Abstract Cessation of the blood circulation for some time during surgery of the aortic arch and repair of congenital heart defects is normally required to allow a bloodless operation field. Hypothermia is the most important mechanism for end-organ protection, particularly the brain, during such operations. Cardiopulmonary bypass is used for core cooling before total hypothermic circulatory arrest (HCA) or selective cerebral perfusion (SCP) are initiated. During hypothermic cardiopulmonary bypass, pH can be managed according to either pH- or alpha-stat principles. In the present work, the optimal pH management strategy for operations requiring HCA or SCP was explored. An experimental porcine model was used. Firstly, outcome was evaluated in a HCA model using either the α- or pH-stat perfusion strategy (I). Secondly, we sought to determine which acid-base management is more effective in attenuating ischemic brain injury during combined HCA and embolization conditions (II). In the third study, the impact of propofol anesthesia and α-stat perfusion strategy on outcome was explored (III). Finally, the acute effects of perfusion strategies in a SCP porcine were compared (IV). Hemodynamics, temperature, EEG (I-III), brain microdialysis, intracranial pressure (I-III), brain tissue oxygen partial pressure (I-III), and intravital microscopy (IV) were monitored intraoperatively. In the chronic studies, survival, postoperative neurologic recovery and brain histopathologic examination were evaluated (I-III). pH-stat strategy was associated with superior outcome compared to the α-stat strategy during a 75-minute period of deep HCA (I). In addition, despite the pH-stat strategy-related cerebral vasodilatation, this method provided better neuroprotection in a setting of cerebral particle embolization prior to a 25-minute period of deep HCA (II). Propofol anesthesia combined with α-stat perfusion strategy was observed to deteriorate the brain injury during HCA evaluated by key brain microdialysis parameters (III). Finally, when employing moderately hypothermic SCP, the differences between pH- and α-stat strategies in cerebral metabolism and microcirculation were minimal. These findings are clinically relevant since α-stat perfusion strategy is still the most commonly used acid-base perfusion strategy during hypothermic cardiopulmonary bypass in adults, and propofol one of the most used anesthetics in clinical practice. It is also noteworthy that the pH-stat strategy is not currently used in adults because of the perceived increased risk of atherosclerotic embolization. However, the advantage of pH-stat strategy over α-stat strategy could not be observed when employing SCP.

Ischemic stroke causes irreversible damage to the brain. The hippocampus is a vulnerable region and plays an important role in cognition and locomotor activity. Puerarin is a phytoestrogen that has beneficial effects in treating neurological disorders. How puerarin protects against hippocampal injury and its molecular mechanisms remain to be elucidated. Transient global brain ischemia was induced by 4-vessel occlusion in adult male Sprague-Dawley rats. The rats were pretreated with puerarin alone or together with LY294002 (an PI3K inhibitor) before ischemia/ reperfusion (I/R). The open-and closed-field tasks and Morris water maze (MWM) test were used to assess the effects of puerarin on anxiety-like behavioral and cognitive impairment following I/R. Hematoxylin-eosin staining(HE) was used to examine the survival of hippocampal CA1 pyramidal neurons, and immunoblotting was performed to examine the expression of the related proteins. By using the rat model for transient I/R, we demonstrated that puerarin pretreatment significantly increased the travelling distance and number of crossings in the open-and closedfield tests, reduced latency and increased the proportion of distance and time in zone IV in the MWM. The number of live cells in the hippocampus is sharply increased by puerarin pretreatment. We further observed that the levels of phosphorylated Akt1, GSK-3 beta and MCL-1were elevated and those of cleaved-caspase-3 were reduced in the puerarin-treatment group. Notably, the PI3K inhibitor LY294002 counteracted all of the effects of puerarin. Our findings suggest that puerarin protects the hippocampus from I/R damage by activating the PI3K/Akt1/GSK-3 beta/MCL-1 signaling pathway.

Abstract In the repair of complex congenital heart defects or in surgery of the aortic arch, normal circulation may be temporarily halted to ensure a clean, bloodless operation field. The brain is the organ most vulnerable to ischemic injury during this no-flow period, and the mortality and morbidity of these procedures today consists mostly of neurological complications. Hypothermia decreases the need for oxygen and other metabolites, and cooling the patient with an extracorporeal heart-lung machine can provide enough time to perform the necessary surgical procedures during a circulatory standstill. This procedure is referred to as hypothermic circulatory arrest (HCA). Sometimes the cerebral circulation can be maintained even if the rest of the body undergoes circulatory arrest, and this strategy, involving separate catheterization of brain-destined vessels, is referred to as selective cerebral perfusion (SCP). In this work, four separate brain protection strategies were evaluated. Two studies were performed on a surviving porcine model (I, II) to evaluate neurological recovery as well as cerebral metabolism and histopathology, and two were acute in design (III, IV), employing the modern technology of intravital microscopy to examine cerebral microcirculation. The first study (I) showed that the administration of hypertonic saline dextran (HSD) led to a decrease in intracranial pressure, improved brain metabolism, better neurological recovery and less histopathological injury of the brain tissue in association with HCA. In the second study (II) a novel pharmacological molecule, levosimendan, reduced the intracranial pressure during the operation, but no improvement in terms of cerebral metabolism, neurological recovery or histopathological brain injury was observed after HCA. In the third study (III), real-time intravital microscopy showed that in association with HCA, a leukocyte depleting filter (LDF) attached to the cardiopulmonary bypass circuit reduces the number of activated leukocytes in cerebral microcirculation. In the fourth study (IV), cerebral metabolism and microcirculation were similar during SCP independent of the acid-base management strategy. The results of this work suggest that HSD could be assessed in human trials, that levosimendan needs further studies to optimize its potential, that the LDF functions as designed and that the differences between the α- and the pH-stat acid-base management strategies with SCP did not differ in moderate hypothermia.

No description available.

Current knowledge indicates that nonthermal muscle metaboreflex activity plays a critical role in the modulation of skin vasodilation and sweating. However, the mechanisms of control have primarily been studied during isometric handgrip exercise in which muscle metaboreceptor activation is induced by a brief post-exercise ischemia of the upper limb. While the reflex increase in mean arterial pressure associated with this period of ischemia is consistent with the activation of muscle metaboreceptors, the change in baroreflex activity may in itself modulate the response. Thus, we sought to understand how these nonthermal stimuli interact in modulating the control of skin perfusion and sweating under conditions of elevated hyperthermia. Furthermore, we examined the mechanisms responsible for the maintenance of arterial blood pressure under varying levels of heat stress during isometric handgrip exercise. Our study findings indicate that the parallel activation of muscle metaboreceptors and baroreceptors during post-exercise ischemia causes divergent influences on the control of skin blood flow and sweating; and these nonthermal stimuli are dependent on the level of hyperthermia. Moreover, we report that heat stress reduces the increase in arterial blood pressure during isometric handgrip exercise and this attenuation is attributed to a blunted increase in peripheral resistance, since cardiac output increased to similar levels for all heat stress conditions. These results provide important insight and understanding into the role of muscle metabo- and baroreflex activity on the control of skin blood flow and sweating; along with further knowledge into the cardiovascular mechanisms responsible for the regulation of arterial blood pressure during hyperthermia.

Stroke is a devastating and debilitating condition resulting from a blockage or hemorrhage in the vasculature of the brain. Despite extensive research, the etiology and pathophysiology of the disease at the level of the cell membrane are poorly understood, and effective treatment has been elusive. Though much research has shown marked increases in lipid metabolism following stroke, the impact of these changes have often been overlooked given the technical challenges associated with identifying regionally specific changes in degenerating tissue. The advent of lipidomics – a systems biology approach to the large-scale profiling of individual lipid species in tissues – has renewed interest in understanding the role of membrane lipids and their metabolites in the cell and in ischemic injury. In this thesis, I have used an unbiased LC-ESI-MS-based lipidomic approach to profile the small molecular weight glycerophosphocholine second messenger lipidome in anterior and posterior regions of cortex and striatum in the forebrain of wild-type and platelet activating factor receptor (PAFR) null-mutant mice before and after middle cerebral artery occlusion (MCAO). From these profiles, I have outlined the potential use of lipid second messenger distribution as topographic landmarks to identify functional subdomains within neural tissue. Further, I have demonstrated that ischemia does not simply disrupt lipid second messenger metabolism globally but produces regionally specific changes in discrete species and that these changes are altered by the loss of lipid regulatory effectors (i.e., PAFR null mutation). Based on the lipid species identified in this profile of healthy and ischemic tissue, I proposed that tight regulation of PC(O-22:6/2:0) homeostasis by PAFR-expressing microglia is ii required for proper dopaminergic signaling in prefrontal cortex. Finally, I have outlined a model whereby increased PAF synthesis following ischemia contributes the inflammatory response by promoting blood-brain barrier permeability, microglial activation and immune cell infiltration in a PAFR-dependent manner.

Parmi les pathologies ischémiques, l'ischémie aiguë des membres inférieurs (IAMI) fait l'objet de nombreuses recherches ayant pour but une meilleure compréhension des mécanismes physiopathologiques et la mise au point de thérapies efficaces. Les cellules progénitrices endothéliales (PEC) participent à la régénération des vaisseaux lors d'événements ischémiques. En pathologie tumorale, la résistance aux traitements disponibles pousse la recherche à trouver de nouvelles cibles thérapeutiques. Depuis plusieurs années, notre équipe travaille sur la molécule CD146. Il a été démontré que la forme soluble de CD146 est une molécule angiogénique impliquée en physiologie et en pathologie. Notre travail a donc consisté à étudier le mécanisme d'action de cette molécule en pathologies. Les travaux de cette thèse comportent plusieurs axes :Un premier dans lequel l'étude des modulations des effets de CD146 soluble sur les PEC a permis de mettre en évidence son récepteur, l'angiomotine. La seconde partie du travail a porté sur l'étude des effets d'un prétraitement par CD146 soluble de PEC sur un modèle d'IAMI chez la souris. In vitro et in vivo, CD146 soluble augmente les propriétés angiogéniques et la viabilité des PEC.Enfin, la troisième partie des travaux réalisés durant ma thèse a porté sur le rôle de sCD146 en pathologie cancéreuse. Nous avons développé des modèles de xénogreffes decellules cancéreuses nous permettant d'examiner les effets de CD146 soluble sur la croissance tumorale par l'injection de la molecule. Les résultats obtenus montrent que CD146 soluble augmente la croissance et la vascularisation tumorale. / Diseases with angiogenic component such as ischaemic pathologies and cancer have a high incidence. Among ischaemic pathologies, the acute ischaemia of the lower limbs made the object of many research having for goal a better comprehension of the physiopathological mechanisms and the development of effective therapies. The endothelial progenitor cells (EPC) take part in the regeneration of the vessels during ischaemia. In tumoral pathology, resistance to available treatments pushes research to find new therapeutic targets. For several years, our team has worked on CD146 molecule. It was shown that the soluble form of CD146 is an angiogenic factor involved in physiology and pathology. Our work thus consisted in studying the mechanism of action of this molecule in pathologies. Work of this thesis comprises several axes: A first in which the study of the modulations of the effects of soluble CD146 on EPC made it possible to highlight its receptor, angiomotin protein. The second part of the work concerned the study of the effects of a pretreatment by soluble CD146 on EPC on a model of IAMI in mouse. In vitro and in vivo, soluble CD146 increases the angiogenic properties and the viability of the EPC. Lastly, the third part of the work completed during my thesis concerned the role of sCD146 in cancerous pathology. We developed xenograft models of cancer cells allowing us to examine the effects of soluble CD146 on the tumor growth by the injection of this molecule. The results obtained show that soluble CD146 increases tumor growth and vascularization.

La maladie cardiovasculaire la plus courante dans les pays industrialisés est la maladie coronarienne responsable d’une ischémie du tissu cardiaque pouvant conduire à l’infarctus du myocarde. Bien que les améliorations de la prise en charge aient considérablement réduit les délais de la reperfusion (seul remède à l’ischémie), l’ischémie/reperfusion (I/R) entraîne des dommages cellulaires et tissulaires ainsi qu’une diminution des capacités fonctionnelles du coeur. Il existe néanmoins des systèmes de cardioprotection endogènes (comme le préconditionnement (préC) ou le postconditionnement (postC)) que l’on peut activer via l’administration de substances pharmacologiques. L’élastine, une protéine fibreuse de la matrice extracellulaire, est responsable de l’élasticité de certains de nos tissus (poumons, peau, <). Des peptides issus de la dégradation de l’élastine (PE) exercent un effet cardioprotecteur envers l’I/R en activant la voie de survie cellulaire RISK. Dans des fibroblastes dermiques, la transduction du signal induit par les peptides d’élastine est médiée de façon précoce par un second messager : le lactosylcéramide (LacCer). Cette étude constitue une première approche des effets du LacCer dans la cardioprotection envers l’I/R. Nous avons montré que le LacCer est un médiateur précoce du signal cardioprotecteur induit par les PE et qu’il protège le coeur des dommages liés à l’I/R dans un modèle de coeur isolé et perfusé en postC. Lors du vieillissement, de nombreuses modifications physiologiques sont à l’origine d’une perte d’efficacité des mécanismes de cardioprotection. Dans ce travail, nous avons également étudié les effets cardioprotecteurs des PE, du LacCer et de l’inhibition de p38MAPK (une protéine probablement impliquée dans la perte des mécanismes cardioprotecteurs liée au vieillissement) envers les dommages liés à l’I/R chez les rats âgés. Nous avons montré que les PE exercent un effet cardioprotecteur en pré+postC contre l’I/R au niveau de la survie cellulaire et au niveau de la récupération des capacités contractiles cardiaques. Le LacCer n’exerce un effet protecteur qu’au niveau de la survie cellulaire et l’inhibition de p38MAPK entraine une meilleure récupération des capacités contractiles sans améliorer la survie cellulaire. / In developed countries the most common cardiovascular disease is coronary heart disease that is responsible for myocardial ischemia and can lead to myocardial infarction. Reperfusion is the only cure for ischemia. Care improvement has dramatically reduced reperfusion delay but ischemia/reperfusion (I/R) causes a lot of cellular and tissular damages and a reduction of cardiac contractile abilities. Nevertheless cardioprotective pathways (like preconditionning (preC) and postconditionning (postC) can be pharmacologically triggered to reduce I/R injury. Elastin is a fibrous protein from extracellular matrix and is responsible for tissues elasticity in lungs, skin, < Peptides derived from elastin fragmentation (EP) exhibit cardioprotective function against I/R by triggering the RISK pathway, a cell survival pathway. In dermic fibroblasts, elastin peptides pathway is mediated by an early messenger : lactosylcéramide (LacCer). In this work we have studied cardioprotective function of LacCer against I/R injury. We show that LacCer is an early messenger of EP cardioprotective pathway and that it also exhibits a cardioprotective function against I/R in an postconditionning isolated rat heart model. During ageing dramatic physiological modifications are responsible for a loss of efficiency of cardioprotection pathways. In this work we have also studied the potential cardioprotective function of EP, LacCer and p38MAPK inhibition (a protein presumably involved in loss of efficiency of cardioprotection pathways during ageing) against I/R injury in aged rats. We have shown that EP exhibit a cardioprotective function against I/R injury in aged rats as well as young rats in a pre+postconditionning protocol. EP enhance contractile abilities recovering and cell survival. LacCer improves only cell survival and p38MAPK inhibition improves only contractile abilities recovering

Atrial fibrillation is the most common type of serious dysrhythmia, with increasing prevalence in older age groups. Thromboembolism is a serious complication seen with atrial fibrillation and can range from ischemic stroke, mesenteric ischemia to acute limb ischemia. The annual incidence of acute limb ischemia secondary to atrial fibrillation is 0.14%[1]. Here we report a case of critical limb ischemia with brachial artery occlusion due to an embolus in a patient with new onset atrial fibrillation. A 90 year-old female patient presented to the hospital with complaints of shortness of breath on exertion, orthopnea and palpitations of one week duration. She denied any chest pain, dizziness, or syncope. Past medical history was significant for longstanding hypertension well controlled with amlodipine and a provoked deep vein thrombosis of the leg 40 years prior to presentation complicated by heparin-induced thrombocytopenia. On examination, she had an irregularly irregular rhythm and an HR in 120s, no murmurs or gallops were appreciated. 12 lead EKG was suggestive of atrial fibrillation with rapid ventricular response. She was started on metoprolol tartrate for rate control and Apixaban for anticoagulation. TSH was normal and serial troponins returned negative. A Transthoracic echocardiogram was obtained and showed an ejection fraction of 55-60%, mildly dilated left atrium, mild MR, there was no evidence of a thrombus or patent foramen ovale. Three hours after the first dose of Apixaban, and right prior to discharge, the patient started complainig of sudden onset sharp pain and paresthesia of the left upper extremity below the elbow. On Inspection, the left upper extremity was pale and cold to touch. Radial and ulnar pulses were absent, confirmed by doppler ultrasound. A stat computed tomography angiography of the left upper extremity showed complete occlusion of the brachial artery at the level of the elbow joint. She was started on Argatroban drip en route for emergent brachial embolectomy after Vascular Surgery consultation. Blood circulation to the arm was fully restored. Apixaban was resumed post-operatively and with clinical improvement, the patient was safely discharged home. Atrial fibrillation, irrespective of the type (persistent, paroxysmal, permanent or silent) leads to increased risk of thromboembolism owing to atrial clot formation[2]. However, the timing of initiation of antithrombotic therapy has been widely discussed and needs to be individualized based on the presence of risk factors for thromboembolism and bleeding. Acute limb ischemia may be defined as sudden loss of blood flow to the limb. The cause being either thrombotic (60%) or embolic (30%). It has been noted that 80% of peripheral emboli originate in the heart secondary to atrial fibrillation[3]. A timely diagnosis and treatment is of utmost importance to decrease morbidity and mortality and to salvage the limb’s functionality. References 1.Thromboembolism in atrial fibrillation Menke J1, Lüthje L, Kastrup A, Larsen J. 2.Writing Committee Members, January CT, Wann LS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014;130(23):e199-e267. doi:10.1161/CIR.0000000000000041. 3.Callum K, Bradbury A. Acute limb ischaemia. BMJ : British Medical Journal. 2000;320(7237):764-767.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21960号 / 医博第4502号 / 新制||医||1037(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 平井 豊博, 教授 松原 和夫, 教授 湊谷 謙司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM