Munir Boodhwani, MD, MMSc, Neel R

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Insulin treatment enhances the myocardial angiogenic response in diabetes Munir Boodhwani, MD, MMSc, Neel R. Sodha, MD, Shigetoshi Mieno, MD, PhD, Basel Ramlawi, MD, MMSc, Shu-Hua Xu, PhD, Jun Feng, MD, PhD, Richard T. Clements, PhD, Marc Ruel, MD, MPH, Frank W. Sellke, MD The Journal of Thoracic and Cardiovascular Surgery Volume 134, Issue 6, Pages 1453-1460 (December 2007) DOI: 10.1016/j.jtcvs.2007.08.025 Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Blood glucose levels in no diabetes (ND), diabetes (DM), and insulin-treated diabetes (IDM) groups over the 7-week experimental protocol. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 1453-1460DOI: (10.1016/j.jtcvs.2007.08.025) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Coronary microvascular reactivity. Percent relaxation to increasing concentrations of vasodilating agents after preconstriction with U46619. Responses to endothelium-dependent vasodilators ADP (A), Substance P (B), and VEGF (C), as well as endothelium-independent vasodilator SNP (D) in the ischemic territory of ND (n = 8), DM (n = 8), and IDM (n = 6) animals. ADP, Adenosine 5′ diphosphate; SNP, sodium nitroprusside; VEGF, vascular endothelial growth factor. *P < .001 vs ND. **P < .01 vs DM. †P < .05 vs controls. ND, DM, and IDM as in Figure 1. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 1453-1460DOI: (10.1016/j.jtcvs.2007.08.025) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Myocardial perfusion. Isotope-labeled microspheres were used to determine baseline-adjusted circumflex territory myocardial blood perfusion in control (n = 8) and diabetic swine (DM, n = 8; IDM, n = 6) after circumflex ameroid occlusion. Adjusted circumflex territory perfusion, which was profoundly reduced in DM animals at rest (A) and with pacing (B), improved with insulin treatment, but still remained lower than controls. *P < .001 vs ND. **P < .001 vs DM and P < .05 vs ND. ND, DM, and IDM as in Figure 1. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 1453-1460DOI: (10.1016/j.jtcvs.2007.08.025) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Left ventricular (LV) function. Diabetic animals demonstrated reduced LV contractility and impaired LV relaxation. Insulin treatment resulted in significant improvement in LV systolic function (n = 4-6/group; *P < .001 vs ND; **P < .01 vs DM; †P < .05 vs ND). ND, DM, and IDM as in Figure 1. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 1453-1460DOI: (10.1016/j.jtcvs.2007.08.025) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Endothelial cell density. CD31+ endothelial cell density per high power field (0.264 mm2) was determined in the ischemic territory of control (n = 8) and diabetic (DM, n = 8; IDM, n = 6) animals. Diabetic animals had reduced endothelial cell density compared with controls, which was significantly improved in insulin-treated diabetic animals. *P < .001 vs ND. **P < .001 vs DM. ND, DM, and IDM as in Figure 1. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 1453-1460DOI: (10.1016/j.jtcvs.2007.08.025) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Myocardial expression of anti-angiogenic mediators. Expression of angiostatin (A) and endostatin (B) was significantly increased in the myocardium of diabetic animals and was significantly reduced in insulin-treated diabetic animals. (n = 4-6/group). *P < .01. **P < .05. ND, DM, and IDM as in Figure 1. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 1453-1460DOI: (10.1016/j.jtcvs.2007.08.025) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 7 Myocardial expression of pro-angiogenic mediators. A, Expression of growth factors, VEGF and Ang-1, their respective receptors, VEGFR2 and Tie-2, as well as downstream mediator eNOS were assessed. B, Quantitative analysis showed that diabetic animals had reduced myocardial expression of VEGF and Ang-1, but VEGFR2 and Tie-2 expression was unchanged. Insulin treatment caused an increase in VEGF and Ang-1 expression as well as a significant increase in Tie-2 expression. Ang-1, Angiopoiten-1; VEGF, vascular endothelial growth factor; eNOS, endothelial nitric oxide synthase (n = 4-6/group). *P < .05 v. ND. **P < .05 vs DM; †P < .001 vs ND. ND, DM, and IDM as in Figure 1. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 1453-1460DOI: (10.1016/j.jtcvs.2007.08.025) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions