [DOI: 10.1007/s00395-019-0745-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 07/30/2019] [Indexed: 12/16/2022]
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16
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Lautz AJ, Zingarelli B. Age-Dependent Myocardial Dysfunction in Critically Ill Patients: Role of Mitochondrial Dysfunction. Int J Mol Sci 2019; 20:ijms20143523. [PMID: 31323783 PMCID: PMC6679204 DOI: 10.3390/ijms20143523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/11/2019] [Accepted: 07/16/2019] [Indexed: 02/06/2023] Open
Abstract
Myocardial dysfunction is common in septic shock and post-cardiac arrest but manifests differently in pediatric and adult patients. By conventional echocardiographic parameters, biventricular systolic dysfunction is more prevalent in children with septic shock, though strain imaging reveals that myocardial injury may be more common in adults than previously thought. In contrast, diastolic dysfunction in general and post-arrest myocardial systolic dysfunction appear to be more widespread in the adult population. A growing body of evidence suggests that mitochondrial dysfunction mediates myocardial depression in critical illness; alterations in mitochondrial electron transport system function, bioenergetic production, oxidative and nitrosative stress, uncoupling, mitochondrial permeability transition, fusion, fission, biogenesis, and autophagy all may play key pathophysiologic roles. In this review we summarize the epidemiologic and clinical phenotypes of myocardial dysfunction in septic shock and post-cardiac arrest and the multifaceted manifestations of mitochondrial injury in these disease processes. Since neonatal and pediatric-specific data for mitochondrial dysfunction remain sparse, conclusive age-dependent differences are not clear; instead, we highlight what evidence exists and identify gaps in knowledge to guide future research. Finally, since focal ischemic injury (with or without reperfusion) leading to myocardial infarction is predominantly an atherosclerotic disease of the elderly, this review focuses specifically on septic shock and global ischemia-reperfusion injury occurring after resuscitation from cardiac arrest.
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Affiliation(s)
- Andrew J Lautz
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Basilia Zingarelli
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45229, USA.
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Pischke SE, Hestenes S, Johansen HT, Fure H, Bugge JF, Espinoza A, Skulstad H, Edvardsen T, Fosse E, Mollnes TE, Halvorsen PS, Nielsen EW. Sepsis causes right ventricular myocardial inflammation independent of pulmonary hypertension in a porcine sepsis model. PLoS One 2019; 14:e0218624. [PMID: 31247004 PMCID: PMC6597071 DOI: 10.1371/journal.pone.0218624] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 06/05/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Right ventricular (RV) myocardial dysfunction is a common feature in septic shock. It can worsen outcome, but the etiology is poorly understood. Pulmonary artery hypertension (PAH) plays a part in the pathogenesis of the right heart dysfunction in sepsis but its importance is unknown. In pigs, PAH in sepsis is substantial and the translational value of porcine sepsis models therefore questioned. We hypothesized that porcine sepsis causes a myocardial inflammatory response which leads to myocardial dysfunction independent of PAH. MATERIALS AND METHODS Sepsis was induced by Escherichia coli-infusion in 10 pigs resulting in PAH and increased right ventricular pressure (RVP). The same degree of RVP was achieved by external pulmonary artery banding (PAB) in a consecutive series of 6 animals. RESULTS Sepsis, but not PAB, led to increase in endothelial damage marker PAI-1 and cytokines TNF and IL-6 (all p<0.05) in plasma. In myocardium, TNF and IL-6 were significantly elevated in sepsis, TNF in both ventricles and IL-6 mostly in RV, while IL-1β, IL-18 and C5a were significantly higher in RV compared to LV after PAB (all p<0.05). Myocardial mRNA levels of IL-1β, IL-6, IL-18, IP-10, E-selectin and PAI-1 were significantly elevated in RV and LV during sepsis compared to PAB, while Caspase-1 was decreased in septic compared to PAB animals (all p<0.05). Cathepsin L activity was increased in RV by PAB, while sepsis inhibited this response. Escherichia coli-induced sepsis caused myocardial inflammation independent of PAH. CONCLUSION Prominent PAH should therefore not exclude porcine sepsis models to further our understanding of human sepsis.
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Affiliation(s)
- Soeren Erik Pischke
- Department of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Siv Hestenes
- Intervention Centre, Oslo University Hospital, Oslo, Norway
- Department of Anaesthesia, Intensive Care and Emergency Medicine, Vestre Viken Baerum Hospital, Baerum, Norway
| | | | - Hilde Fure
- Research Laboratory, Nordland Hospital, Bodø, and Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway
| | - Jan Frederik Bugge
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Andreas Espinoza
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Helge Skulstad
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Thor Edvardsen
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Erik Fosse
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Intervention Centre, Oslo University Hospital, Oslo, Norway
| | - Tom Eirik Mollnes
- Department of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Research Laboratory, Nordland Hospital, Bodø, and Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway
- Centre of Molecular Inflammation Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Per Steinar Halvorsen
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Intervention Centre, Oslo University Hospital, Oslo, Norway
| | - Erik Waage Nielsen
- Department of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Research Laboratory, Nordland Hospital, Bodø, and Faculty of Health Sciences, K.G. Jebsen TREC, University of Tromsø, Tromsø, Norway
- * E-mail:
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