Hypoxic pulmonary vasoconstriction in cardiothoracic surgery: basic mechanisms to potential therapies Ben M Tsai, MD, Meijing Wang, MD, Mark W Turrentine,

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Hypoxic pulmonary vasoconstriction in cardiothoracic surgery: basic mechanisms to potential therapies Ben M Tsai, MD, Meijing Wang, MD, Mark W Turrentine, MD, Yousuf Mahomed, MD, John W Brown, MD, Daniel R Meldrum, MD The Annals of Thoracic Surgery Volume 78, Issue 1, Pages 360-368 (July 2004) DOI: 10.1016/j.athoracsur.2003.11.035

Fig 1 Actual tracing of isolated pulmonary artery ring tension in response to hypoxia. Isolated rat pulmonary artery, suspended on steel wires in a 37°C organ bath containing modified Krebs-Henseleit solution and connected to a force transducer, was precontracted with phenylephrine (10−7 M) and gassed with 95% N2-5% CO2 (hypoxia). The resulting tension tracing exhibits an immediate relaxation preceding a transient vascular contraction. The Annals of Thoracic Surgery 2004 78, 360-368DOI: (10.1016/j.athoracsur.2003.11.035)

Fig 2 Role of endothelium in vascular tone. (A) Nitric oxide (NO), produced by nitric oxide synthase (NOS), stimulates guanylate cyclase (GC) in vascular smooth muscle to produce guanidine 3', 5'-cyclic monophosphate (cGMP). Acetylcholine (Ach) acts through muscarinic receptor (M) binding by stimulating nitric oxide synthase. (B) Prostacyclin (PGI2) produced by the endothelium stimulates adenylate cyclase (AC) in smooth muscle to produce adenosine 3', 5'-cyclic monophosphate (cAMP). (C) β2-Adrenergic receptor (β2) activation also induces adenosine 3', 5'-cyclic monophosphate production. Both adenosine 3', 5'-cyclic monophosphate and guanidine 3', 5'-cyclic monophosphate cause vasodilation. (D) Endothelin-1 (ET-1) binds to ETA receptors on smooth muscle cells and activates phospholipase C (PLC) and protein kinase C (PKC), which results in vasoconstriction. Endothelin-1 mediates vasodilation through ETB receptor activation and subsequent nitric oxide and prostacyclin production. (E) α1-Adrenergic receptor (α1) activation results in vasoconstriction by activating phospholipase C. ( ETA, ETB = endothelin receptors; GTP/= guanosine triphosphate; PE = phenylephrine.) The Annals of Thoracic Surgery 2004 78, 360-368DOI: (10.1016/j.athoracsur.2003.11.035)

Fig 3 Redox sensor and ion channel response to hypoxia in vascular smooth muscle cell. (A) Hypoxia increases reduced β-nicotinamide-adenine dinucleotide (β-NADH) levels, which stimulate adenine dinucleotide phosphate (ADP)-ribosyl cyclase to produce cyclic ADP-ribose (cADPR). Reduced β-nicotinamide-adenine dinucleotide simultaneously inhibits cyclic ADP-ribose hydrolase from metabolizing cyclic ADP-ribose. (B) Accumulation of cyclic ADP-ribose stimulates the sarcoplasmic reticulum (SR) to release calcium (Ca2+). (C) The rise in intracellular calcium closes voltage-gated potassium (Kv) channels in the cell membrane. Blockage of outward potassium (K+) current results in membrane depolarization. (D) Voltage-gated calcium (Cav) channels are then activated, and the subsequent influx of calcium causes contraction by means of myosin light chain kinase activation (MLCK). (ADPR = ADP-ribose; ARC = ADP-ribosyl cyclase; CARH = cyclic ADP-ribose hydrolase; β-NAD+ = β-nicotinamide-adenine dinucleotide.) The Annals of Thoracic Surgery 2004 78, 360-368DOI: (10.1016/j.athoracsur.2003.11.035)

Fig 4 Therapeutic strategies for blocking hypoxic pulmonary vasoconstriction. (A) Inhaled nitric oxide (NO) and (B) prostacyclin (PGI2) activate guanylate cyclase (GC) and adenylate cyclase (AC), respectively, to cause vasodilation. (C) Protein kinase C (PKC) inhibitors prevent protein kinase C–mediated vasoconstriction. (D) Endothelin receptor (ETA, ETB) antagonists prevent endothelin-1 (ET-1) binding to ETA, thus inhibiting vasoconstriction. (E) Potassium channel activation prevents calcium-dependent vasoconstriction. (ATP = adenosine triphosphate; cAMP = adenosine 3', 5'-cyclic monophosphate; cGMP = guanidine 3', 5'-cyclic monophosphate; GTP = guanosine triphosphate; Kv = voltage-gated potassium channel.) The Annals of Thoracic Surgery 2004 78, 360-368DOI: (10.1016/j.athoracsur.2003.11.035)