Activated protein C attenuates cardiopulmonary bypass–induced acute lung injury through the regulation of neutrophil activation Sachiko Yamazaki, MD,

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Activated protein C attenuates cardiopulmonary bypass–induced acute lung injury through the regulation of neutrophil activation Sachiko Yamazaki, MD, Syunji Inamori, ME, Takeshi Nakatani, MD, PhD, Michiharu Suga, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 141, Issue 5, Pages 1246-1252 (May 2011) DOI: 10.1016/j.jtcvs.2010.05.043 Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Microphotograph of the left lung. The left lung section in each group was stained with hematoxylin–eosin. Lungs in the control and DIP groups show interstitial edema, alveolar hemorrhage, and severe neutrophil accumulation. Inflammatory change in the APC group lung is minimized. Original magnification: 200×. Black bar = 50 μm. Control (A), DIP (B), and APC (C) groups. The Journal of Thoracic and Cardiovascular Surgery 2011 141, 1246-1252DOI: (10.1016/j.jtcvs.2010.05.043) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A, Peak airway pressure before CPB and at the end of the experiment. The APC group shows a relatively lower value than the other groups at the end of the experiment, although there are no significant differences among the groups. Results are expressed as mean ± standard error of the mean (SEM). B, Arterial oxygen pressure before CPB and at the end of the experiment. The APC group shows a significantly higher value than the other groups at the end of the experiment. Results are expressed as mean ± SEM. #P < .01 versus the control or DIP group. C, W/D weight ratio of the left lung. The APC group shows a significantly lower value than the other groups. Results are expressed as mean ± SEM. #P < .01 versus the control or DIP group. APC, Activated protein C; CPB, cardiopulmonary bypass; DIP, diisopropyl fluorophosphate; W/D, wet-to-dry. The Journal of Thoracic and Cardiovascular Surgery 2011 141, 1246-1252DOI: (10.1016/j.jtcvs.2010.05.043) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A, Tissue MIP-2 concentration in the left lung. The APC group shows a relatively lower value than the control group and a significantly lower value than the DIP group. Results are expressed as mean ± SEM. #P < .01 versus the DIP group. B, Tissue TNF-α concentration in the left lung. The APC group shows a relatively lower value than the other groups, although there are no significant differences among the groups. Results are expressed as mean ± SEM. C, Tissue IL-1β concentration in the left lung. The APC group shows a relatively lower value than the other groups, although there are no significant differences among the groups. Results are expressed as mean ± SEM. DIP, Diisopropyl fluorophosphate; APC, activated protein C; TNF, tumor necrosis factor; MIP, macrophage inflammatory protein; IL, interleukin. The Journal of Thoracic and Cardiovascular Surgery 2011 141, 1246-1252DOI: (10.1016/j.jtcvs.2010.05.043) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 A, CD11b expression on circulating neutrophils. Percentage change in geometric mean from the value before CPB was calculated. The APC group maintains leveled CD11b expression at all time points, whereas expression in the control and DIP groups increases approximately double at 60 and 120 minutes after the initiation of CPB. Results are expressed as mean ± SEM. ∗P < .05 versus the DIP group. ∗∗P < .05 versus the control or DIP group. B, CD62L expression on circulating neutrophils. Percentage change in geometric mean from the value before CPB was calculated. CD62L expression remains level in the APC throughout the experiment, whereas expression in the control and DIP groups gradually decreases to approximately 50% at 120 minutes after the initiation of CPB. Results are expressed as mean ± SEM. #P < .01 versus the control or DIP group. ∗P < .05 versus the DIP group. CPB, Cardiopulmonary bypass; DIP, diisopropyl fluorophosphate; APC, activated protein C. The Journal of Thoracic and Cardiovascular Surgery 2011 141, 1246-1252DOI: (10.1016/j.jtcvs.2010.05.043) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 A, ACT before CPB and at the end of the experiment. The APC group shows a significantly higher value than the others only before CPB. The values decrease in all groups at the end of the experiment and become similar to one another. Results are expressed as mean ± SEM. ∗P < .05 versus the control or DIP group. B, Blood hemoglobin level before CPB, after CPB, and at the end of the experiment. In all groups, the values after CPB and at the end of the experiments similarly decrease to approximately 70% of initial values. There are no significant differences among the groups at any time point. Results are expressed as mean ± SEM. C, Serum fibrinogen level at the end of the experiment. There are no significant differences among the groups. Results are expressed as mean ± SEM. ACT, Activated clotting time; DIP, diisopropyl fluorophosphate; APC, activated protein C; CPB, cardiopulmonary bypass. The Journal of Thoracic and Cardiovascular Surgery 2011 141, 1246-1252DOI: (10.1016/j.jtcvs.2010.05.043) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions