Assessment of endothelial cell function and physiological microcirculatory reserve by video microscopy using a topical acetylcholine and nitroglycerin challenge

Matthias Peter Hilty, Jacqueline Pichler, Bulent Ergin, Urs Hefti, Tobias Michael Merz, Can Ince, Marco Maggiorini, Matthias Peter Hilty, Jacqueline Pichler, Bulent Ergin, Urs Hefti, Tobias Michael Merz, Can Ince, Marco Maggiorini

Abstract

Background: Assessment of the microcirculation is a promising target for the hemodynamic management of critically ill patients. However, just as the sole reliance on macrocirculatory parameters, single static parameters of the microcirculation may not represent a sufficient guide. Our hypothesis was that by serial topical application of acetylcholine (ACH) and nitroglycerin (NG), the sublingual microcirculation can be challenged to determine its endothelial cell-dependent and smooth muscle-dependent physiological reserve capacity.

Methods: In 41 healthy subjects, sublingual capillary microscopy was performed before and after topical application of ACH and NG. Total vessel density (TVD) was assessed in parallel using manual computer-assisted image analysis as well as a fully automated analysis pathway utilizing a newly developed computer algorithm. Flow velocity was assessed using space-time diagrams of the venules as well as the algorithm-based calculation of an average perfused speed indicator (APSI).

Results: No change in all measured parameters was detected after sublingual topical application of ACH. Sublingual topical application of NG however led to an increase in TVD, space-time diagram-derived venular flow velocity and APSI. No difference was detected in heart rate, blood pressure, and cardiac output as measured by echocardiography, as well as in plasma nitric oxide metabolite content before and after the topical application of ACH and NG.

Conclusions: In healthy subjects, the sublingual microcirculatory physiological reserve can be assessed non-invasively by topical application of nitroglycerin without affecting systemic circulation.

Keywords: Endothelial cell function; Hemodynamic monitoring; Incident dark field; Microcirculation; Vasodilator; Video microscopy.

Figures

Fig. 1
Fig. 1
Plasma nitric oxide metabolite content (p = 0.66) (a) and mean arterial pressure (p = 0.48) (b) before and after topical vasodilator application (intervention). Boxplots represent median, interquartile range, and range. NO nitric oxide
Fig. 2
Fig. 2
Properties of the sublingual microcirculation before (native) and after the topical sublingual application of acetylcholine and nitroglycerin. a Total vessel density (TVD) and space-time diagram-based flow velocity of the venules as determined using manual video analysis. ANOVA p < 0.0001 for TVD and p < 0.01 for space-time diagram-based flow velocity; asterisk denotes values differing from native examination in pairwise analysis (p < 0.05), dagger denotes values differing to acetylcholine stimulation in pairwise analysis (p < 0.05). b Total vessel density and average perfused speed index (APSI) as determined using algorithm-based video analysis. ANOVA p < 0.01 for TVD and p = 0.02 for APSI; asterisk denotes values differing from native examination in pairwise analysis (p < 0.05), dagger denotes values differing to acetylcholine stimulation in pairwise analysis (p < 0.05). Boxplots represent median, interquartile range, and range. Horizontal scattering is applied to the individual data points in order to avoid superimposition
Fig. 3
Fig. 3
Representative still images and space-time diagrams of the venules depicting the native sublingual microcirculation (a) as well as after the topical sublingual application of acetylcholine (b) and nitroglycerin (c). Stimulation with nitroglycerin leads to an increase of total vessel density through recruitment of capillaries and an increase in flow velocity in the capillaries and venules

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