Ventricular and pulmonary vascular remodeling induced by pulmonary overflow in a chronic model of pretricuspid shunt Daniele Linardi, MD, Alessio Rungatscher,

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Ventricular and pulmonary vascular remodeling induced by pulmonary overflow in a chronic model of pretricuspid shunt Daniele Linardi, MD, Alessio Rungatscher, MD, PhD, FAHA, Mohammed Morjan, MD, Paolo Marino, MD, Giovanni Battista Luciani, MD, Alessandro Mazzucco, MD, Giuseppe Faggian, MD The Journal of Thoracic and Cardiovascular Surgery Volume 148, Issue 6, Pages 2609-2617 (December 2014) DOI: 10.1016/j.jtcvs.2014.04.044 Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 A, The infrarenal portion of the aorta and inferior vena cava (IVC) are shown. An 8-0 polypropylene purse suture is applied on the aorta. B, Creation of the shunt: an 18-gauge catheter is inserted between the purse suture on the anterior surface of the aorta and then advanced into the IVC. C and D, The success of the procedure was confirmed by observing mixing of arterial and venous blood in the IVC with distention and pulsations in the IVC. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2609-2617DOI: (10.1016/j.jtcvs.2014.04.044) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Echocardiogram: analysis of RV free wall thickness and RV end-diastolic dimension was performed in the parasternal short axis at the level of the papillary muscles. Using the apical 4-chamber projection to obtain an estimate of TAPSE (tricuspid annular plane systolic excursion). A mesosystolic notch (indicated with a white arrow) appears in the Doppler wave profile of the pulmonary flow of rats subjected to a shunt but not in the Doppler profiles of the sham group. Magnetic resonance: cardiac chamber volumes were increased in both shunt groups. A, Sham; B, shunt for 10 weeks shunt; C, shunt for 20 weeks. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2609-2617DOI: (10.1016/j.jtcvs.2014.04.044) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A-F, Left ventricle hemodynamic data acquired by means of the conductance catheter technique. LVEDP, Left ventricle end-diastolic pressure; Tau, time constant of left ventricular pressure decay; dP/dtmax and dP/dtmin, maximal peak systolic pressure increase and diastolic pressure decrease; EDV, end-diastolic volume; PRSW, preload recruitable stroke work. G-O, Right ventricle hemodynamic data acquired by means of the conductance catheter technique. RVEDP, Right ventricle end-diastolic pressure; Tau, time constant of right ventricular pressure decay; SAP, systolic pulmonary artery pressure; DAP, diastolic pulmonary artery pressure; EA, arterial elastance. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2609-2617DOI: (10.1016/j.jtcvs.2014.04.044) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 A, Normal pulmonary histology in a sham rat. B, After 20 weeks of exposure to volume overload, thickening of the tunica media with muscular hypertrophy is evident. C, Masson trichrome stain. Collagen is marked in blue between muscular cells, revealing low fibrosis. D, Complete occlusion of the intralobular arteries as a result of concentric intimal hyperplasia was found in some of rats shunted for 20 weeks. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2609-2617DOI: (10.1016/j.jtcvs.2014.04.044) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Pressure-volume loops obtained during temporary inferior vena cava occlusion in representative cases from the control group and shunt group after 20 weeks. Left ventricle (LV) analysis (A and B) and right ventricle (RV) analysis (C and D) are shown. The end-systolic pressure-volume relationship (red dotted line) and the end-diastolic pressure-volume relationship (green dotted line) demonstrate worsening of biventricular function. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 2609-2617DOI: (10.1016/j.jtcvs.2014.04.044) Copyright © 2014 The American Association for Thoracic Surgery Terms and Conditions