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J Thorac Cardiovasc Surg 2002;124:479-485
© 2002 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease (CHD)

The role of oxidative stress in the development of pulmonary arteriovenous malformations after cavopulmonary anastomosis

From the Division of Cardiothoracic Surgery, University of California, San Francisco, Calif.

Read at the Eighty-first Annual Meeting of The American Association for Thoracic Surgery, San Diego, Calif, May 6-9, 2001.

Received for publication May 14, 2001. Revisions requested Aug 3, 2001; revisions received Sept 10, 2001. Accepted for publication Sept 18, 2001. Address for reprints: R. Kirk Riemer, PhD, Stanford University, Department of Cardiothoracic Surgery, Falk CVRB-CV116C, Stanford, CA 94305-5407 (E-mail: Riemerk{at}Stanford.edu).

Background: Cavopulmonary anastomosis is used for palliation of cyanotic heart disease. Clinically significant pulmonary arteriovenous malformations occur in up to 25% of patients after surgical intervention. Cavopulmonary anastomosis creates several modifications to pulmonary physiology that may contribute to the development of pulmonary arteriovenous malformations, including reduced pulmonary blood flow and the exclusion of inferior vena caval effluent.
Objective: By comparing the expression of angiogenic and stress-related proteins after cavopulmonary anastomosis and pulmonary artery banding, we sought to determine which genes were upregulated independent of reduced pulmonary blood flow.
Methods: Lambs aged 35 to 45 days were placed into 1 of 3 groups: cavopulmonary anastomosis (n = 6), pulmonary artery banding (n = 6), and sham control (n = 6) animals. In our model pulmonary arteriovenous malformations are detectable by means of bubble-contrast echocardiography 8 weeks after cavopulmonary anastomosis. Lung tissue was harvested for Western blotting at 2 and 5 weeks after surgery.
Results: Cavopulmonary anastomosis and pulmonary artery banding both increased angiogenic gene expression, but only cavopulmonary anastomosis induced the expression of endothelial stress-related genes. Vascular endothelial growth factor was upregulated 2.5-fold after both cavopulmonary anastomosis (P = .002) and pulmonary artery banding (P = .007). Only cavopulmonary anastomosis upregulated 2 stress-related genes, HO1 and GLUT1, 2.7-fold (P = .002) and 3.8-fold (P = .03), respectively. Hypoxia-inducible factor was upregulated 4-fold (P = .003) after cavopulmonary anastomosis. Pulmonary artery banding failed to induce the increased expression of any of these proteins.
Conclusions: Reduced pulmonary blood flow induces a pulmonary angiogenic response but not an endothelial stress response. These results suggest that oxidative stress is more relevant to the formation of pulmonary arteriovenous malformations than angiogenic signaling alone because pulmonary artery banding does not result in pulmonary arteriovenous malformations. Oxidative stress of the pulmonary endothelium resulting from cavopulmonary anastomosis may predispose the affected vasculature to arteriovenous shunting.

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