cchd - a multi-system systemic...
TRANSCRIPT
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CCHD - A Multi-System Systemic Disorder
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Joseph K. Perloff
I have the following disclosures* related to my presentation:
Employee: n/a Grants/Research Contracts: n/a Consulting: n/a Investments: n/a
I will discuss results of clinical trial for the following agents that are currently NOT approved for use in animals. *Disclosures include spouse and immediate family where relevant.
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Hematologic Disorders
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Why Does Red Cell Mass Increase in Cyanotic Congenital Heart Disease?
A decrease in tissue oxygenation provokes renal
release of erythropoietin and an increase in red cell mass that is a desirable compensatory adaptation
to systemic arterial hypoxemia.
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Blood Letting A Therapeutic Anachronism
Phlebotomy reduces red cell mass, reduces oxygen delivery to metabolizing tissues, stimulates a maladaptive release of
erythropoietin, and results in undesirable iron deficiency.
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Whole blood viscosity increases when deformable biconcave disc
become non-deformable iron deficient microspherocytes.
Hematocrit only by automated electronic particle counter
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Iron deficient erythrocytosis in infants predisposes to stroke due to cerebral venous
thrombosis.
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Criteria for Phlebotomy 1. Not based on hematocrit irrespective
of level because erythrocytosis is not a risk factor for stroke due to cerebral arterial thrombosis.
2. Employed for temporary relief of significant hyperviscosity symptoms.
3. The amount of blood removed is the minimum required to achieve relief of hyperviscosity symptoms, generally one unit with isovolumetric saline replacement.
4. Hydroxyurea blunts the erythropoietin rebound.
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Hemostasis in Cyanotic Congenital Heart Disease
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“The temptation to use the anticoagultant drugs may be great. On the basis of the
present studies, their use would appear to be fraught with danger.”
Robert C. Hartmann Johns Hopkins 1952
Intrinsic hemostatic defect(s) and increased tissue vascularity in response to nitic oxide
predispose to hemorrhage.
Erythrocytosis, whether iron replete or iron deficient, is not a risk factor for stroke due to
cerebral arterial thrombosis
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Preoperative Phlebotomy
Whole blood is removed isovolumetrically in daily amounts of 500ml to reduce the hematocrit to just
below 65%. Within hours, platelet counts rise, and platelet aggregation and
hemostasis improve.
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Nitric Oxide and Oxyhemoglobin
The increased endothelial shear stress of erythrocytosis stimulates release of NO that
diffuses luminally to enter red blood cells and enhance release of oxygen from
oxyhemoglobin, and diffuses adluminally to enter medial smooth muscle cells and promote vasodilatation and increased tissue vascularity.
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Epistaxis
Spontaneous: a) Intrinsic hemostatic defect(s) b) Increased nasal mucous
membrane vascularity
Induced: a) Traumatic
b) Drying effect of non-
humidified nasal O2
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Tissue Response to TGF ß and PDGF
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Pulmonary Hemorrhage in Eisenmenger Syndrome
There’s something ominous about blood coming from the mouth like the glow of fire. Anton Chekhov about himself
Hemoptysis (Extrapulmonary Hemorrhage)
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Intrapulmonary Hemorrhage
A common cause of sudden death in
Eisenmenger syndrome
“The histology showed hemorrhagic lung.” Victor Eisenmenger, 1897
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Management of Hemoptysis in Eisenmenger Syndrome
1. Do not bronchoscope:
2. History—of an antiplatelet or anti-inflammatory agent ?
3. Chest x-ray for detection of intrapulmonary hemorrhagic infilrates.
4. CT scan if infiltrates are present
5. Hospitalize for all but mild or moderate intrapulmonary hemorrhage
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Treatment of Intrapulmonary Hemorrhage
1. Normal Platelet Counts: Fresh frozen plasma 2. Thrombocytopenia--platelet transfusion, cryoprecipitate. 3. Excessively low hematocrit---blood transfusion.
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Catamenial Hemoptysis Pulmonary Endometriosis
Hemoptysis that coincides with menses. Rupture of capillaries within endometrial epithelium in the lumen of muscular pulmonary arteries.
Endometrial epithelium (brackets) lining the lumen of a muscular pulmonary artery.
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Catamenial Pneumothorax
Recurrent pneumothorax that coincides with the menstrual cycle as described by Maurer in 1958, and called catemenial pneumothorax by Lillington in 1972.
Pleural Endometriosis
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von Willebrand Factor in CHD
A decrease in or loss of the largest vWF multimetric forms occurs in over 70% of CHD
patients with pulmonary vascular disease, turbulent blood flow or cyanosis.
von Willebrand factor (red) stored in endothelial cells (green)
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Agarose Gel Electrophoresis
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Massive Intrapulmonary Thrombus
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Thrombosis in Dilated Hypertensive Proximal Pulmonary Arteries
A Therapeutic Dilemma
1. Anticoagulants--Efficacy is nil. Risk of aggrevating intrinsic hemostatic defects and provoking hemorrhage is high.
2. Thrombolytic Agents – Efficacy is nil even with intrapulmonary administration.
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Lung Transplantation The Hazard of Cross
Clamping
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Pulmonary Neovascularity A Distinctive Radiologic Feature of
Eisenmenger Syndrome
A. Clusters of dilated, tortuous muscular arteries within alveolar septae. B. Dilated congested capillaries within alveolar tissues. C. Congested capillaries within adventitial tissue (PA--Medium-size muscular pulmonary artery). D. Plexiform lesion of hypertensive pulmoary arteriopathy.
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Coronary Circulation in Cyanotic Congenital Heart Disease
Dilatated tortuous extramural coronary arteries. Basal coronary blood flow and myocardial flow reserve. Coronary microcirculation. Anti-atherogenic effects of CCHD.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Ahmanson/UCLA Adult Congenital Heart Disease Center
Aneurysmal Dilatation of the Coronary Arteries in Cyanotic Congenital Cardiac Disease
Perloff and Roberts Am J Med 1968
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Hypoxemic erythrocytotic adults acclimatized to high
altitude have dilated tortuous extramural
coronary arteries analagous to hypoxemic erythrocytotic
adults with CCHD.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Ahmanson/UCLA Adult Congenital Heart Disease Center
Moderately Dilated Tortuous Coronary Arteries in CCHD
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Increased endothelial shear stress caused by the viscous erythrocytotic perfusate in CCHD and
high altitude provokes elaboration of NO and initiates dilatation of extramural coronary arteries.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Ahmanson/UCLA Adult Congenital Heart Disease Center
However, dilatation exceeds the vasodilator effect because coexisting
medial structural abnormalities cause mural attenuation
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Ahmanson/UCLA Adult Congenital Heart Disease Center
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Basal Myocardial Blood Flow & Flow Reserve in CCHD
Systemic arterial hypoxemia reduces the oxygen content of blood entering the coronary circulation. The oxygen deficit cannot be corrected by an increase in myocardial oxygen extraction, because extraction is already maximal, or by increased coronary arterial dilatation because the extramural coronaries are already maximally dilated.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Coronary Flow and Flow Reserve in CCHD
Basal flow as determined by N-13 PET.
Flow reserve as determined by pharmacologic stress
induced with IV dipyridamole.
Ahmanson/UCLA Adult Congenital Heart Disease Center
32 year old cyanotic woman with an ASD and pulmonary vascular disease.
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Despite increased basal flow, coronary flow reserve is not encroached upon because of
remodeling of the microcirculation.
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The Peruvian
Andes
20,000 feet Peru
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Ahmanson/UCLA Adult Congenital Heart Disease Center
ANATOMY OF THE CORONARY CIRCULATION AT HIGH ALTITUDE Arias-Stella and Topilsky
Peruvian Andes
Acrylic resin casts
Sea Level High Altitude
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Morphometric analyses of coronary arterioles that are immunostained
against SM alpha-actin.
Eisenmenger hearts (A/C): terminal arterioles are fewer in number compared to hypertrophied structurally normal hearts (B/D), but are greater in
diameter (E/G).
A,C,E,G Eisenmenger hearts. B,D,F,H structurally normal hearts with ventricular hypertrophy
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Flow Reserve
Conclusions
Remodeling of the coronary microcirculation is the key mechanism responsible for preservation of
flow reserve in CCHD. Decreased length, volume and surface densities, and greater terminal arteriole diameters reflect remodeling, supplemented by enhanced vasodilatory
capacity.
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Systemic hypoxia changes the organ-specific distribution of vascular endothelial growth factor
(VEGF) and its receptors.
Max Planck Institute, Krakow • VEGF, a homodimeric glycoprotein, plays a key
role in physiological blood vessel formation and angiogenesis.
• Hypoxia induces a marked upregulation of VEGF and a marked increase in angiogenesis-related VEGF gene expression, stimulating new vessel growth.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Ahmanson/UCLA Adult Congenital Heart Disease Center
VEGEF
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Coronary Atherogenesis in CCHD
No angiographic evidence of atherosclerosis compared to the general population with a decade-by-decade incidence of 4.5% to 13.5%.
No necropsy evidence of coronary atherosclerosis.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Paucity of Coronary Atherosclerosis:
Variables
Hypocholesterolemia Hypoxemia
Upregulated nitric oxide Increased bilirubin Low platelet counts
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Ahmanson/UCLA Adult Congenital Heart Disease Center
CCHD UCLA Registry Non-fasting Total Cholesterol
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Hypocholesterolemia
Cyanosis & hypoxemia are necessary but insufficient causes of hypocholesterolemia which tends to persist after surgical elimination of cyanosis. Cyanosis & hypoxemia apparently provoke induction of hypocholesterolemic gene(s).
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Hypoxemic erythrocytotic adults acclimatized to high altitude have low levels of total cholesterol, low LDL cholesterol, elevated HDL
cholesterol and dilated atheroma-free coronary
arteries.
Ahmanson/UCLA Adult Congenital Heart Disease Center
High Living is Healthy
Altitude Favorably Affects Cholesterol Levels
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Antiatherogenic Effects of Hypoxemia
• Hypoxemia is associated with reductions in oxidized plasma LDL and reductions in atherogenic oxidized intimal LDL.
• Larger LDL particles are relatively resistant to oxidation.
• Lack of small density oxidation-sensitive LDL behaves similarly.
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Antiatherogenic Nitric Oxide
NO is a paracrine molecule that inhibits platelet adherence and aggregation, stimulates disaggregation of preformed platelet aggregates, and inhibits monocyte adherence and infiltration.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Ahmanson/UCLA Adult Congenital Heart Disease Center
Experimental Evidence of NO Effect
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Ahmanson/UCLA Adult Congenital Heart Disease Center
Bilirubin in CCHD
Typical levels of total bilirubin
CCHD
3.7mg/dL
Reference
0-1.0 mg/dL
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Bilirubin Kinetics
Bilirubin is formed from the breakdown of heme, a process that is excessive in the presence of
the erythrocytosis of CCHD, and that coincides with a substantial increase in unconjugated bilirubin,
a natural antioxidant that protects LDL cholesterol from oxidation.
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Calcium Bilirubinate Gall Stones in CCHD
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Gilbert’s Syndrome An Experiment of Nature
Gilbert’s Syndrome is an inborn error of
metabolism characterized by a benign elevation of unconjugated bilirubin with no liver damage or
hematologic abnormality, but with immunity from atherosclerosis.
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Low Platelet Counts are Anti-atherogenic
Platelet counts are low-normal or thrombocytopenic in CCHD because the shunted systemic venous megakaryocytes are deprived of their pulmonary transit,
thus decreasing platelet production in the lungs.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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How Platelets are Formed 1) Whole megakaryocytes from the bone marrow enter the
systemic venous circulation. 2) Platelets are formed by fragmentation of the cytoplasm
of circulating systemic venous megakaryocytes during their pulmonary transit.
Marrow Megakaryocyte
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Perloff, et al Am J Cardiol 2000
In Bone Marrow
Leaving Bone Marrow Lodged in a
Pulmomary Arteriole
Megakaryocytes
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Carotid Intimal Medial Thickness (IMT) as
a Measure of Atherosclerosis.
Carotid IMT as determined by B-Mode ultrasound imaging is significantly decreased in
adults with cyanotic congenital heart diseae.
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The Coronary Circulation in Cyanotic Congenital Heart Disease
Conclusions
Extramural coronary arteries are dilated and tortuous because endothelial vasodilator substances act in concert with medial abnormalities to cause mural attenuation.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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The Coronary Circulation in Cyanotic Congenital Heart Disease
Conclusions
Basal coronary blood flow is increased in the dilated extramural coronary arteries, but flow reserve remains normal because the coronary microcirculation remodels.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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Conclusions, cont’d
The dilated extramural coronary arteries are atheroma-free because of the combined anti-atherogenic effects of hypocholesterolemia, hypoxemia, upregulated endothelial NO, increased bilirubin, and low platelet counts.
Ahmanson/UCLA Adult Congenital Heart Disease Center
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The Kidney in CCHD
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Efficacy of long-term treatment of asymptomatic hyperuricemia is unproven. In the UCLA Adult Congenital Heart Disease Clinic, asymptomatic hyperuricemia is not routinely treated.
Hyperuricemia in CCHD occurs because of increased production and decreased renal clearance of uric acid.
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Urate Deposits
Painless Suprapatellar Effusion
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Albuminuria Glomerular capillaries are porous to albumin which is retained because the protein molecule is catatonic while the glomerular capillary wall is negatively charged.
The viscosity of erythrocytosis increases glomerular perfusion pressure and overcomes the cationic effect, so albumin leaves the glomerulus.
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Glomerular Vascular Abnormalities in CCHD Nitric Oxide and the Kidney
NO is synthesized in the cytosol of mesangeal cells and glomerular capillary endothelial cells and functions as an autocrine hormone that modulates the glomerular response to increased perfusion resistance of erythrocytosis. Glomerular arterioles and capillaries dilate, and glomerular blood flow, vascularity and size increase.
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Light Microscopy
Hypervascular Glomerulus
Electron Microscopy
Normals
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Shunted systemic venous
megakaryocytes:
Light and electron microscopy.
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Nonvascular Glomerular Abnormalities
Shunted systemic venous megakaryocytes carry cytoplasmic PDGF and TGF beta to glomerular capillary beds. These mitogens and cytokines act locally because of their short half life, stimulating mesenchymally derived cells, enhancing connective tissue formation, and promoting protein synthesis, extracellular matrix, fibrosis and cell proliferation.
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Digits and Long Bones
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Clubbing & Osteoarthropathy
Fingertip Megakaryocyte PDGF and TGF beta
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Technetium 99m Uptake The Clubbed Digits
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Hypertrophic Osteoarthrophy
Sub-periostial technetium 99m uptake
Long Bones
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Respiration & Ventilation in CCHD
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J. S. Haldane
In 1922, Haldane and Douglas placed a patient with cyanotic congenital heart disease in an oxygen-rich atmosphere and
observed that the cyanosis persisted.
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Dickinson W. Richards 1931
When the patient was placed in the oxygen chamber, the arterial oxygen saturation rose only 5%, scarcely more than the change that would occur in a normal person. Thus, the pulmonary alveoli oxygenated satisfactorily the blood that passed through them.
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Response to Exercise
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The Carotid Body & the Regulation of Breathing
The carotid body is 4-5 mm oval nodule of chemoreceptor tissue involved in the regulation of breathing. It
enlarges considerably in CCHD because of the stimuli of hypoxia, acidosis, and hypocarbia. However its
chemoreflex ventilatory response is blunted.
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Chemoreflex Ventilatory Responses at High Altitude
1) The blunted response to hypoxia and
inhaled O2 at high altitude are not reversed by descent to sea level.
2) The blunted responses in CCHD after relief of cyanosis are being investigated.
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CCHD--A Low Altitude Risk for Carotid Body Tumor
High altitude induces carotid body hyperplasia. Carotid body tumors are
frequent among high altitude Peruvians, and have been reported in CCHD.
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The Central Nervous System in
CCHD
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Healed & Fresh Brain Abcess
Healed Fresh
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The central nervous system and the cardiovascular system form almost simultaneously in early gestation. It is therefore not surprising that structural abnormalities of the brain accompany structural abnormalities of the
heart.
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Third trimester fetuses with certain types of
congenital heart disease have impaired neuro-axonal development and smaller than normal brain volumes adjusted for
gestational age and birth weight.
Brain Volume in Fetuses With Congenital Heart Disease
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Gynecologic Endocrinology in CCHD
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Dysfunctional bleeding is common in females with CCHD, implying an anovulatory state with
unopposed estrogen production and continuous endometrial stimulation that risks endometrial
adenocarcinoma.
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A Multi-System Systemic Disorder
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Ahmanson/UCLA Adult Congenital Heart Disease Center
Thank you