Primære resultatvurdering i en Pig Model af akut myokardieinfarkt
Summary
Pålidelig og nøjagtig resultat vurdering er nøglen til oversættelse af prækliniske terapier til klinisk behandling. Den nuværende Artiklen beskriver, hvordan man vurderer tre klinisk relevante primære effektmål parametre for hjertefunktionen og skader i en gris akut myokardieinfarkt model.
Abstract
Mortality after acute myocardial infarction remains substantial and is associated with significant morbidity, like heart failure. Novel therapeutics are therefore required to confine cardiac damage, promote survival and reduce the disease burden of heart failure. Large animal experiments are an essential part in the translational process from experimental to clinical therapies. To optimize clinical translation, robust and representative outcome measures are mandatory. The present manuscript aims to address this need by describing the assessment of three clinically relevant outcome modalities in a pig acute myocardial infarction (AMI) model: infarct size in relation to area at risk (IS/AAR) staining, 3-dimensional transesophageal echocardiography (TEE) and admittance-based pressure-volume (PV) loops. Infarct size is the main determinant driving the transition from AMI to heart failure and can be quantified by IS/AAR staining. Echocardiography is a reliable and robust tool in the assessment of global and regional cardiac function in clinical cardiology. Here, a method for three-dimensional transesophageal echocardiography (3D-TEE) in pigs is provided. Extensive insight into cardiac performance can be obtained by admittance-based pressure-volume (PV) loops, including intrinsic parameters of myocardial function that are pre- and afterload independent. Combined with a clinically feasible experimental study protocol, these outcome measures provide researchers with essential information to determine whether novel therapeutic strategies could yield promising targets for future testing in clinical studies.
Introduction
Hjertesvigt med reduceret uddrivningsfraktion (HFrEF) tegner sig for omkring 50% af alle hjertesvigt sager, der påvirker en anslået 1 – 2% af mennesker i den vestlige verden en. Dens mest udbredte årsag er akut myokardieinfarkt (AMI). Som akut dødelighed efter AMI er faldet betydeligt på grund af øget bevidsthed og forbedrede behandlingsmuligheder, har fokus flyttet mod sin kroniske følgesygdomme; den mest fremtrædende væsen HFrEF 2,3. Sammen med stigende sundhedsudgifter 4, den voksende epidemi af hjertesvigt understreger behovet for nye diagnostik og behandlinger, der kan studeres i et stærkt translationel svin model af negativ remodeling efter AMI som tidligere beskrevet 5.
Begge, determinanter (fx infarkt størrelse) og funktionelle vurderinger (fx ekkokardiografi) af negativ remodeling anvendes ofte til effekten afprøvning af nye lægemidler, der angiver behovet for reliable og relativt billige metoder. Formålet med den aktuelle dokument er at imødekomme dette behov ved at indføre vigtige og pålidelige effektmål for effektivitetsforsoegene i en gris model af akut myokardieinfarkt. Disse omfatter infarkt størrelse (IS) i forhold til området med risiko (AAR), 3D transesophageal ekkokardiografi (3D-TEE) og detaljeret optagelse-baserede tryk-volumen (PV) erhvervelse loop.
Infarkt størrelse er den vigtigste faktor for negativ remodellering og overlevelse efter AMI 6. Selv rettidig reperfusion af iskæmisk myocardium kan redde reversibelt tilskadekomne cardiomyocytter og begrænse infarktstørrelse, reperfusion selv forårsager yderligere skade ved produktion af oxidativ stress og en uforholdsmæssig inflammatorisk respons (iskæmi-reperfusion skade (IRI)) 7. Derfor IRI er blevet identificeret som et lovende terapeutisk mål. Evnen af hidtil ukendte terapeutiske midler til at mindske infarktstørrelse kvantificeres ved at vurdere infarktstørrelse i forholdtil området med risiko (AAR). AAR kvantificering er obligatorisk at korrigere for inter-individuel variation i koronar anatomi dyremodeller, som en større AAR fører til en større absolut infarkt størrelse. Da infarkt størrelse er direkte relateret til hjerte-ydeevne og myokardie kontraktilitet, kan variationer i AAR påvirke studere resultatmål uanset behandlingsmodaliteter 8.
Tre-dimensionel transesofageal ekkokardiografi (3D-TEE) er en sikker, pålidelig og, vigtigst af alt, klinisk anvendelig billig metode til at måle hjertefunktionen ikke-invasivt. Ud fra følgende betragtninger transtorakal ekkokardiografi (TTE) billeder er begrænset til 2D parasternal kort- og akse synspunkter i grise 9, kan 3D-TEE anvendes til at opnå komplet 3-dimensionelle billeder af den venstre ventrikel. Derfor kræver det ikke matematiske tilnærmelser af venstre ventrikel (LV) mængder såsom den modificerede Simpsons regel 10. Sidstnævnte falder kort af corrrekte anslå LV mængder efter LV remodeling på grund af manglen på cylindriske geometri 11. Desuden 3D-TEE er foretrække over epikardial ekkokardiografi, da det ikke kræver kirurgiske indgreb, som er blevet observeret at udøve hjertebeskyttende effekter i den nuværende model 12. Selv om brugen af 2D-TEE til vurdering af myocardial funktion er blevet beskrevet før 13,14, begrænsninger med hensyn ventrikulær geometri svarer til dem observeret i 2D-TTE og afhænger af omfanget af LV remodeling. Derfor jo større infarkt (og således højere sandsynlighed for hjertesvigt), jo mere sandsynligt 2D-målinger bliver fejlbehæftet af ukorrekte geometriske antagelser og jo højere behovet for 3D teknikker.
Ikke desto mindre er de fleste billeddannende modaliteter begrænset i deres evne til at vurdere iboende funktionelle egenskaber af myocardium. PV loops give sådanne relevante yderligere oplysninger og erhvervelsen er derforbeskrevet detaljeret nedenfor.
Protocol
Representative Results
Discussion
Cardiac remodeling er i høj grad afhængig af myocardial infarktstørrelse og kvaliteten af myocardieinfarkt reparere 6,26. For at vurdere den førstnævnte på en standardiseret måde, den foreliggende manuskript tilvejebringer en elegant fremgangsmåde til in vivo infusion af Evans blue kombineret med ex vivo TTC-farvning, som er blevet valideret og ekstensivt anvendt 8,16,27,28. Denne metode giver mulighed for kvantificering af risikoområdet (AAR) og infarkt størrelse i forh…
Declarações
The authors have nothing to disclose.
Acknowledgements
The authors gratefully acknowledge Marlijn Jansen, Joyce Visser, Grace Croft, Martijn van Nieuwburg, Danny Elbersen and Evelyn Velema for their excellent technical support during the animal experiments.
Materials
| 3-dimensional transesophageal echocardiography | |||
| iE33 ultrasound device | Philips | – | |
| X7-2t transducer | Philips | – | |
| Aquasonic® 100 ultrasound transmission gel | Parker Laboratories Inc. | 01-34 | Alternative product can be used |
| Battery handle type C (laryngoscope handle) | Riester | 12303 | |
| Ri-Standard Miller blade MIL 4 (laryngoscope blade) | Riester | 12225 | |
| Qlab 10.0 (3DQ Advanced) analysis software | Philips | – | |
| Name | Company | Catalog Number | Comments |
| Pressure-volume loop acquisition | |||
| Cardiac defibrillator | Philips | ||
| 0.9% saline | Braun | ||
| 8F Percutaneous Sheath Introducer Set | Arrow | CP-08803 | Alternative product can be used |
| 9F Radifocus® Introducer II Standard Kit | Terumo | RS*A90K10SQ | Alternative product can be used |
| 8F Fogarty catheter | Edward Life Sciences | 62080814F | Alternative product can be used |
| 7F Criticath™ SP5107H TD catheter (Swan-Ganz) | Becton Dickinson (BD) | 680078 | Alternative product can be used |
| Ultraview SL Patient Monitor and Invasive Command Module (external cardiac output device) | Spacelabs Healthcare | 91387 | Alternative product can be used |
| ADVantage system™ | Transonic SciSense | – | |
| 7F tetra-polar admittance catheter (7.0 VSL Pigtail / no lumen) | Transonic SciSense | – | |
| Multi-channel acquisition system (Iworx 404) | Iworx | – | |
| Labscribe V2.0 analysis software | Iworx | – | Alternative product can be used |
| Name | Company | Catalog Number | Comments |
| Infarct size / area-at-risk quantification | |||
| Diathermy | – | Alternative product can be used | |
| Lebsch knife | – | Alternative product can be used | |
| Hammer | – | Alternative product can be used | |
| Bone marrow wax | Syneture | Alternative product can be used | |
| Klinkenberg scissors | – | Alternative product can be used | |
| Retractor | – | Alternative product can be used | |
| Surgical scissors | – | ||
| 7F Percutaneous Sheath Introducer Set | Arrow | CP-08703 | Alternative product can be used |
| 8F Percutaneous Sheath Introducer Set | Arrow | CP-08803 | Alternative product can be used |
| 7F JL4 guiding catheter | Boston Scientific | H749 34357-662 | Alternative product can be used |
| 8F JL4 guiding catheter | Boston Scientific | H749 34358-662 | Alternative product can be used |
| COPILOT Bleedback Control Valves | Abbott Vascular | 1003331 | Alternative product can be used |
| BD Connecta™ | Franklin Lakes | 394995 | Alternative product can be used |
| Contrast agent | Telebrix | ||
| Persuader 9 Steerable Guidewire 9 (0.014", 180 cm, straight tip), hydrophilic coating | Medtronic Inc. | 9PSDR180HS | Alternative product can be used |
| SAPPHIRE™ Coronary Dilatation Catheter (PTCA balloon suitable for the size of the particular coronary artery (2.75 – 3.25 mm)) | OrbusNeich | 103-3015 | Alternative product can be used |
| Evans Blue | Sigma-Aldrich | E2129-100G | Toxic. Alternative product can be used |
| 2,3,5-triphenyl-tetrazolium chloride (TTC) | Sigma-Aldrich | T8877-100G | Irritant. Alternative product can be used |
| 9V battery | – | – | |
| Ruler | – | – | |
| Photocamera | Sony | – | |
| ImageJ | National Institutes of Health | – | Alternative product can be used |
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