Combined endothelial and myocardial protection by endothelin antagonism enhances transplant allograft preservation Paul W.M. Fedak, MD, PhD, Vivek Rao,

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Combined endothelial and myocardial protection by endothelin antagonism enhances transplant allograft preservation Paul W.M. Fedak, MD, PhD, Vivek Rao, MD, PhD, Subodh Verma, MD, PhD, Danny Ramzy, MD, Laura Tumiati, BSc, Santiago Miriuka, MD, Patty Boylen, Richard D. Weisel, MD, Christopher M. Feindel, MD The Journal of Thoracic and Cardiovascular Surgery Volume 129, Issue 2, Pages 407-415 (February 2005) DOI: 10.1016/j.jtcvs.2004.09.031 Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 ERB supplementation during allograft storage enhances LV functional recovery after orthotopic transplantation. Despite the intermittent perfusion of shed donor blood during the period of ischemic storage, control hearts (ERB-treated hearts) had reduced LV function after orthotopic heart transplantation compared with baseline measures. Top, Two independent and load-insensitive measures of LV performance indicated improved functional recovery in ERB-treated hearts (ERB+) after transplantation (PRSW expressed as percentage of baseline: 88% ± 6% vs 46% ± 2%; P = .02). Bottom, The PRSW relationship in cardiac allografts is shown at baseline (before transplantation) and after transplantation in control hearts (ERB−) and ERB-treated hearts (ERB+). The PRSW relationship showed the characteristic downward (reduced slope) and rightward (increased volume-axis intercept) displacement after transplantation compared with baseline curves, indicating allograft LV contractile dysfunction.15 However, this displacement of the PRSW relationship was attenuated in ERB-treated hearts. The values have been normalized as described by Ryan and colleagues.15 *P < .05. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 407-415DOI: (10.1016/j.jtcvs.2004.09.031) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Transplant-associated endothelial dysfunction is limited by ERB during allograft storage. Coronary vasoreactivity was assessed by using an ex vivo macrovascular tissue bath apparatus. Vasoreactivity in the donor heart was comparable between groups immediately after cardioplegic arrest at the time of harvest (Post-Arrest). Endothelial-dependent vasoreactivity was impaired in both groups 48 hours after transplantation, whereas endothelial-independent vasoreactivity was unchanged, collectively indicating endothelial dysfunction. ERB treatment during storage limited the late endothelial dysfunction associated with prolonged allograft storage and transplantation (%Emax to bradykinin: 67% ± 6% vs 45% ± 2%; P = .001). BK, Bradykinin; SNP, sodium Nitroprusside. %Emax, Percentage of maximal elastance. *P < .05. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 407-415DOI: (10.1016/j.jtcvs.2004.09.031) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 ET-1 and proinflammatory cytokine expression. Myocardial samples from the left ventricle were examined for ET-1 protein levels immediately before allograft harvest in the beating heart (Pre-Arrest), at the end of allograft storage (Storage), and after transplantation and surgical reperfusion for 60 minutes (Reperfusion). ET-1 expression was reduced from baseline in the quiescent heart during storage but increased with reperfusion (36 ± 8 vs 15 ± 4 fmol/mg, P = .001). ERB treatment during storage did not influence the expression of myocardial ET-1. Protein levels of the proinflammatory cytokines TNF-α and TGF-β were assessed by means of immunoblotting in myocardial samples from the left ventricle. The levels of TNF-α were reduced in ERB-treated hearts during allograft storage. *P < .05. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 407-415DOI: (10.1016/j.jtcvs.2004.09.031) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Cardiac metabolism. Myocardial metabolism was assessed by measuring the extraction or production of lactate, oxygen, and acid by the heart. As expected, cardiac metabolism was reduced in the quiescent heart after cardioplegic arrest. Notably, cardiac metabolism was similar between groups, thereby excluding enhanced metabolic recovery as the underlying mechanism of benefit on myocardial and endothelial function. The Journal of Thoracic and Cardiovascular Surgery 2005 129, 407-415DOI: (10.1016/j.jtcvs.2004.09.031) Copyright © 2005 The American Association for Thoracic Surgery Terms and Conditions