EFFECTS OF A NOVEL ANTICOAGULANT COMPOUND (TV7130) IN AN OVINE MODEL OF SEPTIC SHOCK Fuhong Su,* Hongchuan Huang,* Xinrong He,* David Simuen,* Jingwei Xie, † Aric Orbach, ‡ Orit Cohen-Barak, ‡ Michael Piagnerelli,* and Jean-Louis Vincent* Departments of *Intensive Care and † Molecular Biology, Erasme Hospital, Universite ´ Libre de Bruxelles, Brussels, Belgium; and ‡ Teva Pharmaceutical Industries Ltd, Netanya, Israel Received 19 Jan 2010; first review completed 7 Feb 2010; accepted in final form 3 May 2010 ABSTRACT—We compared the effects of a new compound (TV7130) with those of activated protein C (APC) in a large animal model of septic shock. Thirty-two fasted, anesthetized, invasively monitored, mechanically ventilated female sheep received 1.5 g/kg body weight of feces into the abdomen to induce sepsis. Immediately after feces injection, all animals received a bolus followed by a continuous infusion of saline (n = 8, bolus 1.5 mL for 15 min, infusion 1.5 mL/[kgIh]), low-dose TV7130 (n = 8; 0.4 mg/kg bolus, 0.4 mg/[kgIh] infusion), high-dose TV7130 (n = 8; 0.8 mg/kg bolus, 0.8 mg/[kgIh] infusion), or APC (n = 8; saline bolus, APC infusion of 0.024 mg/[kgIh]). Experiments were pursued until each sheep’s spontaneous death. There were no significant differences among groups in heart rate or cardiac index, but mean arterial pressure, systemic vascular resistance index, and left ventricular stroke work index decreased less in the high-dose TV7130 and APC groups than in the other groups. Gas exchange was preserved better in the high-dose TV7130 and APC groups. Interleukin 6 and lactate concentrations were lower in the high-dose TV7130 and APC groups than in the other groups. Functional capillary density and proportion of perfused vessels, evaluated in the sublingual region using sidestream dark-field videomicroscopy, were significantly higher in the TV7130 and APC groups than in the vehicle group at 16 h. Survival time was significantly longer in the high-dose TV7130 and APC groups than in the other groups (log-rank test, P = 0.0002). TV7130 has similar effects to APC and may be a promising agent for the management of severe sepsis. KEYWORDS—Sepsis, anticoagulant, activated protein C, microcirculation, survival INTRODUCTION Septic shock remains one of the leading causes of death in the intensive care unit (1). Septic shock is characterized by alterations in the coagulant/anticoagulant balance resulting in activated coagulation and impaired fibrinolysis. Recombinant human activated protein C (APC) has been shown to exert beneficial cytoprotective and anti-inflammatory effects asso- ciated with decreased mortality and improved organ dysfunc- tion in sepsis patients (2). These results have stimulated the search for new compounds that may act via a similar mecha- nism in septic shock, especially if they can be available at a lower cost. TV7130 is a molecule consisting of three amino acidsVtwo unnatural D-cyclohexylglycine and L-azetidine-2carboxylic acid and one natural converted to its aldehyde form L-arginal. It exists as a mixture of four aldehyde (either free or latent) forms, constantly in equilibrium: cis and trans amino cyclols (Acis-40%, Atrans-13%), aldehyde hydrate (B-45%), and free aldehyde (C-2%). TV7130 has been shown to be effective in producing anticoagulation and decreasing mortality in various rodent models of sepsis and disseminated intravascular coag- ulation (DIC) (unpublished company data). The aim of the current study was to investigate the effects of TV7130 in a clinically relevant sheep model of septic shock induced by fecal peritonitis (3) and to compare them with those of APC, which has been shown to postpone the occurrence of hypo- tension, improve gas exchange, have an anticoagulant effect, and prolong survival time in this model (4). METHODS Surgical preparation Care and handling of the animals was in accordance with National Institutes of Health guidelines (Institute of Laboratory Animal Resources). Thirty-four female sheep were fasted for 24 h with free access to water before the experiment. On the day of the experiment, the animals were weighed, premedicated with i.m. midazolam (0.25 mg/kg, Dormicum; Roche SA, Brussels, Belgium) and ketamine hydrochloride (20 mg/kg, Imalgine; Merial, Lyon, France) and placed in the supine position. The cephalic vein was cannulated with a periph- eral venous 18-gauge catheter (Surflo I.V. Catheter; Terumo, Leuven, Belgium). After i.v. administration of fentanyl (30 2g/kg; Janssen, Beerse, Belgium) and rocuronium (0.1 mg/kg, Esmeron; Organon, Oss, the Netherlands), the trachea was intubated (size 8.0, Hi-Contour; Mallinckrodt Medical, Athlone, Ireland). Mechanical ventilation was started on a controlled-volume mode (Servo ven- tilator 900 C; Siemens-Elema, Solna, Sweden) with a tidal volume of 9 mL/kg, a positive end-expiratory pressure (PEEP) of 5 cm H 2 O, an inspired oxygen fraction (FIO 2 ) of 1, an inspiratory-expiratory time (I/E) of 1:2, and a square wave pattern. Respiratory rate was adjusted to maintain end-tidal carbon diox- ide pressure (47210 A Capnometer; Boehlingen, Germany) between 35 and 45 mmHg. A 60-cm plastic tube (inner diameter, 1.8 cm) was inserted into the stomach to drain its contents and prevent rumen distension. A 14F Foley catheter was placed to measure urine output. Left femoral artery and vein were surgically exposed, and an arterial catheter (6F Vygon; Cirencester, UK) was introduced and connected to a pressure transducer (Edwards Lifesciences Corp, Irvine, Calif ) zeroed at midchest level. An introducer was inserted through the femoral vein, and a 7F Swan-Ganz catheter (Edwards Lifesciences Corp) was advanced into the pulmonary artery under monitoring of pressure waveforms. A midline laparotomy was performed and, after cecotomy, 1.5 g/kg body weight of feces was collected. The cecum was closed, and the area around the cut was dis- infected with iodine. An additional pouch suture was performed to prevent contamination, and the cecum was returned to the abdominal cavity. A large plastic tube was inserted through the abdominal wall for later injection of feces. The abdomen was then closed in two layers. After the surgical preparation, animals were turned to the prone posi- tion and allowed to stabilize for 1 h before baseline measurements were 622 SHOCK, Vol. 34, No. 6, pp. 622Y627, 2010 Address reprint requests to Jean-Louis Vincent, MD, PhD, Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, 1070 Brussels, Belgium. E-mail: jlvincen@ulb.ac.be. This study was supported by a research grant from Teva Pharmaceutical Industries. DOI: 10.1097/SHK.0b013e3181e684c3 Copyright Ó 2010 by the Shock Society Copyright © 2010 by the Shock Society. Unauthorized reproduction of this article is prohibited.