Ozone Therapy Protects Against Rejection in a Lung Transplantation Model: A New Treatment? Norberto Santana-Rodríguez, MD, PhD, Pedro Llontop, PhD, Bernardino.

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Ozone Therapy Protects Against Rejection in a Lung Transplantation Model: A New Treatment? Norberto Santana-Rodríguez, MD, PhD, Pedro Llontop, PhD, Bernardino Clavo, MD, PhD, María D. Fiuza-Pérez, MD, PhD, Keila Zerecero, MVD, Adil Ayub, MD, Khalid Alshehri, MD, Nagib A. Yordi, MD, PhD, Lamberto Re, MD, PhD, Wissam Raad, MD, Leandro Fernández-Pérez, MD, PhD, Ricardo García-Herrera, PhD, Chyun-Yin J. Huang, MD, Faiz Y. Bhora, MD, FACS The Annals of Thoracic Surgery Volume 104, Issue 2, Pages 458-464 (August 2017) DOI: 10.1016/j.athoracsur.2017.02.054 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Macroscopic view of cardiopulmonary block at 3 months after lung transplantation (LT). (A) The sham group shows normal appearance of left lung (arrow). (B) The LT group shows dark and atrophic tissue of left LT (arrow). (C) The ozone (O3)-LT group shows a shorter lung but natural appearance of left LT (arrow). The Annals of Thoracic Surgery 2017 104, 458-464DOI: (10.1016/j.athoracsur.2017.02.054) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Histologic view at 3 months after lung transplantation (LT). (A) The sham group shows vascular congestion and hyperinflation. (B) The LT group shows intense interstitial fibrosis with the presence of some giant cells, indicating severe chronic rejection (CR) observed in all animals of the LT group. (C) The ozone (O3)-LT group shows mild acute rejection (AR) observed in just 1 of the animals of this group. (D) The O3-LT group shows natural appearance of the left LT treated with O3 observed in the rest of the evaluated animals of this group. (×10 [A], ×200 [B and C], ×40 [D].) The Annals of Thoracic Surgery 2017 104, 458-464DOI: (10.1016/j.athoracsur.2017.02.054) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 RNA expression of genes normalized to cyclophilin polypeptide (PPIA). (A) The sham group versus the lung transplantation (LT) group shows a significant increase of Hspb27 (p < 0.001), Epas1 (p < 0.001), Sepp1 (p = 0.0042), Sftpb (p = 0.001), Plvap (p = 0.0024), Cldn5 (p < 0.0001), and Fmo2 (p = 0.0168) mRNA expression in the LT group. (B) The sham group versus the ozone (O3)-LT group shows significant decrease of Gpx (p = 0.036), Vegfa (p = 0.036), Sftpb (p = 0.025), Plvap (p = 0.025), Kfl2 (p = 0.036), and Thbd (p = 0.036) with O3 treatment. (C) In the LT group versus the O3-LT group, O3 treatment significantly decreases the expression of all genes related to oxidative stress (OS) and chronic rejection (CR) such as Hspb27 (p ≤ 0.0001), Prdx (p = 0.0392), Epas1 (p < 0.001), Gpx3 (p = 0.0024), Vegfa (p = 0.088), Sftpa1 (p = 0.0191), Sftpb (p = 0.0001), Plvap (p = 0.0002), Klf2 (p < 0.0001), Cldn5 (p < 0.0001), Thbd (p = 0.0015), Dsip (p = 0.0271), and Fmo2 (p = 0.0024), except Sepp1. The Annals of Thoracic Surgery 2017 104, 458-464DOI: (10.1016/j.athoracsur.2017.02.054) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions