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Kellihan HB, Cutchin E, Sirochman A, Gasper D. Severe Pulmonary Hypertension and Pulmonary Thrombi in a Dog. CASE (PHILADELPHIA, PA.) 2024; 8:273-278. [PMID: 38524883 PMCID: PMC10959734 DOI: 10.1016/j.case.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
•PAs can protrude from the lung with severe obstruction and dilation. •Dogs can develop PT secondary to protein-losing nephropathy. •Evidence of classic histopathologic changes associated with chronic PH was present. •Dogs can live with chronic severe PA obstruction and severe PH secondary to PT.
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Affiliation(s)
- Heidi B. Kellihan
- Department of Medical Sciences, University of Wisconsin School of Veterinary Medicine, Madison, Wisconsin
| | - Elizabeth Cutchin
- Department of Medical Sciences, University of Wisconsin School of Veterinary Medicine, Madison, Wisconsin
| | - Anna Sirochman
- Department of Medical Sciences, University of Wisconsin School of Veterinary Medicine, Madison, Wisconsin
| | - David Gasper
- Department of Pathobiological Sciences, University of Wisconsin School of Veterinary Medicine, Madison, Wisconsin
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Merit VT, Kirk ME, Schultz JG, Hansen JV, Lyhne MD, Kramer AD, Pedersen CCE, Karout L, Kalra MK, Andersen A, Nielsen-Kudsk JE. Changes in Pulmonary Vascular Resistance and Obstruction Score Following Acute Pulmonary Embolism in Pigs. Crit Care Explor 2024; 6:e1040. [PMID: 38511125 PMCID: PMC10954062 DOI: 10.1097/cce.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES To investigate the contribution of mechanical obstruction and pulmonary vasoconstriction to pulmonary vascular resistance (PVR) in acute pulmonary embolism (PE) in pigs. DESIGN Controlled, animal study. SETTING Tertiary university hospital, animal research laboratory. SUBJECTS Female Danish slaughter pigs (n = 12, ~60 kg). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PE was induced by infusion of autologous blood clots in pigs. CT pulmonary angiograms were performed at baseline, after PE (first experimental day [PEd0]) and the following 2 days (second experimental day [PEd1] and third experimental day [PEd2]), and clot burden quantified by a modified Qanadli Obstruction Score. Hemodynamics were evaluated with left and right heart catheterization and systemic invasive pressures each day before, under, and after treatment with the pulmonary vasodilators sildenafil (0.1 mg/kg) and oxygen (Fio2 40%). PE increased PVR (baseline vs. PEd0: 178 ± 54 vs. 526 ± 160 dynes; p < 0.0001) and obstruction score (baseline vs. PEd0: 0% vs. 45% ± 13%; p < 0.0001). PVR decreased toward baseline at day 1 (baseline vs. PEd1: 178 ± 54 vs. 219 ± 48; p = 0.16) and day 2 (baseline vs. PEd2: 178 ± 54 vs. 201 ± 50; p = 0.51). Obstruction score decreased only slightly at day 1 (PEd0 vs. PEd1: 45% ± 12% vs. 43% ± 14%; p = 0.04) and remained elevated throughout the study (PEd1 vs. PEd2: 43% ± 14% vs. 42% ± 17%; p = 0.74). Sildenafil and oxygen in combination decreased PVR at day 0 (-284 ± 154 dynes; p = 0.0064) but had no effects at day 1 (-8 ± 27 dynes; p = 0.4827) or day 2 (-18 ± 32 dynes; p = 0.0923). CONCLUSIONS Pulmonary vasoconstriction, and not mechanical obstruction, was the predominant cause of increased PVR in acute PE in pigs. PVR rapidly declined over the first 2 days after onset despite a persistent mechanical obstruction of the pulmonary circulation from emboli. The findings suggest that treatment with pulmonary vasodilators might only be effective in the acute phase of PE thereby limiting the window for such therapy.
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Affiliation(s)
- Victor T Merit
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Mathilde E Kirk
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jacob G Schultz
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jacob V Hansen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Mads D Lyhne
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark
| | - Anders D Kramer
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | | | - Lina Karout
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | | | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus N, Denmark
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Nitrite and tempol combination promotes synergic effects and alleviates right ventricular wall stress during acute pulmonary thromboembolism. Nitric Oxide 2021; 115:23-29. [PMID: 34133975 DOI: 10.1016/j.niox.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/29/2021] [Accepted: 06/11/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The mechanical obstruction and pulmonary vasoconstriction are major determinants of the sudden right ventricular (RV) afterload increases observed during acute pulmonary thromboembolism (APT). Vasodilators and antioxidants agents have been shown to mitigate pulmonary hypertension. We examined whether sodium nitrite and the antioxidant tempol combination could be advantageous in an APT sheep model. METHODS APT was induced in anesthetized sheep by autologous blood clots (250 mg/kg) into the right atrium. Thirty minutes after APT induction, the animals received a continuous infusion of tempol (1.0 mg/kg/min), increasing sodium nitrite infusion (5, 15, and 50 μmol/kg), or a simultaneous combination of both drugs. Saline was used as a control treatment. Hemodynamic measurements were carried out every 15 min. Also, whole blood nitrite and serum 8-isoprostanes levels were measured. RESULTS APT induced sustained pulmonary hypertension, increased dp/dtmax, and rate pressure product (RPP). Nitrite or tempol treatments attenuated these increases (P < 0.05). When both drugs were combined, we found a robust reduction in the RV RPP compared with the treatments alone (P < 0.05). The sole nitrite infusion increased blood nitrite concentrations by 35 ± 6 μM (P < 0.05), whereas the nitrite and tempol combination produced higher blood nitrite concentrations by approximately 54 ± 7 μM. Tempol or nitrite infusions, both alone or combined, blunted the increases in 8-isoprostane concentrations observed after APT. CONCLUSIONS Nitrite and tempol combination protects against APT-induced RV wall stress. The association of both drugs may offer an advantage to treat RV failure during severe APT.
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Andersen A, Waziri F, Schultz JG, Holmboe S, Becker SW, Jensen T, Søndergaard HM, Dodt KK, May O, Mortensen UM, Kim WY, Mellemkjær S, Nielsen-Kudsk JE. Pulmonary vasodilation by sildenafil in acute intermediate-high risk pulmonary embolism: a randomized explorative trial. BMC Pulm Med 2021; 21:72. [PMID: 33639897 PMCID: PMC7916297 DOI: 10.1186/s12890-021-01440-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 02/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate if acute pulmonary vasodilation by sildenafil improves right ventricular function in patients with acute intermediate-high risk pulmonary embolism (PE). METHODS Single center, explorative trial. Patients with PE were randomized to a single oral dose of sildenafil 50 mg (n = 10) or placebo (n = 10) as add-on to conventional therapy. The time from hospital admission to study inclusion was 2.3 ± 0.7 days. Right ventricular function was evaluated immediately before and shortly after (0.5-1.5 h) randomization by right heart catheterization (RHC), trans-thoracic echocardiography (TTE), and cardiac magnetic resonance (CMR). The primary efficacy endpoint was cardiac index measured by CMR. RESULTS Patients had acute intermediate-high risk PE verified by computed tomography pulmonary angiography, systolic blood pressure of 135 ± 18 (mean ± SD) mmHg, increased right ventricular/left ventricular ratio 1.1 ± 0.09 and increased troponin T 167 ± 144 ng/L. Sildenafil treatment did not improve cardiac index compared to baseline (0.02 ± 0.36 l/min/m2, p = 0.89) and neither did placebo (0.00 ± 0.34 l/min/m2, p = 0.97). Sildenafil lowered mean arterial blood pressure (- 19 ± 10 mmHg, p < 0.001) which was not observed in the placebo group (0 ± 9 mmHg, p = 0.97). CONCLUSION A single oral dose of sildenafil 50 mg did not improve cardiac index but lowered systemic blood pressure in patients with acute intermediate-high risk PE. The time from PE to intervention, a small patient sample size and low pulmonary vascular resistance are limitations of this study that should be considered when interpreting the results. TRIAL REGISTRATION The trial was retrospectively registered at www.clinicaltrials.gov (NCT04283240) February 2nd 2020, https://clinicaltrials.gov/ct2/show/NCT04283240?term=NCT04283240&draw=2&rank=1 .
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Affiliation(s)
- Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Farhad Waziri
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Jacob Gammelgaard Schultz
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Sarah Holmboe
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | | | - Tage Jensen
- Department of Internal Medicine, Region Hospital of Randers, Randers, Denmark
| | | | - Karen Kaae Dodt
- Department of Internal Medicine, Region Hospital of Horsens, Horsens, Denmark
| | - Ole May
- Department of Internal Medicine, Region Hospital of Herning, Herning, Denmark
| | - Ulrik Markus Mortensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Won Yong Kim
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Søren Mellemkjær
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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The effect of sildenafil on pulmonary haemodynamics in a canine model of chronic embolic pulmonary hypertension. Res Vet Sci 2020; 133:106-110. [PMID: 32961474 DOI: 10.1016/j.rvsc.2020.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/08/2020] [Accepted: 08/30/2020] [Indexed: 01/07/2023]
Abstract
The effects of different doses of orally administered sildenafil on pulmonary haemodynamics in dogs with pulmonary hypertension (PH) have not been documented in an invasive and quantitative manner. In this study, we examined the effects of oral sildenafil using a canine model of chronic embolic PH (CEPH). This CEPH model was created by repeatedly injecting microspheres through a catheter into the pulmonary artery under general anaesthesia at regular weekly intervals over several months. The CEPH dogs received 1, 2 or 4 mg/kg of sildenafil orally twice a day for seven days. Then, haemodynamic measurements including pulmonary artery pressure (PAP), systemic artery pressure (SAP), pulmonary artery wedge pressure (PAWP), right atrial pressure (RAP) and cardiac output (CO) were obtained after seven days of sildenafil administration via right heart catheterisation and oscillometric blood pressure measurements. Sildenafil was well tolerated in this study. Sildenafil administered at doses of 2 and 4 mg/kg significantly decreased systolic PAP compared with before administration. In addition, all doses of sildenafil significantly decreased the mean and diastolic PAP. Furthermore, 4 mg/kg of sildenafil significantly decreased PAP compared with 1 mg/kg. Sildenafil also significantly decreased pulmonary vascular resistance without notable changes in SAP or systemic vascular resistance. The PAWP, RAP and CO did not increase significantly at any doses. In conclusion, the oral administration of sildenafil to CEPH models decreased PAP in a dose-dependent manner.
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Schultz J, Andersen A, Gade IL, Kjaergaard B, Nielsen-Kudsk JE. Riociguat, sildenafil and inhaled nitric oxide reduces pulmonary vascular resistance and improves right ventricular function in a porcine model of acute pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 9:293-301. [PMID: 31025569 DOI: 10.1177/2048872619840772] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pulmonary vasodilators as add-on to current treatment strategies in acute pulmonary embolism may improve right ventricular unloading and hence improve patient outcome. We aimed to investigate whether stimulation of the nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway with riociguat, sildenafil or inhaled NO causes pulmonary vasodilation and improves right ventricular function in a porcine model of acute intermediate risk pulmonary embolism. METHODS Two large autologous blood clots were administered to the pulmonary circulation of 28 pigs (60 kg). Animals were randomized to four increasing, clinically equivalent doses of riociguat (n=6), sildenafil (n=6), inhaled NO (n=6) or vehicle (n=6). Sham animals (n=4) did not receive pulmonary embolism or treatment. Haemodynamic responses were evaluated at baseline, after pulmonary embolism and after each dose using invasive pressure measurements, transoesophageal echocardiography, respiratory parameters and blood analysis. RESULTS Pulmonary embolism caused a three-fold increase in pulmonary vascular resistance compared with baseline (pulmonary embolism: 352±29 vs. baseline: 107±6 dynes, p<0.0001). All treatments lowered pulmonary vascular resistance compared with vehicle (riociguat: -158±35, sildenafil: -224±35, inhaled NO: -156±35 dynes, p<0.0001). Sildenafil, but neither inhaled NO nor riociguat, caused a decrease in systemic vascular resistance (sildenafil 678±41 vs. vehicle 1081±93 dynes, p=0.02) and increased cardiac output (sildenafil 8.8±0.8 vs. vehicle: 5.9±0.2 L/min, p<0.001). Systemic blood pressure was unaltered in all treatment groups. CONCLUSION Stimulation of the NO-sGC-cGMP pathway by riociguat, sildenafil and inhaled NO reduces pulmonary vascular resistance in a porcine model of acute pulmonary embolism without lowering systemic blood pressure.
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Affiliation(s)
- Jacob Schultz
- Department of Cardiology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
| | - Inger Lise Gade
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark
- Department of Haematology, Aalborg University Hospital, Denmark
| | | | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Denmark
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Lyhne MD, Kline JA, Nielsen-Kudsk JE, Andersen A. Pulmonary vasodilation in acute pulmonary embolism - a systematic review. Pulm Circ 2020; 10:2045894019899775. [PMID: 32180938 PMCID: PMC7057411 DOI: 10.1177/2045894019899775] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/18/2019] [Indexed: 01/17/2023] Open
Abstract
Acute pulmonary embolism is the third most common cause of cardiovascular death. Pulmonary embolism increases right ventricular afterload, which causes right ventricular failure, circulatory collapse and death. Most treatments focus on removal of the mechanical obstruction caused by the embolism, but pulmonary vasoconstriction is a significant contributor to the increased right ventricular afterload and is often left untreated. Pulmonary thromboembolism causes mechanical obstruction of the pulmonary vasculature coupled with a complex interaction between humoral factors from the activated platelets, endothelial effects, reflexes and hypoxia to cause pulmonary vasoconstriction that worsens right ventricular afterload. Vasoconstrictors include serotonin, thromboxane, prostaglandins and endothelins, counterbalanced by vasodilators such as nitric oxide and prostacyclins. Exogenous administration of pulmonary vasodilators in acute pulmonary embolism seems attractive but all come with a risk of systemic vasodilation or worsening of pulmonary ventilation-perfusion mismatch. In animal models of acute pulmonary embolism, modulators of the nitric oxide-cyclic guanosine monophosphate-protein kinase G pathway, endothelin pathway and prostaglandin pathway have been investigated. But only a small number of clinical case reports and prospective clinical trials exist. The aim of this review is to give an overview of the causes of pulmonary embolism-induced pulmonary vasoconstriction and of experimental and human investigations of pulmonary vasodilation in acute pulmonary embolism.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeffrey Allen Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Pariaut R, Jung SW, Vila J, Newhard DK. Resolution of caval syndrome during initial hemodynamic stabilization in dogs with heartworm disease. J Vet Emerg Crit Care (San Antonio) 2020; 30:295-301. [PMID: 32077239 DOI: 10.1111/vec.12948] [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: 01/11/2018] [Revised: 07/27/2018] [Accepted: 09/10/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report on the spontaneous resolution of caval syndrome in 5 dogs selected for their response to medical stabilization prior to scheduled heartworm extraction. SERIES SUMMARY Five dogs with heartworm caval syndrome were treated with sildenafil, fluid, and supplemental oxygen therapy. Moreover, 4 of 5 dogs were also administered pimobendan to achieve hemodynamic stabilization in preparation for percutaneous heartworm extraction. Spontaneous heartworm migration back into the pulmonary arteries was detected from 2 h to 5 days after treatment initiation. UNIQUE INFORMATION PROVIDED Unanticipated spontaneous resolution of caval syndrome was documented in a low number of dogs after initiation of a patient stabilization protocol aiming at improving right ventricular hemodynamics and reducing pulmonary artery pressure prior to scheduled heartworm extraction. At this time, it is unknown if intervention to improve the hemodynamic status of the animal prior to heartworm extraction improves procedure outcome, and which factors contributed to the migration of the heartworms back into the pulmonary arteries in these selected cases. Therefore, this approach cannot be recommended in place of current recommendations for treatment of caval syndrome.
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Affiliation(s)
- Romain Pariaut
- Department of Clinical Sciences, Cornell University, Ithaca, New York
| | - Seung Woo Jung
- Department of Clinical Sciences, Auburn University, Auburn, Alaska
| | | | - Daniel K Newhard
- Department of Clinical Sciences, Auburn University, Auburn, Alaska
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Reinero C, Visser LC, Kellihan HB, Masseau I, Rozanski E, Clercx C, Williams K, Abbott J, Borgarelli M, Scansen BA. ACVIM consensus statement guidelines for the diagnosis, classification, treatment, and monitoring of pulmonary hypertension in dogs. J Vet Intern Med 2020; 34:549-573. [PMID: 32065428 PMCID: PMC7097566 DOI: 10.1111/jvim.15725] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 01/30/2020] [Indexed: 01/01/2023] Open
Abstract
Pulmonary hypertension (PH), defined by increased pressure within the pulmonary vasculature, is a hemodynamic and pathophysiologic state present in a wide variety of cardiovascular, respiratory, and systemic diseases. The purpose of this consensus statement is to provide a multidisciplinary approach to guidelines for the diagnosis, classification, treatment, and monitoring of PH in dogs. Comprehensive evaluation including consideration of signalment, clinical signs, echocardiographic parameters, and results of other diagnostic tests supports the diagnosis of PH and allows identification of associated underlying conditions. Dogs with PH can be classified into the following 6 groups: group 1, pulmonary arterial hypertension; group 2, left heart disease; group 3, respiratory disease/hypoxia; group 4, pulmonary emboli/pulmonary thrombi/pulmonary thromboemboli; group 5, parasitic disease (Dirofilaria and Angiostrongylus); and group 6, disorders that are multifactorial or with unclear mechanisms. The approach to treatment of PH focuses on strategies to decrease the risk of progression, complications, or both, recommendations to target underlying diseases or factors contributing to PH, and PH‐specific treatments. Dogs with PH should be monitored for improvement, static condition, or progression, and any identified underlying disorder should be addressed and monitored simultaneously.
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Affiliation(s)
- Carol Reinero
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, Missouri
| | - Lance C Visser
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, Davis, California
| | - Heidi B Kellihan
- Department of Medical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, Wisconsin
| | - Isabelle Masseau
- Department of Sciences Cliniques, Faculté de Médecine Vétérinaire, Université de Montréal, Saint-Hyacinthe, Quebec, Canada
| | - Elizabeth Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, Medford, Massachusetts
| | - Cécile Clercx
- Department of Clinical Sciences of Companion Animals and Equine, University of Liège, Liège, Belgium
| | - Kurt Williams
- Department of Pathobiology and Diagnostic Investigation, College of Veterinary Medicine, Michigan State University, East Lansing, Michigan
| | - Jonathan Abbott
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, Tennessee
| | - Michele Borgarelli
- Department of Small Animal Clinical Sciences, Virginia Maryland College of Veterinary Medicine, Blacksburg, Virginia
| | - Brian A Scansen
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
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Lagos-Carvajal AP, Teixeira-Neto FJ, Becerra-Velásquez DR, Diniz MS, Klein AV, Rocha TLA, Dias-Junior CA. Adrenomedullin induces pulmonary vasodilation but does not attenuate pulmonary hypertension in a sheep model of acute pulmonary embolism. Life Sci 2015; 139:139-44. [PMID: 26316450 DOI: 10.1016/j.lfs.2015.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 08/05/2015] [Accepted: 08/17/2015] [Indexed: 11/19/2022]
Abstract
AIMS The pulmonary vasodilation induced by adrenomedullin may be beneficial in the acute pulmonary embolism (APE) setting. This study examined effects of adrenomedullin in sheep with microsphere-induced APE. MAIN METHODS Twenty four anesthetized, mechanically ventilated sheep were randomly assigned into 3 groups (n=8 per group): animals not subjected to any intervention (Sham), animals with APE induced by microspheres (500 mg, intravenously) treated 30 min later by intravenous physiological saline (Emb group) or intravenous adrenomedullin (50 ng/kg/min) during 30 min (Emb+Adm group). Plasma concentrations of cyclic adenosine (cAMP) and guanosine monophosphate (cGMP) were determined by enzyme immunoassay. KEY FINDINGS Variables did not change over time in sham animals. In both embolized groups, microsphere injection significantly (P<0.05) increased pulmonary vascular resistance index (PVRI) and mean pulmonary artery pressure (MPAP) from baseline by 181% and 111-142%, respectively (% change in mean values). Adrenomedullin significantly decreased PVRI (18%-25%) and significantly increased cardiac index (22%-25%) from values recorded 30 min after APE (E30), without modifying MPAP. Adrenomedullin decreased mean arterial pressure (18%-24%) and systemic vascular resistance index (32%-40%). Embolization significantly increased arterial-to-end tidal CO2 gradient, alveolar-to-arterial O2 gradient, and pulmonary shunt fraction from baseline, but these variables were unaffected by adrenomedullin. While adrenomedullin significantly increased plasma cAMP, cGMP levels were unaltered. SIGNIFICANCE Adrenomedullin induces systemic and pulmonary vasodilation, possibly via a cAMP mediated mechanism, without modifying the gas exchange impairment associated with APE. The pulmonary anti-hypertensive effect of adrenomedullin may be offset by increases in cardiac index.
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Affiliation(s)
- Angie Paola Lagos-Carvajal
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Francisco José Teixeira-Neto
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil; Departamento de Cirurgia e Anestesiologia Veterinária, Faculdade de Medicina Veterinária e Zootecnia, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Diana Rocío Becerra-Velásquez
- Departamento de Cirurgia e Anestesiologia Veterinária, Faculdade de Medicina Veterinária e Zootecnia, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Miriely Steim Diniz
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Adriana Vieira Klein
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Thalita Leone Alves Rocha
- Departamento de Farmacologia, Instituto de Biociências de Botucatu, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Carlos Alan Dias-Junior
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil; Departamento de Farmacologia, Instituto de Biociências de Botucatu, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil.
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Effects of different inspired oxygen fractions on sildenafil-induced pulmonary anti-hypertensive effects in a sheep model of acute pulmonary embolism. Life Sci 2015; 127:26-31. [DOI: 10.1016/j.lfs.2015.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 01/21/2015] [Accepted: 02/02/2015] [Indexed: 11/22/2022]
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Brenner JS, Greineder C, Shuvaev V, Muzykantov V. Endothelial nanomedicine for the treatment of pulmonary disease. Expert Opin Drug Deliv 2014; 12:239-61. [PMID: 25394760 DOI: 10.1517/17425247.2015.961418] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Even though pulmonary diseases are among the leading causes of morbidity and mortality in the world, exceedingly few life-prolonging therapies have been developed for these maladies. Relief may finally come from nanomedicine and targeted drug delivery. AREAS COVERED Here, we focus on four conditions for which the pulmonary endothelium plays a pivotal role: acute respiratory distress syndrome, primary graft dysfunction occurring immediately after lung transplantation, pulmonary arterial hypertension and pulmonary embolism. For each of these diseases, we first evaluate the targeted drug delivery approaches that have been tested in animals. Then we suggest a 'need specification' for each disease: a list of criteria (e.g., macroscale delivery method, stability, etc.) that nanomedicine agents must meet in order to warrant human clinical trials and investment from industry. EXPERT OPINION For the diseases profiled here, numerous nanomedicine agents have shown promise in animal models. However, to maximize the chances of creating products that reach patients, nanomedicine engineers and clinicians must work together and use each disease's need specification to guide the design of practical and effective nanomedicine agents.
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Affiliation(s)
- Jacob S Brenner
- University of Pennsylvania, Perelman School of Medicine, Department of Pharmacology and Center for Targeted Therapeutics and Translational Nanomedicine , TRC10-125, 3600 Civic Center Boulevard, Philadelphia, PA 19104 , USA +1 215 898 9823 ; +1 215 573 9135 ;
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Jiang G, Li B, Zhang G, Xu E, Liu Y, Xu Z. Effects of sildenafil on prognosis in patients with pulmonary hypertension after left-sided valvular surgery. Heart Lung Circ 2014; 23:680-5. [PMID: 24613188 DOI: 10.1016/j.hlc.2013.12.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 11/18/2013] [Accepted: 12/30/2013] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Sildenafil (Viagra, Pfizer) is being used to treat pulmonary hypertension (PH). However, there are limited data on the effects of sildenafil on patients with PH after left-sided valvular surgery. The purpose of this study was to determine the optimal dosage and the effects of sildenafil on prognosis of patients with PH after left-sided valvular surgery. METHODS This randomised controlled trial, double-blind study enrolled patients with PH undergoing left-sided valvular surgery in our hospital from January to December, 2010. Ninety patients were enrolled. And 0.5 mg/kg sildenafil citrate or placebo was administered through nasogastric tubes, the haemodynamics changes in the 0.5/1/2/4 hours were assessed. The sildenafil citrate/placebo was continued to the discharges and the early prognoses of these patients were compared. RESULTS Compared with placebo, a 0.5 mg/kg dose of sildenafil significantly reduced the time of mechanical ventilation, stay-in-ICU and hospitalisation duration. CONCLUSIONS Sildenafil might be beneficial to the early prognosis of patients with PH after left-sided valvular surgery.
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Abstract
Diseases of the pulmonary vasculature are a cause of increased pulmonary vascular resistance (PVR) in pulmonary embolism, chronic thromboembolic pulmonary hypertension (CTEPH), and pulmonary arterial hypertension or decreased PVR in pulmonary arteriovenous malformations on hereditary hemorrhagic telangiectasia, portal hypertension, or cavopulmonary anastomosis. All these conditions are associated with a decrease in both arterial PO2 and PCO2. Gas exchange in pulmonary vascular diseases with increased PVR is characterized by a shift of ventilation and perfusion to high ventilation-perfusion ratios, a mild to moderate increase in perfusion to low ventilation-perfusion ratios, and an increased physiologic dead space. Hypoxemia in these patients is essentially explained by altered ventilation-perfusion matching amplified by a decreased mixed venous PO2 caused by a low cardiac output. Hypocapnia is accounted for by hyperventilation, which is essentially related to an increased chemosensitivity. A cardiac shunt on a patent foramen ovale may be a cause of severe hypoxemia in a proportion of patients with pulmonary hypertension and an increase in right atrial pressure. Gas exchange in pulmonary arteriovenous malformations is characterized by variable degree of pulmonary shunting and/or diffusion-perfusion imbalance. Hypocapnia is caused by an increased ventilation in relation to an increased pulmonary blood flow with direct peripheral chemoreceptor stimulation by shunted mixed venous blood flow.
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Affiliation(s)
- C Mélot
- Department of Emergency Medicine, Erasme University Hospital, Brussels, Belgium.
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Elevated Plasma Hemoglobin Levels Increase Nitric Oxide Consumption in Experimental and Clinical Acute Pulmonary Thromboembolism*. Crit Care Med 2013; 41:e118-24. [DOI: 10.1097/ccm.0b013e31827c0b43] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Neto-Neves EM, Dias-Junior CA, Uzuelli JA, Pereira RP, Spiller F, Czaikoski PG, Tanus-Santos JE. Sildenafil improves the beneficial hemodynamic effects exerted by atorvastatin during acute pulmonary thromboembolism. Eur J Pharmacol 2011; 670:554-60. [DOI: 10.1016/j.ejphar.2011.09.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 08/26/2011] [Accepted: 09/07/2011] [Indexed: 11/16/2022]
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Dias CA, Neto-Neves EM, Montenegro MF, Tanus-Santos JE. Losartan exerts no protective effects against acute pulmonary embolism-induced hemodynamic changes. Naunyn Schmiedebergs Arch Pharmacol 2011; 385:211-7. [PMID: 21964667 DOI: 10.1007/s00210-011-0695-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 09/20/2011] [Indexed: 11/30/2022]
Abstract
The acute obstruction of pulmonary vessels by venous thrombi is a critical condition named acute pulmonary embolism (APE). During massive APE, severe pulmonary hypertension may lead to death secondary to right heart failure and circulatory shock. APE-induced pulmonary hypertension is aggravated by active pulmonary vasoconstriction. While blocking the effects of some vasoconstrictors exerts beneficial effects, no previous study has examined whether angiotensin II receptor blockers protect against the hemodynamic changes associated with APE. We examined the effects exerted by losartan on APE-induced hemodynamic changes. Hemodynamic evaluations were performed in non-embolized lambs treated with saline (n = 4) and in lambs that were embolized with silicon microspheres and treated with losartan (30 mg/kg followed by 1 mg/kg/h, n = 5) or saline (n = 7) infusions. The plasma and lung angiotensin-converting enzyme (ACE) activity were assessed using a fluorometric method. APE increased mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance index (PVRI) by 21 ± 2 mmHg and 375 ± 20 dyn s cm⁻⁵ m⁻², respectively (P < 0.05). Losartan decreased MPAP significantly (by approximately 15%), without significant changes in PVRI and tended to decrease cardiac index (P > 0.05). Lung and plasma ACE activity were similar in both embolized and non-embolized animals. Our findings show evidence of lack of activation of the renin-angiotensin system during APE. The lack of significant effects of losartan on the pulmonary vascular resistance suggests that losartan does not protect against the hemodynamic changes found during APE.
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Affiliation(s)
- Carlos A Dias
- Department of Pharmacology, Campus Centro-Oeste Dona Lindu, Federal University of Sao Joao Del Rei, Rua Sebastiao Goncalves Coelho 400, 35501-296 Divinopolis, MG, Brazil
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Marshall PS, Mathews KS, Siegel MD. Diagnosis and management of life-threatening pulmonary embolism. J Intensive Care Med 2011; 26:275-94. [PMID: 21606060 DOI: 10.1177/0885066610392658] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 04/22/2010] [Indexed: 01/01/2023]
Abstract
Pulmonary embolus (PE) is estimated to cause 200 000 to 300 000 deaths annually. Many deaths occur in hemodynamically unstable patients and the estimated mortality for inpatients with hemodynamic instability is between 15% and 25%. The diagnosis of PE in the critically ill is often challenging because the presentation is nonspecific. Computed tomographic pulmonary angiography appears to be the most useful study for diagnosis of PE in the critically ill. For patients with renal insufficiency and contrast allergy, the ventilation perfusion scan provides an alternative. For patients too unstable to travel, echocardiography (especially transesophageal echocardiography) is another option. A positive result on lower extremity Doppler ultrasound can also aid in the decision to treat. The choice of treatment in PE depends on the estimated risk of poor outcome. The presence of hypotension is the most significant predictor of poor outcome and defines those with massive PE. Normotensive patients with evidence of right ventricular (RV) dysfunction, as assessed by echocardiography, comprise the sub-massive category and are at intermediate risk of poor outcomes. Clinically, those with sub-massive PE are difficult to distinguish from those with low-risk PE. Cardiac troponin, brain natriuretic peptide, and computed tomographic pulmonary angiography can raise the suspicion that a patient has sub-massive PE, but the echocardiogram remains the primary means of identifying RV dysfunction. The initial therapy for patients with PE is anticoagulation. Use of vasopressors, inotropes, pulmonary artery (PA) vasodilators and mechanical ventilation can stabilize critically ill patients. The recommended definitive treatment for patients with massive PE is thrombolysis (in addition to anticoagulation). In massive PE, thrombolytics reduce the risk of recurrent PE, cause rapid improvement in hemodynamics, and probably reduce mortality compared with anticoagulation alone. For patients with a contraindication to anticoagulation and thrombolytic therapy, surgical embolectomy and catheter-based therapies are options. Thrombolytic therapy in sub-massive PE results in improved pulmonary perfusion, reduced PA pressures, and a less complicated hospital course. No survival benefit has been documented, however. If one is considering the use of thrombolytic therapy in sub-massive PE, the limited documented benefit must be weighed against the increased risk of life-threatening hemorrhage. The role of surgical embolectomy and catheter-based therapies in this population is unclear. Evidence suggests that sub-massive PE is a heterogeneous group with respect to risk. It is possible that those at highest risk may benefit from thrombolysis, but existing studies do not identify subgroups within the sub-massive category. The role of inferior vena cava (IVC) filters, catheter-based interventions, and surgical embolectomy in life-threatening PE has yet to be completely defined.
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Affiliation(s)
- Peter S Marshall
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Kusum S Mathews
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mark D Siegel
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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Metalloproteinase inhibition protects against cardiomyocyte injury during experimental acute pulmonary thromboembolism*. Crit Care Med 2011; 39:349-56. [DOI: 10.1097/ccm.0b013e3181fa3dfe] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Dias-Junior CA, Neto-Neves EM, Montenegro MF, Tanus-Santos JE. Hemodynamic effects of inducible nitric oxide synthase inhibition combined with sildenafil during acute pulmonary embolism. Nitric Oxide 2010; 23:284-8. [PMID: 20804854 DOI: 10.1016/j.niox.2010.08.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 08/24/2010] [Indexed: 11/27/2022]
Abstract
While endogenous nitric oxide (NO) may be relevant to the beneficial hemodynamic effects produced by sildenafil during acute pulmonary embolism (APE), huge amounts of inducible NO synthase (iNOS)-derived NO may contribute to lung injury. We hypothesized that iNOS inhibition with S-methylisothiourea could attenuate APE-induced increases in oxidative stress and pulmonary hypertension and, therefore, could improve the beneficial hemodynamic and antioxidant effects produced by sildenafil during APE. Hemodynamic evaluations were performed in non-embolized dogs treated with saline (n=4), S-methylisothiourea (0.01 mg/kg followed by 0.5 mg/kg/h, n=4), sildenafil (0.3 mg/kg, n=4), or S-methylisothiourea followed by sildenafil (n=4), and in dogs that received the same drugs and were embolized with silicon microspheres (n=8 for each group). Plasma nitrite/nitrate (NOx) and thiobarbituric acid reactive substances (TBARS) concentrations were determined by Griess and a fluorometric assay, respectively. APE increased mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance index (PVRI) by 25±1.7 mm Hg and by 941±34 dyn s cm(-5) m(-2), respectively. S-methylisothiourea neither attenuated APE-induced pulmonary hypertension, nor enhanced the beneficial hemodynamic effects produced by sildenafil after APE (>50% reduction in pulmonary vascular resistance). While sildenafil produced no change in plasma NOx concentrations, S-methylisothiourea alone or combined with sildenafil blunted APE-induced increases in NOx concentrations. Both drugs, either alone or combined, produced antioxidant effects. In conclusion, although iNOS-derived NO may play a key role in APE-induced oxidative stress, our results suggest that the iNOS inhibitor S-methylisothiourea neither attenuates APE-induced pulmonary hypertension, nor enhances the beneficial hemodynamic effects produced by sildenafil.
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Affiliation(s)
- Carlos A Dias-Junior
- Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Av. Bandeirantes, 3900, 14049-900 Ribeirao Preto, SP, Brazil
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Feng JH, Li WM, Wu XP, Tan XY, Gao YH, Han CL, Li SQ, Xie HN. Hemodynamic effect of apelin in a canine model of acute pulmonary thromboembolism. Peptides 2010; 31:1772-8. [PMID: 20561551 DOI: 10.1016/j.peptides.2010.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 06/07/2010] [Accepted: 06/07/2010] [Indexed: 12/28/2022]
Abstract
The peptide apelin is expressed in the pulmonary vasculature and is involved in the pathogenesis of many cardiovascular diseases. It has a biphasic role in the regulation of vasomotor tone related to the vascular endothelium. In this study, we induced acute pulmonary embolism (APE) in dogs with autologous blood clots to assess the effect of apelin on pulmonary and systemic circulation in the acute phase of APE. The expression of apelin mRNA was found to be upregulated in the lung tissue in the early several hours after APE induction and decreased at 24 h. The expression of apelin protein in the pulmonary arteries did not change within 24 h after APE, but significantly increased in the bronchial epithelial cells as early as 1h and decreased at 24 h. In normal anesthetized dogs, intravenous bolus administration of apelin significantly reduced the mean arterial pressure (MAP), but did not significantly affect the mean pulmonary arterial pressure (MPAP). In the dogs with APE, apelin decreased MPAP, whereas its impact on MAP was not significantly different from that in the control group. Taken together, the level of endogenous apelin did not change significantly in the pulmonary arterial wall, whereas its expression in the bronchial epithelium was upregulated in the early stage of APE. The effect of exogenous apelin on vasomotor tone was complicated: it resulted in differential changes in the pulmonary and systemic arterial pressures under different physiological and pathological conditions.
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Affiliation(s)
- Jing-Hui Feng
- Department of Geratology, First Clinical College of Harbin Medical University, Harbin, Heilongjiang, China
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Kooter AJ, Ijzerman RG, Kamp O, Boonstra AB, Smulders YM. No effect of epoprostenol on right ventricular diameter in patients with acute pulmonary embolism: a randomized controlled trial. BMC Pulm Med 2010; 10:18. [PMID: 20353588 PMCID: PMC2859373 DOI: 10.1186/1471-2466-10-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Accepted: 03/30/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Right ventricular dilatation in the setting of acute pulmonary embolism is associated with an adverse prognosis. Treatment with a pulmonary vasodilator has never been studied systematically. We evaluated the effect of epoprostenol on right ventricular diameter and function in patients with acute pulmonary embolism and right ventricular dilatation. METHODS In a randomized, single-blind study, 14 patients with acute pulmonary embolism received epoprostenol or placebo infusion for 24 hours on top of conventional treatment. Effects on right ventricular end-diastolic diameter, systolic pulmonary artery pressure, right ventricle fractional area change and tricuspid annular plane systolic excursion were assessed by serial echocardiography. Furthermore Troponin T and NT-proBNP were measured serially. RESULTS Compared to placebo, epoprostenol was associated with a relative change from baseline in right ventricular end-diastolic diameter of +2% after 2.5 hours and -8% after 24 hours. Epoprostenol did not have a significant effect on systolic pulmonary artery pressure, right ventricular fractional area change and tricuspid annular plane systolic excursion, nor on biochemical parameters. CONCLUSION In patients with acute pulmonary embolism and right ventricular overload, treatment with epoprostenol did not improve right ventricular dilatation or any other measured variables of right ventricular overload. TRIAL REGISTRATION REGISTRATION URL: NCT01014156Medical ethical committee: Medisch-ethische toetsingscommissie (METc) from the VUmc (free university medical centre).
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Affiliation(s)
- Albertus J Kooter
- Department of Internal Medicine, VU University Medical Center, Amsterdam, the Netherlands.
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Bonatti HJR, Harris T, Bauer T, Enfield K, Sabri S, Sawyer RG, Matsumoto AH, Lowson S, Hagspiel KD. Transfemoral catheter thrombolysis and use of sildenafil in acute massive pulmonary embolism. J Cardiothorac Vasc Anesth 2010; 24:980-4. [PMID: 20138786 DOI: 10.1053/j.jvca.2009.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Indexed: 11/11/2022]
Affiliation(s)
- Hugo J R Bonatti
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
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Watts JA, Marchick MR, Kline JA. Right ventricular heart failure from pulmonary embolism: key distinctions from chronic pulmonary hypertension. J Card Fail 2010; 16:250-9. [PMID: 20206901 DOI: 10.1016/j.cardfail.2009.11.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 11/05/2009] [Accepted: 11/30/2009] [Indexed: 01/05/2023]
Abstract
BACKGROUND The right ventricle normally operates as a low pressure, high-flow pump connected to a high-capacitance pulmonary vascular circuit. Morbidity and mortality in humans with pulmonary hypertension (PH) from any cause is increased in the presence of right ventricular (RV) dysfunction, but the differences in pathology of RV dysfunction in chronic versus acute occlusive PH are not widely recognized. METHODS AND RESULTS Chronic PH that develops over weeks to months leads to RV concentric hypertrophy without inflammation that may progress slowly to RV failure. In contrast, pulmonary embolism (PE) results in an abrupt vascular occlusion leading to increased pulmonary artery pressure within minutes to hours that causes immediate deformation of the RV. RV injury is secondary to mechanical stretch, shear force, and ischemia that together provoke a cytokine and chemokine-mediated inflammatory phenotype that amplifies injury. CONCLUSIONS This review will briefly describe causes of pulmonary embolism and chronic PH, models of experimental study, and pulmonary vascular changes, and will focus on mechanisms of right ventricular dysfunction, contrasting mechanisms of RV adaptation and injury in these 2 settings.
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Affiliation(s)
- John A Watts
- Emergency Medicine Research, Carolinas Medical Center, 1542 Garden Terrace, Charlotte, NC 28203, USA.
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Uzuelli JA, Dias-Junior CAC, Izidoro-Toledo TC, Gerlach RF, Tanus-Santos JE. Circulating cell-free DNA levels in plasma increase with severity in experimental acute pulmonary thromboembolism. Clin Chim Acta 2009; 409:112-6. [PMID: 19751713 DOI: 10.1016/j.cca.2009.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 09/04/2009] [Accepted: 09/04/2009] [Indexed: 01/01/2023]
Abstract
BACKGROUND The diagnosis of acute pulmonary thromboembolism (APT) and its severity is challenging. No previous study has examined whether there is a linear relation between plasma DNA concentrations and the severity of APT. We examined this hypothesis in anesthetized dogs. We also examined the changes in plasma DNA concentrations in microspheres lung embolization and whether the therapy of APT with nitrite could modify APT-induced changes in plasma DNA concentrations. In vitro DNA release from blood clots was also studied. METHODS APT was induced with autologous blood clots (saline, 1, 3, or 5 ml/kg) injected into the right atrium. A group of dogs received 300 microm microspheres into the inferior vena cava to produce similar pulmonary hypertension. Another group of dogs received 6.75 micromol/kg nitrite after APT with blood clots of 5 ml/kg. Hemodynamic evaluations were carried out for 120 min. DNA was extracted from plasma samples using QIAamp DNA Blood Mini Kit and quantified using Quant-iT PicoGreen dsDNA detection kit at baseline and 120 min after APT. RESULTS APT produced dose-dependent increases in plasma DNA concentrations, which correlated positively with pulmonary vascular resistance (P=0.002, r=0.897) and with mean pulmonary arterial pressure (P=0.006, r=0.856). Conversely, lung embolization with microspheres produced no significant changes in plasma DNA concentrations. While nitrite attenuated APT-induced pulmonary hypertension, it produced no changes in plasma DNA concentrations. Blood clots released dose-dependent amounts of DNA in vitro. CONCLUSIONS Cell-free DNA concentrations increase in proportion to the severity of APT, probably as a result of increasing amounts of thrombi obstructing the pulmonary vessels.
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Affiliation(s)
- Juliana A Uzuelli
- Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirao Preto, SP, Brazil
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Dias-Junior CA, Cau SB, Oliveira AM, Castro MM, Montenegro MF, Gerlach RF, Tanus-Santos JE. Nitrite or sildenafil, but not BAY 41-2272, blunt acute pulmonary embolism-induced increases in circulating matrix metalloproteinase-9 and oxidative stress. Thromb Res 2009; 124:349-55. [DOI: 10.1016/j.thromres.2008.12.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 11/22/2008] [Accepted: 12/09/2008] [Indexed: 10/21/2022]
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Goggs R, Benigni L, Fuentes VL, Chan DL. Pulmonary thromboembolism. J Vet Emerg Crit Care (San Antonio) 2009; 19:30-52. [DOI: 10.1111/j.1476-4431.2009.00388.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Galea M, Quiney N. Sildenafil in Acute Pulmonary Embolism: Case Report and Review of Literature. J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We discuss the use of sildenafil in a patient who sustained a massive pulmonary embolism (PE). She remained haemodynamically unstable after thrombolysis, and needed large doses of inotropic support. She was treated with oral sildenafil at a dose of 75 mg three times a day which enabled weaning from inotropic support and clinical improvement.
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Affiliation(s)
| | - Nial Quiney
- Consultant in Anaesthesia and Intensive Care Royal Surrey County Hospital, Guildford
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Rao YJ, Xi L. Pivotal effects of phosphodiesterase inhibitors on myocyte contractility and viability in normal and ischemic hearts. Acta Pharmacol Sin 2009; 30:1-24. [PMID: 19060915 DOI: 10.1038/aps.2008.1] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Phosphodiesterases (PDEs) are enzymes that degrade cellular cAMP and cGMP and are thus essential for regulating the cyclic nucleotides. At least 11 families of PDEs have been identified, each with a distinctive structure, activity, expression, and tissue distribution. The PDE type-3, -4, and -5 (PDE3, PDE4, PDE5) are localized to specific regions of the cardiomyocyte, such as the sarcoplasmic reticulum and Z-disc, where they are likely to influence cAMP/cGMP signaling to the end effectors of contractility. Several PDE inhibitors exhibit remarkable hemodynamic and inotropic properties that may be valuable to clinical practice. In particular, PDE3 inhibitors have potent cardiotonic effects that can be used for short-term inotropic support, especially in situations where adrenergic stimulation is insufficient. Most relevant to this review, PDE inhibitors have also been found to have cytoprotective effects in the heart. For example, PDE3 inhibitors have been shown to be cardioprotective when given before ischemic attack, whereas PDE5 inhibitors, which include three widely used erectile dysfunction drugs (sildenafil, vardenafil and tadalafil), can induce remarkable cardioprotection when administered either prior to ischemia or upon reperfusion. This article provides an overview of the current laboratory and clinical evidence, as well as the cellular mechanisms by which the inhibitors of PDE3, PDE4 and PDE5 exert their beneficial effects on normal and ischemic hearts. It seems that PDE inhibitors hold great promise as clinically applicable agents that can improve cardiac performance and cell survival under critical situations, such as ischemic heart attack, cardiopulmonary bypass surgery, and heart failure.
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Dias-Junior CA, Montenegro MF, Florencio BC, Tanus-Santos JE. Sildenafil Improves the Beneficial Haemodynamic Effects of Intravenous Nitrite Infusion during Acute Pulmonary Embolism. Basic Clin Pharmacol Toxicol 2008; 103:374-9. [DOI: 10.1111/j.1742-7843.2008.00299.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Moreno H. Management of critical haemodynamic complications of amniotic fluid embolism. Int J Obstet Anesth 2008; 17:189-90; author reply 190. [PMID: 18308557 DOI: 10.1016/j.ijoa.2007.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Severity dependent increases in circulating cardiac troponin I and MMP-9 concentrations after experimental acute pulmonary thromboembolism. Clin Chim Acta 2008; 388:184-8. [DOI: 10.1016/j.cca.2007.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Revised: 09/28/2007] [Accepted: 11/04/2007] [Indexed: 10/22/2022]
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Dose-dependent beneficial hemodynamic effects of BAY 41-2272 in a canine model of acute pulmonary thromboembolism. Eur J Pharmacol 2007; 581:132-7. [PMID: 18076875 DOI: 10.1016/j.ejphar.2007.11.030] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Revised: 11/06/2007] [Accepted: 11/15/2007] [Indexed: 11/21/2022]
Abstract
The current therapy of acute pulmonary embolism is focused on removing the mechanical obstruction of the pulmonary vessels. However, accumulating evidence suggests that pulmonary vasoconstriction drives many of the hemodynamic changes found in this condition. We examined the effects of stimulation of soluble guanylate cyclase with BAY 41-2272 (5-Cyclopropyl-2-[1-(2-fluoro-benzyl)-1H-pyrazolo[3,4-b]pyridin-3-yl]-pyrim idin-4-ylamine) in an anesthetized dog model of acute pulmonary embolism. Hemodynamic and arterial blood gas evaluations were performed in non-embolized dogs treated with vehicle (N=5), and in embolized dogs (intravenous injections of microspheres) that received BAY 41-2272 intravenously in doses of 0.03, 0.1, 0.3, and 1 mg/kg/h or vehicle (1 ml/kg/h of 1.13% ethanol in saline, volume/volume). Plasma cGMP and thiobarbituric acid reactive substances concentrations were determined using a commercial enzyme immunoassay and a fluorometric method, respectively. The infusion of BAY 41-2272 resulted in a decrease in pulmonary artery pressure by approximately 29%, and in pulmonary vascular resistance by approximately 46% of the respective increases induced by lung embolization (both P<0.05). While the higher doses of BAY 41-2272 produced no additional effects on the pulmonary circulation, they caused significant arterial hypotension and reduction in systemic vascular resistance (both P<0.05). Although BAY 41-2272 increased cGMP concentrations (P<0.05), it did not affect the hypoxemia and the increased oxidative stress caused by lung embolization. These results suggest that stimulation of soluble guanylate cyclase with low (but not high) doses of BAY 41-2272 produces selective pulmonary vasodilation during acute pulmonary embolism. The dose-dependent systemic effects produced by BAY 41-2272, however, may limit its usefulness in larger doses.
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Dias-Junior CAC, Sertorio JTC, Tanus-Santos JE. Aminoguanidine produces beneficial haemodynamic effects in a canine model of acute pulmonary thromboembolism. Acta Physiol (Oxf) 2007; 191:189-96. [PMID: 17784902 DOI: 10.1111/j.1748-1716.2007.01746.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Activating the nitric oxide (NO)-cyclic guanosine 3',5'-monophosphate (cGMP) pathway improves haemodynamics following acute pulmonary thromboembolism (APT). However, the role of NO synthase (NOS) isoforms in the responses to APT has not been determined. We examined the effects of selective and non-selective inducible NOS (iNOS) inhibition. METHODS Haemodynamic evaluations were performed in non-embolized dogs treated with saline (control group; n = 4), L-NAME (NAME group; n = 3), or aminoguanidine (AG group; n = 3), and in dogs that received the same drugs and were embolized with 5 mL kg(-1) of clots made with autologous blood (Emb group, n = 9; NAME + Emb group, n = 4 and AG + Emb group, n = 7). The lung concentrations of nitrite/nitrate (NOx) and cGMP were determined by chemiluminescence and ELISA respectively. RESULTS Acute pulmonary thromboembolism increased mean pulmonary arterial pressure (MPAP) and pulmonary vascular resistance index (PVRI) by 21.4 +/- 1.7 mmHg and by 843 +/- 34 dyn s cm(-5) m(-2), respectively, in Emb group. MPAP and PVRI increased to higher levels in the NAME + Emb group 15 min after APT and all dogs in this group died 15-30 min after APT. Conversely, lower MPAP and PVRI levels were found in the AG + Emb group 2 h after APT compared with the Emb group (both P < 0.05). Higher NOx concentrations were found in the Emb group compared with the other groups (all P < 0.05). Higher cGMP concentrations were found in the Emb and AG + Emb groups compared with the other groups (all P < 0.05). CONCLUSIONS These results indicate that endogenous NO protects against APT-induced cardiovascular responses. Moreover, iNOS-derived NO possibly produces unfavourable effects, which are counteracted by aminoguanidine. However, non-NO-related mechanisms may also be involved.
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Affiliation(s)
- C A C Dias-Junior
- Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo - FMRP-USP, Ribeirao Preto, SP, Brazil
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Souza-Costa DC, Figueiredo-Lopes L, Alves-Filho JC, Semprini MC, Gerlach RF, Cunha FQ, Tanus-Santos JE. Protective effects of atorvastatin in rat models of acute pulmonary embolism: Involvement of matrix metalloproteinase-9*. Crit Care Med 2007; 35:239-45. [PMID: 17133179 DOI: 10.1097/01.ccm.0000251638.67104.c3] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Matrix metalloproteinases (MMPs) have been implicated in the pathophysiology of acute pulmonary embolism (APE)-induced pulmonary hypertension. Here, we evaluate the effects of atorvastatin pretreatment on APE-induced pulmonary hypertension, 24-hr mortality rate, and changes in plasma and lung MMP-2 and MMP-9 activities. DESIGN Controlled animal study. SETTING University research laboratory. SUBJECTS Male Wistar rats. INTERVENTIONS Rats received atorvastatin (30 mg/kg/day orally) or tap water for 2 wks. In study 1, we examined whether atorvastatin affected APE-induced pulmonary hypertension by using a rat isolated lung perfusion model of APE. In study 2, we examined whether atorvastatin affects the survival rate after APE, which was induced by rapid intravenous injection of 14 mg/kg of a suspension of microspheres (or saline) into the tail vein. MEASUREMENTS AND MAIN RESULTS Plasma nitrite/nitrate concentrations were measured by chemiluminescence. Pretreatment with atorvastatin was associated with 49% higher nitrite/nitrate levels compared with controls (p < .05). In study 1, whereas APE increased mean pulmonary artery pressure (MPAP) by 13.0 +/- 1.6 mm Hg in perfused lungs isolated from rats pretreated with water, pretreatment with atorvastatin attenuated by 27% the increases in MPAP after APE. In study 2, pretreatment with atorvastatin was associated with a significant increase in 24-hr survival rate after APE, which was 48% in embolized rats pretreated with water and 64% in rats pretreated with atorvastatin (p < .05). Gelatin zymography of lung and plasma MMP-2 and MMP-9 was performed. Lungs and plasma from embolized rats showed higher levels of both pro- and activated forms of MMP-9 compared with those from nonembolized animals (all p < .05). However, pretreatment with atorvastatin attenuated by 32% the increases in lung-activated MMP-9 levels after APE (p < .05). CONCLUSIONS These results suggest that pretreatment with atorvastatin attenuates APE-induced pulmonary hypertension and increases 24-hr survival rate by mechanisms that result in attenuated increases in lung activated MMP-9 after APE.
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Affiliation(s)
- Debora C Souza-Costa
- Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Av. Bandeirantes 3900, 14049-900 Ribeirao Preto, SP, Brazil
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Fortuna GM, Figueiredo-Lopes L, Dias-Junior CAC, Gerlach RF, Tanus-Santos JE. A role for matrix metalloproteinase-9 in the hemodynamic changes following acute pulmonary embolism. Int J Cardiol 2007; 114:22-7. [PMID: 16650492 DOI: 10.1016/j.ijcard.2005.11.109] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2005] [Revised: 11/17/2005] [Accepted: 11/17/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Matrix metalloproteinases (MMPs) modulate vascular contractility and may affect acute pulmonary embolism (APE)-induced pulmonary hypertension. We examined the effects of the administration of doxycycline (a MMP inhibitor) following APE in anesthetized dogs. METHODS Sham operated dogs (N=5) received only saline. APE was induced by intravenous injections of microspheres in amounts to increase mean pulmonary artery pressure (MPAP) by 20 mm Hg, and embolized dogs received saline (Emb group, N=8), or doxycycline (10 mg/kg, i.v.) 5 or 30 min of APE (Emb+Doxy 5 and Emb+Doxy 30 groups, N=9 and 8, respectively). Hemodynamic evaluation was performed at baseline and 5-120 after APE. Gelatin zymography of MMP-2 and MMP-9 from plasma samples was performed. RESULTS No significant hemodynamic changes were found in Sham animals. Embolization increased MPAP by 218+/-16% and the pulmonary vascular resistance index (PVRI) by 289+/-42% in Emb group (both P<0.05). Doxycyline increased the cardiac index by 24+/-5% and reduced PVRI by 23+/-4% 120 min of APE in Doxy 30+Emb group. In addition, doxycyline reduced MPAP and PVRI 30 min after APE with maximum effects seen 120 min after APE (25+/-4% decrease in MPAP and 33+/-6% decrease in PVRI; both P<0.05) in Doxy+5 group. Plasma pro-MMP-9 and MMP-9 levels increased only in Emb group and MMP-2 remained unaltered. CONCLUSIONS Our study shows that doxycycline attenuates APE-induced pulmonary hypertension, and indicates that MMP-9 has a role in APE-induced pulmonary hypertension. MMP-9 may be a pharmacological target in APE.
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Affiliation(s)
- Geisa M Fortuna
- Department of Pharmacology, Faculty of Medical Sciences, State University of Campinas, 13081-970, Campinas, SP, Brazil
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Dias-Junior CA. The use of sildenafil in the therapy of massive pulmonary embolism. Intensive Care Med 2006; 32:1284. [PMID: 16788805 DOI: 10.1007/s00134-006-0243-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2006] [Indexed: 10/24/2022]
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Serres F, Nicolle AP, Tissier R, Gouni V, Pouchelon JL, Chetboul V. Efficacy of Oral Tadalafil, a New Long-acting Phosphodiesterase-5 Inhibitor, for the Short-term Treatment of Pulmonary Arterial Hypertension in a Dog. ACTA ACUST UNITED AC 2006; 53:129-33. [PMID: 16533328 DOI: 10.1111/j.1439-0442.2006.00800.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Systolic pulmonary arterial hypertension (PAH) was diagnosed in a 15-year-old intact male Yorkshire terrier presented for progressive dyspnoea and coughing. Several examinations were performed (thoracic radiographs, faecal analysis, heartworm antigen test, tracheal fluoroscopy, abdominal ultrasound, complete blood cell count, urine and serum biochemistry) but the PAH remained of unknown origin. Despite medical treatment (diuretics and angiotensin-converting enzyme inhibitor), cardiovascular and respiratory signs dramatically worsened over a 1-month period, with several daily syncope, cyanosis and tachypnoea at rest requiring permanent oxygen therapy. Oral tadalafil (Cialis), a new long-acting phosphodiesterase-5 inhibitor, belonging to the same family as sildenafil (Viagra), was added to the background therapy. The condition of the dog improved quickly (< 24 h), and short-term follow up (7 days) showed a decrease in systolic pulmonary arterial pressure up to 26 mmHg concomitant with the disappearance of all respiratory and cardiac signs of PAH (cyanosis, syncope and tachypnoea). This case is of interest because it concerns the first reported short-term use of tadalafil in canine PAH. However, long-term studies with a large number of diseased animals are now required before prescription by general practitioners could be recommended.
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Affiliation(s)
- F Serres
- Unité pédagogique de Médecine, 7 Avenue du Général de Gaulle, 94 704 Maisons-Alfort Cedex, France
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l-Arginine and Pulmonary Embolism. Crit Care Med 2006. [DOI: 10.1097/01.ccm.0000202203.98420.a5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tanus-Santos JE. l-Arginine and Pulmonary Embolism. Crit Care Med 2006; 34:934; author reply 934-5. [PMID: 16505695 DOI: 10.1097/01.ccm.0000203088.60597.a6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dias-Junior CA, Tanus-Santos JE. Hemodynamic effects of sildenafil interaction with a nitric oxide donor compound in a dog model of acute pulmonary embolism. Life Sci 2006; 79:469-74. [PMID: 16504213 DOI: 10.1016/j.lfs.2006.01.034] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Revised: 11/14/2005] [Accepted: 01/19/2006] [Indexed: 11/25/2022]
Abstract
Sildenafil attenuates acute pulmonary embolism (APE)-induced pulmonary hypertension. However, the hemodynamic effects of sildenafil in combination with other vasodilators during APE have not been examined yet. In the present study, we examined the hemodynamic effects of combined diethylenetriamine/nonoate (DETA-NO, 1microMol kg(-1), i.v.) and sildenafil (0.25mg/kg, i.v.) in an anesthetized dog model of APE. Plasma nitrite/nitrate (NO(x)) and cyclic GMP concentrations were determined using an ozone-based chemiluminescence assay and a commercial enzyme immunoassay, respectively. We found that this dose of DETA-NO did not attenuate APE-induced pulmonary hypertension. However, significant decreases in mean pulmonary artery pressure were observed 15, 30 and 45min after the administration of sildenafil alone or after the combined administration of DETA-NO and sildenafil (all P<0.05). No significant differences among groups were observed in the respiratory parameters. While DETA-NO significantly increased NO(x) concentrations by approximately 4microM, cyclic GMP concentrations increased only when sildenafil was administered (all P<0.05). These results show that the combined administration of 1microMol kg(-1) of DETA-NO and sildenafil is not advantageous compared with sildenafil alone, thus suggesting that sildenafil alone produced maximum attenuation of APE-induced pulmonary hypertension, as far as the NO-cGMP pathway is concerned.
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Affiliation(s)
- Carlos A Dias-Junior
- Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Av. Bandeirantes, 3900, 14049-900, Ribeirao Preto, SP, Brazil, 14049-900
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Ganière V, Feihl F, Tagan D. Dramatic beneficial effects of sildenafil in recurrent massive pulmonary embolism. Intensive Care Med 2006; 32:452-4. [PMID: 16450094 DOI: 10.1007/s00134-005-0058-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 12/21/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Sildenafil has a well established pulmonary vasodilatory effect, but has seldom been used in critically ill patients. We report a case of severe recurrent pulmonary embolism in which sildenafil was used as a rescue therapy. RESULTS After oral administration of 50 mg of sildenafil, cardiac index increased from 2.11/min/m(2) to 3.21/min/m(2); mean pulmonary artery pressure decreased from 56 mmHg to 46 mmHg, and pulmonary vascular resistance index decreased from 700 dynes/cm(-5)/m(2) to 425 dynes/cm(-5)/m(2), without reduction of arterial systemic pressure. Clinical condition also improved during the following days under treatment of 50 mg sildenafil three times daily. CONCLUSIONS These observations should stimulate studies with sildenafil in the ICU setting. Sildenafil is easy to administer in every ICU and at any time. If its potential is confirmed, it may be a life-saving drug in some emergency situations caused by severe pulmonary hypertension.
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Affiliation(s)
- Vincent Ganière
- Hôpital Riviera, Site du Samaritain, Département de Médecine Interne, Boulevard Paderewski 5, 1800, Vevey, Switzerland
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Souza-Costa DC, Zerbini T, Palei AC, Gerlach RF, Tanus-Santos JE. L-arginine attenuates acute pulmonary embolism-induced increases in lung matrix metalloproteinase-2 and matrix metalloproteinase-9. Chest 2005; 128:3705-10. [PMID: 16304337 DOI: 10.1378/chest.128.5.3705] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To evaluate the effects of L-arginine on acute pulmonary embolism (APE)-induced pulmonary hypertension and increases in lung matrix metalloproteinase (MMP)-2 and MMP-9 activities. DESIGN Prospective trial. SETTING University laboratory. INTERVENTIONS Using an isolated lung perfusion rat model of APE, we examined whether L-arginine (0, 0.5, 3, and 10 mmol/L; five to seven rats per group) attenuates the pulmonary hypertension induced by the injection of 6.6 mg/kg of 300 microm microspheres into the pulmonary artery. In a second series of experiments (6 to 11 rats per group), we investigated whether nonselective inhibition of nitric oxide (NO) synthases with N(G)-nitro-L-arginine methyl ester (L-NAME; 4 mmol/L) decreases the effects produced by L-arginine. Lung MMP-2 and MMP-9 activities were determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis gelatin zymography. RESULTS L-arginine at 0.5, 3, and 10 mmol/L attenuated APE-induced pulmonary hypertension by 25 to 42% (all p < 0.05). The protective effect of L-arginine was completely reversed by inhibition of NO synthesis with L-NAME. APE was associated with increased lung MMP-2 and MMP-9 activities (both p < 0.05). While L-arginine at 0.5 mmol/L produced no effect on MMPs, L-arginine 3 at mmol/L and 10 mmol/L attenuated the increases in MMP-2 and MMP-9 activities after APE (both p < 0.05). CONCLUSIONS L-arginine attenuates APE-induced pulmonary hypertension through mechanisms involving increased NO synthesis and maybe attenuation of lung MMP-2 and MMP-9 activities.
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Affiliation(s)
- Debora C Souza-Costa
- Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil
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Souza-Silva AR, Dias-Junior CA, Uzuelli JA, Moreno H, Evora PR, Tanus-Santos JE. Hemodynamic effects of combined sildenafil and L-arginine during acute pulmonary embolism-induced pulmonary hypertension. Eur J Pharmacol 2005; 524:126-31. [PMID: 16253237 DOI: 10.1016/j.ejphar.2005.09.022] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Revised: 09/12/2005] [Accepted: 09/21/2005] [Indexed: 11/20/2022]
Abstract
Sildenafil attenuates acute pulmonary embolism-induced pulmonary hypertension. However, the hemodynamic effects of sildenafil in combination with other vasodilators during acute pulmonary embolism have not been examined yet. In the present study, we examined the hemodynamic effects of combined sildenafil (0.25 mg/kg, i.v.) and L-arginine (100, 200, 500, and 1000 mg/kg/h, i.v.) in an anesthetized dog model of acute pulmonary embolism. Plasma nitrite/nitrate (NO(x)) and cGMP concentrations were determined using an ozone-based chemiluminescence assay and a commercial enzyme immunoassay, respectively. We found that L-arginine alone did not attenuate acute pulmonary embolism-induced pulmonary hypertension. However, significant decreases in mean pulmonary artery pressure were observed 30, 45, 60, and 75 min after the administration of sildenafil alone or after the combined administration of sildenafil and L-arginine (all P < 0.05). No significant differences among groups were observed in the respiratory parameters. While L-arginine significantly increased NO(x) concentrations, cGMP concentrations increased only when sildenafil was administered (all P < 0.05). These results suggest that while sildenafil attenuates acute pulmonary embolism-induced pulmonary hypertension, L-arginine does not enhance the beneficial hemodynamic effects of sildenafil. In addition, these findings suggest that stimulation of NO synthesis with L-arginine during acute pulmonary embolism does not produce beneficial effects.
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Affiliation(s)
- Allethea R Souza-Silva
- Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Brazil
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