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Yang S, Wang C, Ruan C, Chen M, Cao R, Sheng L, Chang N, Xu T, Zhao P, Liu X, Zhu F, Xiao Q, Gao S. Novel Insights into the Cardioprotective Effects of Calcitriol in Myocardial Infarction. Cells 2022; 11:1676. [PMID: 35626713 PMCID: PMC9139780 DOI: 10.3390/cells11101676] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 05/10/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Increasing evidence indicates that vitamin D deficiency negatively affects the cardiovascular system. Here we studied the therapeutic effects of calcitriol in myocardial infarction (MI) and investigated its underlying mechanisms. METHODS A MI model of Kun-ming mice induced by left anterior descending coronary artery ligation was utilized to study the potential therapeutic effects of calcitriol on MI. AC16 human cardiomyocyte-like cells treated with TNF-α were used for exploring the mechanisms that underlie the cardioprotective effects of calcitriol. RESULTS We observed that calcitriol reversed adverse cardiovascular function and cardiac remodeling in post-MI mice. Mechanistically, calcitriol suppressed MI-induced cardiac inflammation, ameliorated cardiomyocyte death, and promoted cardiomyocyte proliferation. Specifically, calcitriol exerted these cellular effects by upregulating Vitamin D receptor (VDR). Increased VDR directly interacted with p65 and retained p65 in cytoplasm, thereby dampening NF-κB signaling and suppressing inflammation. Moreover, up-regulated VDR was translocated into nuclei where it directly bound to IL-10 gene promoters to activate IL-10 gene transcription, further inhibiting inflammation. CONCLUSION We provide new insights into the cellular and molecular mechanisms underlying the cardioprotective effects of calcitriol, and we present comprehensive evidence to support the preventive and therapeutic effects of calcitriol on MI.
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Affiliation(s)
- Simin Yang
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
| | - Chunmiao Wang
- Department of Cardiology, The First Affiliated Hospital, Anhui Medical University, Hefei 230022, China;
| | - Chengshao Ruan
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
| | - Meiling Chen
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
- Cancer Hospital, Chinese Academy of Sciences, Hefei 230031, China;
| | - Ran Cao
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
- Cancer Hospital, Chinese Academy of Sciences, Hefei 230031, China;
| | - Liang Sheng
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
- Cancer Hospital, Chinese Academy of Sciences, Hefei 230031, China;
| | - Naiying Chang
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
- Cancer Hospital, Chinese Academy of Sciences, Hefei 230031, China;
| | - Tong Xu
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
| | - Peiwen Zhao
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
| | - Xuesheng Liu
- Department of Anesthesiology, The First Affiliated Hospital, Anhui Medical University, Hefei 230022, China;
| | - Fengqin Zhu
- Cancer Hospital, Chinese Academy of Sciences, Hefei 230031, China;
| | - Qingzhong Xiao
- Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Shan Gao
- Department of Pharmacology, Basic Medical College, Anhui Medical University, Hefei 230032, China; (S.Y.); (C.R.); (M.C.); (R.C.); (L.S.); (N.C.); (T.X.); (P.Z.)
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Schimmel K, Ichimura K, Reddy S, Haddad F, Spiekerkoetter E. Cardiac Fibrosis in the Pressure Overloaded Left and Right Ventricle as a Therapeutic Target. Front Cardiovasc Med 2022; 9:886553. [PMID: 35600469 PMCID: PMC9120363 DOI: 10.3389/fcvm.2022.886553] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/06/2022] [Indexed: 12/31/2022] Open
Abstract
Myocardial fibrosis is a remodeling process of the extracellular matrix (ECM) following cardiac stress. "Replacement fibrosis" is a term used to describe wound healing in the acute phase of an injury, such as myocardial infarction. In striking contrast, ECM remodeling following chronic pressure overload insidiously develops over time as "reactive fibrosis" leading to diffuse interstitial and perivascular collagen deposition that continuously perturbs the function of the left (L) or the right ventricle (RV). Examples for pressure-overload conditions resulting in reactive fibrosis in the LV are systemic hypertension or aortic stenosis, whereas pulmonary arterial hypertension (PAH) or congenital heart disease with right sided obstructive lesions such as pulmonary stenosis result in RV reactive fibrosis. In-depth phenotyping of cardiac fibrosis has made it increasingly clear that both forms, replacement and reactive fibrosis co-exist in various etiologies of heart failure. While the role of fibrosis in the pathogenesis of RV heart failure needs further assessment, reactive fibrosis in the LV is a pathological hallmark of adverse cardiac remodeling that is correlated with or potentially might even drive both development and progression of heart failure (HF). Further, LV reactive fibrosis predicts adverse outcome in various myocardial diseases and contributes to arrhythmias. The ability to effectively block pathological ECM remodeling of the LV is therefore an important medical need. At a cellular level, the cardiac fibroblast takes center stage in reactive fibrotic remodeling of the heart. Activation and proliferation of endogenous fibroblast populations are the major source of synthesis, secretion, and deposition of collagens in response to a variety of stimuli. Enzymes residing in the ECM are responsible for collagen maturation and cross-linking. Highly cross-linked type I collagen stiffens the ventricles and predominates over more elastic type III collagen in pressure-overloaded conditions. Research has attempted to identify pro-fibrotic drivers causing fibrotic remodeling. Single key factors such as Transforming Growth Factor β (TGFβ) have been described and subsequently targeted to test their usefulness in inhibiting fibrosis in cultured fibroblasts of the ventricles, and in animal models of cardiac fibrosis. More recently, modulation of phenotypic behaviors like inhibition of proliferating fibroblasts has emerged as a strategy to reduce pathogenic cardiac fibroblast numbers in the heart. Some studies targeting LV reactive fibrosis as outlined above have successfully led to improvements of cardiac structure and function in relevant animal models. For the RV, fibrosis research is needed to better understand the evolution and roles of fibrosis in RV failure. RV fibrosis is seen as an integral part of RV remodeling and presents at varying degrees in patients with PAH and animal models replicating the disease of RV afterload. The extent to which ECM remodeling impacts RV function and thus patient survival is less clear. In this review, we describe differences as well as common characteristics and key players in ECM remodeling of the LV vs. the RV in response to pressure overload. We review pre-clinical studies assessing the effect of anti-fibrotic drug candidates on LV and RV function and their premise for clinical testing. Finally, we discuss the mode of action, safety and efficacy of anti-fibrotic drugs currently tested for the treatment of left HF in clinical trials, which might guide development of new approaches to target right heart failure. We touch upon important considerations and knowledge gaps to be addressed for future clinical testing of anti-fibrotic cardiac therapies.
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Affiliation(s)
- Katharina Schimmel
- Division Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, CA, United States,Stanford Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Kenzo Ichimura
- Division Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, CA, United States,Stanford Cardiovascular Institute, Stanford University, Stanford, CA, United States
| | - Sushma Reddy
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, United States,Pediatric Cardiology, Stanford University, Stanford, CA, United States
| | - Francois Haddad
- Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, CA, United States,Stanford Cardiovascular Institute, Stanford University, Stanford, CA, United States,Cardiovascular Medicine, Stanford University, Stanford, CA, United States
| | - Edda Spiekerkoetter
- Division Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, United States,Vera Moulton Wall Center for Pulmonary Vascular Disease, Stanford University, Stanford, CA, United States,Stanford Cardiovascular Institute, Stanford University, Stanford, CA, United States,*Correspondence: Edda Spiekerkoetter,
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3
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Properties and Functions of Fibroblasts and Myofibroblasts in Myocardial Infarction. Cells 2022; 11:cells11091386. [PMID: 35563692 PMCID: PMC9102016 DOI: 10.3390/cells11091386] [Citation(s) in RCA: 67] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/12/2022] [Accepted: 04/16/2022] [Indexed: 12/14/2022] Open
Abstract
The adult mammalian heart contains abundant interstitial and perivascular fibroblasts that expand following injury and play a reparative role but also contribute to maladaptive fibrotic remodeling. Following myocardial infarction, cardiac fibroblasts undergo dynamic phenotypic transitions, contributing to the regulation of inflammatory, reparative, and angiogenic responses. This review manuscript discusses the mechanisms of regulation, roles and fate of fibroblasts in the infarcted heart. During the inflammatory phase of infarct healing, the release of alarmins by necrotic cells promotes a pro-inflammatory and matrix-degrading fibroblast phenotype that may contribute to leukocyte recruitment. The clearance of dead cells and matrix debris from the infarct stimulates anti-inflammatory pathways and activates transforming growth factor (TGF)-β cascades, resulting in the conversion of fibroblasts to α-smooth muscle actin (α-SMA)-expressing myofibroblasts. Activated myofibroblasts secrete large amounts of matrix proteins and form a collagen-based scar that protects the infarcted ventricle from catastrophic complications, such as cardiac rupture. Moreover, infarct fibroblasts may also contribute to cardiac repair by stimulating angiogenesis. During scar maturation, fibroblasts disassemble α-SMA+ stress fibers and convert to specialized cells that may serve in scar maintenance. The prolonged activation of fibroblasts and myofibroblasts in the infarct border zone and in the remote remodeling myocardium may contribute to adverse remodeling and to the pathogenesis of heart failure. In addition to their phenotypic plasticity, fibroblasts exhibit remarkable heterogeneity. Subsets with distinct phenotypic profiles may be responsible for the wide range of functions of fibroblast populations in infarcted and remodeling hearts.
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Nuclear Molecular Imaging of Cardiac Remodeling after Myocardial Infarction. Pharmaceuticals (Basel) 2022; 15:ph15020183. [PMID: 35215296 PMCID: PMC8875369 DOI: 10.3390/ph15020183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 12/03/2022] Open
Abstract
The role of molecular imaging technologies in detecting, evaluating, and monitoring cardiovascular disease and their treatment is expanding rapidly. Gradually replacing the conventional anatomical or physiological approaches, molecular imaging strategies using biologically targeted markers provide unique insight into pathobiological processes at molecular and cellular levels and allow for cardiovascular disease evaluation and individualized therapy. This review paper will discuss currently available and developing molecular-based single-photon emission computed tomography (SPECT) and positron emission tomography (PET) imaging strategies to evaluate post-infarction cardiac remodeling. These approaches include potential targeted methods of evaluating critical biological processes, such as inflammation, angiogenesis, and scar formation.
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Gupta S, Ge Y, Singh A, Gräni C, Kwong RY. Multimodality Imaging Assessment of Myocardial Fibrosis. JACC Cardiovasc Imaging 2021; 14:2457-2469. [PMID: 34023250 DOI: 10.1016/j.jcmg.2021.01.027] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 01/19/2021] [Accepted: 01/25/2021] [Indexed: 02/07/2023]
Abstract
Myocardial fibrosis, seen in ischemic and nonischemic cardiomyopathies, is associated with adverse cardiac outcomes. Noninvasive imaging plays a key role in early identification and quantification of myocardial fibrosis with the use of an expanding array of techniques including cardiac magnetic resonance, computed tomography, and nuclear imaging. This review discusses currently available noninvasive imaging techniques, provides insights into their strengths and limitations, and examines novel developments that will affect the future of noninvasive imaging of myocardial fibrosis.
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Affiliation(s)
- Sumit Gupta
- Department of Radiology Brigham and Women's Hospital, Boston, Massachusetts, USA; Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yin Ge
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Amitoj Singh
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christoph Gräni
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raymond Y Kwong
- Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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6
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Januzzi JL, Stevenson LW. National and Local Politics of the Heart. J Am Coll Cardiol 2021; 77:1744-1746. [PMID: 33832601 DOI: 10.1016/j.jacc.2021.02.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/24/2021] [Accepted: 02/24/2021] [Indexed: 11/19/2022]
Affiliation(s)
- James L Januzzi
- Massachusetts General Hospital, Baim Institute for Clinical Research, Harvard Medical School, Boston, Massachusetts, USA.
| | - Lynne W Stevenson
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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7
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Sui S, Hou Y. Assessing Doxorubicin-Induced Cardiomyopathy by 99mTc-3PRGD2 Scintigraphy Targeting Integrin αvβ3 in a Rat Model. Nuklearmedizin 2021; 60:289-298. [PMID: 33638136 DOI: 10.1055/a-1331-7138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The present study evaluated interstitial alterations in doxorubicin-induced cardiomyopathy using a radiolabeled RGD peptide 99mTc-3PRGD2 specific for integrin αvβ3 that targets myofibroblasts.Cardiomyopathy was induced in 20 Sprague-Dawley rats by intraperitoneal doxorubicin injections (2.5 mg/kg/week) for up to six weeks. 99mTc-3PRGD2 scintigraphy was performed in control rats (n = 6) at baseline and three, six, and nine weeks after first doxorubicin administration (n = 6, 6, and 5 for each time point). For another three rats of 6-week modeling, cold c(RGDyK) was co-injected with 99mTc-3PRGD2 to evaluate specific radiotracer binding. Semi-quantitative parameters were acquired to compare radiotracer uptake among all groups. The biodistribution of 99mTc-3PRGD2 was evaluated by a γ-counter after scintigraphy. Haematoxylin and eosin, and Masson's staining were used to evaluate myocardial injury and fibrosis, while western blotting and immunofluorescence co-localization were used to analyze integrin αvβ3 expression in the myocardium.The 99mTc-3PRGD2 half-life in the cardiac region (Heartt 1/2) of the 9-week model and heart radioactivity percentage (%Heart20 min, %Heart40 min and %Heart60 min) of the 6 and 9-week models were significantly increased compared to the control. Heart-to-background ratio (HBR20 min, HBR40 min and HBR60 min) increase began in the third week, continued until the sixth week, and was reversed in the ninth week, which paralleled the changing trend of cardiac integrin αvβ3 expression. The myocardial biodistribution of 99mTc-3PRGD2 was significantly correlated with integrin β3 expression.The 99mTc-3PRGD2 scintigraphy allows for non-invasive visualization of interstitial alterations during doxorubicin-induced cardiomyopathy.
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Affiliation(s)
- Shi Sui
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yang Hou
- Department of Radiology, Shengjing Hospital of China Medical University, Shenyang, China
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8
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Zhou IY, Montesi SB, Akam EA, Caravan P. Molecular Imaging of Fibrosis. Mol Imaging 2021. [DOI: 10.1016/b978-0-12-816386-3.00077-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abstract
Myocardial fibrosis, the expansion of the cardiac interstitium through deposition of extracellular matrix proteins, is a common pathophysiologic companion of many different myocardial conditions. Fibrosis may reflect activation of reparative or maladaptive processes. Activated fibroblasts and myofibroblasts are the central cellular effectors in cardiac fibrosis, serving as the main source of matrix proteins. Immune cells, vascular cells and cardiomyocytes may also acquire a fibrogenic phenotype under conditions of stress, activating fibroblast populations. Fibrogenic growth factors (such as transforming growth factor-β and platelet-derived growth factors), cytokines [including tumour necrosis factor-α, interleukin (IL)-1, IL-6, IL-10, and IL-4], and neurohumoral pathways trigger fibrogenic signalling cascades through binding to surface receptors, and activation of downstream signalling cascades. In addition, matricellular macromolecules are deposited in the remodelling myocardium and regulate matrix assembly, while modulating signal transduction cascades and protease or growth factor activity. Cardiac fibroblasts can also sense mechanical stress through mechanosensitive receptors, ion channels and integrins, activating intracellular fibrogenic cascades that contribute to fibrosis in response to pressure overload. Although subpopulations of fibroblast-like cells may exert important protective actions in both reparative and interstitial/perivascular fibrosis, ultimately fibrotic changes perturb systolic and diastolic function, and may play an important role in the pathogenesis of arrhythmias. This review article discusses the molecular mechanisms involved in the pathogenesis of cardiac fibrosis in various myocardial diseases, including myocardial infarction, heart failure with reduced or preserved ejection fraction, genetic cardiomyopathies, and diabetic heart disease. Development of fibrosis-targeting therapies for patients with myocardial diseases will require not only understanding of the functional pluralism of cardiac fibroblasts and dissection of the molecular basis for fibrotic remodelling, but also appreciation of the pathophysiologic heterogeneity of fibrosis-associated myocardial disease.
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Affiliation(s)
- Nikolaos G Frangogiannis
- Department of Medicine (Cardiology), The Wilf Family Cardiovascular Research Institute, Albert Einstein College of Medicine, 1300 Morris Park Avenue Forchheimer G46B, Bronx, NY 10461, USA
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10
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Abstract
Significance: Fibrosis is a stereotypic, multicellular tissue response to diverse types of injuries that fundamentally result from a failure of cell/tissue regeneration. This complex tissue remodeling response disrupts cellular/matrix composition and homeostatic cell-cell interactions, leading to loss of normal tissue architecture and progressive loss of organ structure/function. Fibrosis is a common feature of chronic diseases that may affect the lung, kidney, liver, and heart. Recent Advances: There is emerging evidence to support a combination of genetic, environmental, and age-related risk factors contributing to susceptibility and/or progression of fibrosis in different organ systems. A core pathway in fibrogenesis involving these organs is the induction and activation of nicotinamide adenine dinucleotide phosphate oxidase (NOX) family enzymes. Critical Issues: We explore current pharmaceutical approaches to targeting NOX enzymes, including repurposing of currently U.S. Food and Drug Administration (FDA)-approved drugs. Specific inhibitors of various NOX homologs will aid establishing roles of NOXs in the various organ fibroses and potential efficacy to impede/halt disease progression. Future Directions: The discovery of novel and highly specific NOX inhibitors will provide opportunities to develop NOX inhibitors for treatment of fibrotic pathologies.
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Affiliation(s)
- Karen Bernard
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Victor J Thannickal
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Varasteh Z, Mohanta S, Robu S, Braeuer M, Li Y, Omidvari N, Topping G, Sun T, Nekolla SG, Richter A, Weber C, Habenicht A, Haberkorn UA, Weber WA. Molecular Imaging of Fibroblast Activity After Myocardial Infarction Using a 68Ga-Labeled Fibroblast Activation Protein Inhibitor, FAPI-04. J Nucl Med 2019; 60:1743-1749. [PMID: 31405922 DOI: 10.2967/jnumed.119.226993] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/29/2019] [Indexed: 11/16/2022] Open
Abstract
Heart failure remains a major source of late morbidity and mortality after myocardial infarction (MI). The temporospatial presence of activated fibroblasts in the injured myocardium predicts the quality of cardiac remodeling after MI. Therefore, monitoring of activated fibroblasts is of great interest for studying cardiac remodeling after MI. Fibroblast activation protein (FAP) expression is upregulated in activated fibroblasts. This study investigated the feasibility of imaging activated fibroblasts with a new 68Ga-labeled FAP inhibitor (68Ga-FAPI-04) for PET imaging of fibroblast activation in a preclinical model of MI. Methods: MI and sham-operated rats were scanned with 68Ga-FAPI-04 PET/CT (1, 3, 6, 14, 23, and 30 d after MI) and with 18F-FDG (3 d after MI). Dynamic 68Ga-FAPI-04 PET and blocking studies were performed on MI rats 7 d after coronary ligation. After in vivo scans, the animals were euthanized and their hearts harvested for ex vivo analyses. Cryosections were prepared for autoradiography, hematoxylin and eosin (H&E), and immunofluorescence staining. Results: 68Ga-FAPI-04 uptake in the injured myocardium peaked on day 6 after coronary ligation. The tracer accumulated intensely in the MI territory, as identified by decreased 18F-FDG uptake and confirmed by PET/MR and H&E staining. Autoradiography and H&E staining of cross-sections revealed that 68Ga-FAPI-04 accumulated mainly at the border zone of the infarcted myocardium. In contrast, there was only minimal uptake in the infarct of the blocked rats, comparable to the uptake in the remote noninfarcted myocardium (PET image-derived ratio of infarct uptake to remote uptake: 6 ± 2). Immunofluorescence staining confirmed the presence of FAP-positive myofibroblasts in the injured myocardium. Morphometric analysis of the whole-heart sections demonstrated 3- and 8-fold higher FAP-positive fibroblast density in the border zone than in the infarct center and remote area, respectively. Conclusion: 68Ga-FAPI-04 represents a promising radiotracer for in vivo imaging of post-MI fibroblast activation. Noninvasive imaging of activated fibroblasts may have significant diagnostic and prognostic value, which could aid clinical management of patients after MI.
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Affiliation(s)
- Zohreh Varasteh
- Department of Nuclear Medicine, Klinikum rechts der Isar der TUM, Munich, Germany
| | - Sarajo Mohanta
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-Universität, Munich, Germany.,German Centre for Cardiovascular Research, Munich Heart Alliance, Munich, Germany; and
| | - Stephanie Robu
- Department of Nuclear Medicine, Klinikum rechts der Isar der TUM, Munich, Germany
| | - Miriam Braeuer
- Department of Nuclear Medicine, Klinikum rechts der Isar der TUM, Munich, Germany
| | - Yuanfang Li
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-Universität, Munich, Germany
| | - Negar Omidvari
- Department of Nuclear Medicine, Klinikum rechts der Isar der TUM, Munich, Germany
| | - Geoffrey Topping
- Department of Nuclear Medicine, Klinikum rechts der Isar der TUM, Munich, Germany
| | - Ting Sun
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-Universität, Munich, Germany
| | - Stephan G Nekolla
- Department of Nuclear Medicine, Klinikum rechts der Isar der TUM, Munich, Germany
| | - Antonia Richter
- Department of Nuclear Medicine, Klinikum rechts der Isar der TUM, Munich, Germany
| | - Christian Weber
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-Universität, Munich, Germany.,German Centre for Cardiovascular Research, Munich Heart Alliance, Munich, Germany; and
| | - Andreas Habenicht
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-Universität, Munich, Germany
| | - Uwe A Haberkorn
- Department of Nuclear Medicine, University of Heidelberg, Heidelberg, Germany
| | - Wolfgang A Weber
- Department of Nuclear Medicine, Klinikum rechts der Isar der TUM, Munich, Germany
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Humeres C, Frangogiannis NG. Fibroblasts in the Infarcted, Remodeling, and Failing Heart. JACC Basic Transl Sci 2019; 4:449-467. [PMID: 31312768 PMCID: PMC6610002 DOI: 10.1016/j.jacbts.2019.02.006] [Citation(s) in RCA: 210] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 02/07/2023]
Abstract
Expansion and activation of fibroblasts following cardiac injury is important for repair but may also contribute to fibrosis, remodeling, and dysfunction. The authors discuss the dynamic alterations of fibroblasts in failing and remodeling myocardium. Emerging concepts suggest that fibroblasts are not unidimensional cells that act exclusively by secreting extracellular matrix proteins, thus promoting fibrosis and diastolic dysfunction. In addition to their involvement in extracellular matrix expansion, activated fibroblasts may also exert protective actions, preserving the cardiac extracellular matrix, transducing survival signals to cardiomyocytes, and regulating inflammation and angiogenesis. The functional diversity of cardiac fibroblasts may reflect their phenotypic heterogeneity.
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Key Words
- AT1, angiotensin type 1
- ECM, extracellular matrix
- FAK, focal adhesion kinase
- FGF, fibroblast growth factor
- IL, interleukin
- MAPK, mitogen-activated protein kinase
- MRTF, myocardin-related transcription factor
- PDGF, platelet-derived growth factor
- RNA, ribonucleic acid
- ROCK, Rho-associated coiled-coil containing kinase
- ROS, reactive oxygen species
- SMA, smooth muscle actin
- TGF, transforming growth factor
- TRP, transient receptor potential
- cytokines
- extracellular matrix
- fibroblast
- infarction
- lncRNA, long noncoding ribonucleic acid
- miRNA, micro–ribonucleic acid
- remodeling
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Affiliation(s)
- Claudio Humeres
- The Wilf Family Cardiovascular Research Institute, Department of Medicine (Cardiology), Albert Einstein College of Medicine, Bronx, New York
| | - Nikolaos G Frangogiannis
- The Wilf Family Cardiovascular Research Institute, Department of Medicine (Cardiology), Albert Einstein College of Medicine, Bronx, New York
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13
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Montesi SB, Désogère P, Fuchs BC, Caravan P. Molecular imaging of fibrosis: recent advances and future directions. J Clin Invest 2019; 129:24-33. [PMID: 30601139 DOI: 10.1172/jci122132] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Fibrosis, the progressive accumulation of connective tissue that occurs in response to injury, causes irreparable organ damage and may result in organ failure. The few available antifibrotic treatments modify the rate of fibrosis progression, but there are no available treatments to reverse established fibrosis. Thus, more effective therapies are urgently needed. Molecular imaging is a promising biomedical methodology that enables noninvasive visualization of cellular and subcellular processes. It provides a unique means to monitor and quantify dysregulated molecular fibrotic pathways in a noninvasive manner. Molecular imaging could be used for early detection, disease staging, and prognostication, as well as for assessing disease activity and treatment response. As fibrotic diseases are often molecularly heterogeneous, molecular imaging of a specific pathway could be used for patient stratification and cohort enrichment with the goal of improving clinical trial design and feasibility and increasing the ability to detect a definitive outcome for new therapies. Here we review currently available molecular imaging probes for detecting fibrosis and fibrogenesis, the active formation of new fibrous tissue, and their application to models of fibrosis across organ systems and fibrotic processes. We provide our opinion as to the potential roles of molecular imaging in human fibrotic diseases.
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Affiliation(s)
| | - Pauline Désogère
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Athinoula A. Martinos Center for Biomedical Imaging and.,Institute for Innovation in Imaging, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bryan C Fuchs
- Division of Surgical Oncology, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Caravan
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Athinoula A. Martinos Center for Biomedical Imaging and.,Institute for Innovation in Imaging, Massachusetts General Hospital, Boston, Massachusetts, USA
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Graziani F, Varone F, Crea F, Richeldi L. Treating heart failure with preserved ejection fraction: learning from pulmonary fibrosis. Eur J Heart Fail 2018; 20:1385-1391. [PMID: 30085383 DOI: 10.1002/ejhf.1286] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 06/25/2018] [Accepted: 07/02/2018] [Indexed: 12/16/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) has a poor prognosis, and an effective treatment is currently lacking. Increasing evidence suggests a prevailing pathogenic role of cardiac fibrosis in HFpEF, which generates the possibility of a mechanistic overlap with pulmonary fibrosis. Indeed, cardiac and pulmonary fibrosis share some characteristics and molecular pathways, such as that of transforming growth factor-β. If pulmonary and cardiac fibrosis share common pathways, we can hypothesize a beneficial effect of anti-fibrotic drugs used in idiopathic pulmonary fibrosis on cardiac outcomes. Of note, pirfenidone has been tested in animal models of cardiac fibrosis and was found to be effective in reducing ventricular remodelling. Yet, no results are hitherto available for humans. In this review article, we discuss the potential benefit of anti-fibrotic treatment in HFpEF. In particular, we propose to reappraise safety data collected in placebo-controlled trials of anti-fibrotic drugs in idiopathic pulmonary fibrosis, to explore the hypothesis that these might reduce cardiac fibrosis.
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Affiliation(s)
- Francesca Graziani
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Varone
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Richeldi
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Frangogiannis NG. Cardiac fibrosis: Cell biological mechanisms, molecular pathways and therapeutic opportunities. Mol Aspects Med 2018; 65:70-99. [PMID: 30056242 DOI: 10.1016/j.mam.2018.07.001] [Citation(s) in RCA: 505] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022]
Abstract
Cardiac fibrosis is a common pathophysiologic companion of most myocardial diseases, and is associated with systolic and diastolic dysfunction, arrhythmogenesis, and adverse outcome. Because the adult mammalian heart has negligible regenerative capacity, death of a large number of cardiomyocytes results in reparative fibrosis, a process that is critical for preservation of the structural integrity of the infarcted ventricle. On the other hand, pathophysiologic stimuli, such as pressure overload, volume overload, metabolic dysfunction, and aging may cause interstitial and perivascular fibrosis in the absence of infarction. Activated myofibroblasts are the main effector cells in cardiac fibrosis; their expansion following myocardial injury is primarily driven through activation of resident interstitial cell populations. Several other cell types, including cardiomyocytes, endothelial cells, pericytes, macrophages, lymphocytes and mast cells may contribute to the fibrotic process, by producing proteases that participate in matrix metabolism, by secreting fibrogenic mediators and matricellular proteins, or by exerting contact-dependent actions on fibroblast phenotype. The mechanisms of induction of fibrogenic signals are dependent on the type of primary myocardial injury. Activation of neurohumoral pathways stimulates fibroblasts both directly, and through effects on immune cell populations. Cytokines and growth factors, such as Tumor Necrosis Factor-α, Interleukin (IL)-1, IL-10, chemokines, members of the Transforming Growth Factor-β family, IL-11, and Platelet-Derived Growth Factors are secreted in the cardiac interstitium and play distinct roles in activating specific aspects of the fibrotic response. Secreted fibrogenic mediators and matricellular proteins bind to cell surface receptors in fibroblasts, such as cytokine receptors, integrins, syndecans and CD44, and transduce intracellular signaling cascades that regulate genes involved in synthesis, processing and metabolism of the extracellular matrix. Endogenous pathways involved in negative regulation of fibrosis are critical for cardiac repair and may protect the myocardium from excessive fibrogenic responses. Due to the reparative nature of many forms of cardiac fibrosis, targeting fibrotic remodeling following myocardial injury poses major challenges. Development of effective therapies will require careful dissection of the cell biological mechanisms, study of the functional consequences of fibrotic changes on the myocardium, and identification of heart failure patient subsets with overactive fibrotic responses.
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Affiliation(s)
- Nikolaos G Frangogiannis
- The Wilf Family Cardiovascular Research Institute, Department of Medicine (Cardiology), Albert Einstein College of Medicine, 1300 Morris Park Avenue, Forchheimer G46B, Bronx, NY, 10461, USA.
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de Haas HJ, Narula J. Playing slot to hitting the jackpot in molecular imaging: On probability of uncovering subcellular pathogenesis vs achieving clinical applicability. J Nucl Cardiol 2018; 25:1124-1127. [PMID: 28353214 DOI: 10.1007/s12350-017-0850-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 12/27/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Hans J de Haas
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jagat Narula
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, New York, NY, 10029, USA.
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Mechanisms of Fibroblast Activation in the Remodeling Myocardium. CURRENT PATHOBIOLOGY REPORTS 2017; 5:145-152. [PMID: 29057165 DOI: 10.1007/s40139-017-0132-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Activated fibroblasts are critically implicated in repair and remodeling of the injured heart. This manuscript discusses recent progress in the cell biology of fibroblasts in the infarcted and remodeling myocardium, highlighting advances in understanding the origin, function and mechanisms of activation of these cells. RECENT FINDINGS Following myocardial injury, fibroblasts undergo activation and myofibroblast transdifferentiation. Recently published studies have suggested that most activated myofibroblasts in the infarcted and pressure-overloaded hearts are derived from resident fibroblast populations. In the healing infarct, fibroblasts undergo dynamic phenotypic alterations in response to changes in the cytokine milieu and in the composition of the extracellular matrix. Fibroblasts do not simply serve as matrix-producing cells, but may also regulate inflammation, modulate cardiomyocyte survival and function, mediate angiogenesis, and contribute to phagocytosis of dead cells. SUMMARY In the injured myocardium, fibroblasts are derived predominantly from resident populations and serve a wide range of functions.
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Narula J, Dilsizian V, Chandrashekhar Y. Molecular Imaging: From Deep Pearl Diving to Enlightenment. JACC Cardiovasc Imaging 2015; 8:1472-1474. [PMID: 26699118 DOI: 10.1016/j.jcmg.2015.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jagat Narula
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York.
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Y Chandrashekhar
- University of Minnesota/VA Medical Center, Minneapolis, Minnesota
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Novel plasma and imaging biomarkers in heart failure with preserved ejection fraction. IJC HEART & VASCULATURE 2015; 9:55-62. [PMID: 28785707 PMCID: PMC5497340 DOI: 10.1016/j.ijcha.2015.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/25/2015] [Indexed: 12/17/2022]
Abstract
Existing diagnostic guidelines for heart failure with preserved ejection fraction (HFPEF) primarily comprise natriuretic peptides and echocardiographic assessment, highlighting the role of diastolic dysfunction. However, recent discoveries of novel plasma markers implicated in pathophysiology of heart failure and technological advances in imaging provide additional biomarkers which are potentially applicable to HFPEF. The evidence base for plasma extra-cellular matrix (ECM) peptides, galectin-3, ST2, GDF-15 and pentraxin-3 is reviewed. Furthermore, the capabilities of novel imaging techniques to assess existing parameters (e.g. left ventricular ejection fraction, systolic & diastolic function, chamber size) and additional derangements of the ECM, myocardial mechanics and ischaemia evaluation are addressed.
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Kiugel M, Dijkgraaf I, Kytö V, Helin S, Liljenbäck H, Saanijoki T, Yim CB, Oikonen V, Saukko P, Knuuti J, Roivainen A, Saraste A. Dimeric [(68)Ga]DOTA-RGD peptide targeting αvβ 3 integrin reveals extracellular matrix alterations after myocardial infarction. Mol Imaging Biol 2015; 16:793-801. [PMID: 24984688 DOI: 10.1007/s11307-014-0752-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE We evaluated a dimeric RGD-peptide, [(68)Ga]DOTA-E-[c(RGDfK)]2, for positron emission tomography (PET) imaging of myocardial integrin expression associated with extracellular matrix remodeling after myocardial infarction (MI) in rat. PROCEDURES Male Sprague-Dawley rats were studied at 7 days and 4 weeks after MI induced by permanent ligation of the left coronary artery and compared with sham-operated controls. RESULTS In vivo imaging revealed higher tracer uptake in the infarcted area than in the remote non-infarcted myocardium of the same rats both at 7 days (MI/remote ratio, 2.25 ± 0.24) and 4 weeks (MI/remote ratio, 2.13 ± 0.37) post-MI. Compared with sham-operated rats, tracer uptake was higher also in the remote, non-infarcted myocardium of MI rats both at 7 days and 4 weeks where it coincided with an increased interstitial fibrosis. Standardized uptake values correlated well with the results of tracer kinetic modeling. Autoradiography confirmed the imaging results showing 5.1 times higher tracer uptake in the infarcted than remote area. Tracer uptake correlated with the amount of β3 integrin subunits in the infarcted area. CONCLUSIONS Our results show that integrin-targeting [(68)Ga]DOTA-E-[c(RGDfK)]2 is a potential tracer for monitoring of myocardial extracellular matrix remodeling after MI using PET.
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Affiliation(s)
- Max Kiugel
- Turku PET Centre, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
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Du W, Tao H, Zhao S, He ZX, Li Z. Translational applications of molecular imaging in cardiovascular disease and stem cell therapy. Biochimie 2015; 116:43-51. [PMID: 26134715 DOI: 10.1016/j.biochi.2015.06.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 06/25/2015] [Indexed: 12/21/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of mortality and morbidity worldwide. Molecular imaging techniques provide valuable information at cellular and molecular level, as opposed to anatomical and structural layers acquired from traditional imaging modalities. More specifically, molecular imaging employs imaging probes which interact with specific molecular targets and therefore makes it possible to visualize biological processes in vivo. Molecular imaging technology is now progressing towards preclinical and clinical application that gives an integral and comprehensive guidance for the investigation of cardiovascular disease. In addition, cardiac stem cell therapy holds great promise for clinical translation. Undoubtedly, combining stem cell therapy with molecular imaging technology will bring a broad prospect for the study and treatment of cardiac disease. This review will focus on the progresses of molecular imaging strategies in cardiovascular disease and cardiac stem cell therapy. Furthermore, the perspective on the future role of molecular imaging in clinical translation and potential strategies in defining safety and efficacy of cardiac stem cell therapies will be discussed.
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Affiliation(s)
- Wei Du
- Collaborative Innovation Center for Biotherapy, Nankai University School of Medicine, Tianjin, China; Tianjin Key Laboratory of Tumor Microenvironment and Neurovascular Regulation, Nankai University School of Medicine, Tianjin, China; The Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin, China
| | - Hongyan Tao
- Collaborative Innovation Center for Biotherapy, Nankai University School of Medicine, Tianjin, China; Tianjin Key Laboratory of Tumor Microenvironment and Neurovascular Regulation, Nankai University School of Medicine, Tianjin, China
| | - Shihua Zhao
- Department of Radiology, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Zuo-Xiang He
- Department of Nuclear Imaging, Fuwai Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China.
| | - Zongjin Li
- Collaborative Innovation Center for Biotherapy, Nankai University School of Medicine, Tianjin, China; Tianjin Key Laboratory of Tumor Microenvironment and Neurovascular Regulation, Nankai University School of Medicine, Tianjin, China; The Key Laboratory of Bioactive Materials, Ministry of Education, College of Life Sciences, Nankai University, Tianjin, China.
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Labeling galectin-3 for the assessment of myocardial infarction in rats. EJNMMI Res 2014; 4:75. [PMID: 26116131 PMCID: PMC4452687 DOI: 10.1186/s13550-014-0075-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 12/01/2014] [Indexed: 01/01/2023] Open
Abstract
Background Galectin-3 is a ß-galactoside-binding lectin expressed in most of tissues in normal conditions and overexpressed in myocardium from early stages of heart failure (HF). It is an established biomarker associated with extracellular matrix (ECM) turnover during myocardial remodeling. The aim of this study is to test the ability of 123I-galectin-3 (IG3) to assess cardiac remodeling in a model of myocardial infarction (MI) using imaging techniques. Methods Recombinant galectin-3 was labeled with iodine-123 and in vitro binding assays were conducted to test 123I-galectin-3 ability to bind to ECM targets. For in vivo studies, a rat model of induced-MI was used. Animals were subjected to magnetic resonance and micro-SPETC/micro-CT imaging two (2 W-MI) or four (4 W-MI) weeks after MI. Sham rats were used as controls. Pharmacokinetic, biodistribution, and histological studies were also performed after intravenous administration of IG3. Results In vitro studies revealed that IG3 shows higher binding affinity (measured as counts per minute, cpm) (p < 0.05) to laminin (2.45 ± 1.67 cpm), fibronectin (4.72 ± 1.95 cpm), and collagen type I (1.88 ± 0.53 cpm) compared to bovine serum albumin (BSA) (0.88 ± 0.31 cpm). Myocardial quantitative IG3 uptake (%ID/g) was higher (p < 0.01) in the infarct of 2 W-MI rats (0.15 ± 0.04%) compared to control (0.05 ± 0.03%). IG3 infarct uptake correlates with the extent of scar (rs = 1, p = 0.017). Total collagen deposition in the infarct (percentage area) was higher (p < 0.0001) at 2 W-MI (24.2 ± 5.1%) and 4 W-MI (30.4 ± 7.5%) compared to control (1.9 ± 1.1%). However, thick collagen content in the infarct (square micrometer stained) was higher at 4 W-MI (20.5 ± 11.2 μm2) compared to control (4.7 ± 2.0 μm2, p < 0.001) and 2 W-MI (10.6 ± 5.1 μm2, p < 0.05). Conclusions This study shows, although preliminary, enough data to consider IG3 as a potential contrast agent for imaging of myocardial interstitial changes in rats after MI. Labeling strategies need to be sought to improve in vivo IG3 imaging, and if proven, galectin-3 might be used as an imaging tool for the assessment and treatment of MI patients.
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van den Berg TNA, Deinum J, Bilos A, Donders ART, Rongen GA, Riksen NP. The effect of eplerenone on adenosine formation in humans in vivo: a double-blinded randomised controlled study. PLoS One 2014; 9:e111248. [PMID: 25356826 PMCID: PMC4214740 DOI: 10.1371/journal.pone.0111248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 09/19/2014] [Indexed: 11/19/2022] Open
Abstract
Background It has been suggested that mineralocorticoid receptor antagonists have direct cardioprotective properties, because these drugs reduce mortality in patients with heart failure. In murine models of myocardial infarction, mineralocorticoid receptor antagonists reduce infarct size. Using gene deletion and pharmacological approaches, it has been shown that extracellular formation of the endogenous nucleoside adenosine is crucial for this protective effect. We now aim to translate this finding to humans, by investigating the effects of the selective mineralocorticoid receptor antagonist eplerenone on the vasodilator effect of the adenosine uptake inhibitor dipyridamole, which is a well-validated surrogate marker for extracellular adenosine formation. Methods and Results In a randomised, double-blinded, placebo-controlled, cross-over study we measured the forearm blood flow response to the intrabrachial administration of dipyridamole in 14 healthy male subjects before and after treatment with placebo or eplerenone (50 mg bid for 8 days). The forearm blood flow during administration of dipyridamole (10, 30 and 100 µg·min−1·dl−1) was 1.63 (0.60), 2.13 (1.51) and 2.71 (1.32) ml·dl−1·min−1 during placebo use, versus 2.00 (1.45), 2.68 (1.87) and 3.22 (1.94) ml·dl−1·min−1 during eplerenone treatment (median (interquartile range); P = 0.51). Concomitant administration of the adenosine receptor antagonist caffeine attenuated dipyridamole-induced vasodilation to a similar extent in both groups. The forearm blood flow response to forearm ischemia, as a stimulus for increased formation of adenosine, was similar during both conditions. Conclusion In a dosage of 50 mg bid, eplerenone does not augment extracellular adenosine formation in healthy human subjects. Therefore, it is unlikely that an increased extracellular adenosine formation contributes to the cardioprotective effect of mineralocorticoid receptor antagonists. Trial Registration ClinicalTrials.gov, NCT01837108
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Affiliation(s)
- T. N. A. van den Berg
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Albert Bilos
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - A. Rogier T. Donders
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gerard A. Rongen
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Niels P. Riksen
- Department of Pharmacology-Toxicology, Radboud University Medical Center, Nijmegen, the Netherlands
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
- * E-mail:
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Sun Y, Zeng Y, Zhu Y, Feng F, Xu W, Wu C, Xing B, Zhang W, Wu P, Cui L, Wang R, Li F, Chen X, Zhu Z. Application of (68)Ga-PRGD2 PET/CT for αvβ3-integrin imaging of myocardial infarction and stroke. Theranostics 2014; 4:778-86. [PMID: 24955139 PMCID: PMC4063976 DOI: 10.7150/thno.8809] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/30/2014] [Indexed: 01/14/2023] Open
Abstract
Purpose: Ischemic vascular diseases, including myocardial infarction (MI) and stroke, have been found to be associated with elevated expression of αvβ3-integrin, which provides a promising target for semi-quantitative monitoring of the disease. For the first time, we employed 68Ga-S-2-(isothiocyanatobenzyl)-1,4,7-triazacyclononane-1,4,7-triacetic acid-PEG3-E[c(RGDyK)]2 (68Ga-PRGD2) to evaluate the αvβ3-integrin-related repair in post-MI and post-stroke patients via positron emission tomography/computed tomography (PET/CT). Methods: With Institutional Review Board approval, 23 MI patients (3 days-2 years post-MI) and 16 stroke patients (3 days-13 years post-stroke) were recruited. After giving informed consent, each patient underwent a cardiac or brain PET/CT scan 30 min after the intravenous injection of 68Ga-PRGD2 in a dose of approximately 1.85 MBq (0.05 mCi) per kilogram body weight. Two stroke patients underwent repeat scans three months after the event. Results: Patchy 68Ga-PRGD2 uptake occurred in or around the ischemic regions in 20/23 MI patients and punctate multifocal uptake occurred in 8/16 stroke patients. The peak standardized uptake values (pSUVs) in MI were 1.94 ± 0.48 (mean ± SD; range, 0.62-2.69), significantly higher than those in stroke (mean ± SD, 0.46 ± 0.29; range, 0.15-0.93; P < 0.001). Higher 68Ga-PRGD2 uptake was observed in the patients 1-3 weeks after the initial onset of the MI/stroke event. The uptake levels were significantly correlated with the diameter of the diseases (r = 0.748, P = 0.001 for MI and r = 0.835, P = 0.003 for stroke). Smaller or older lesions displayed no uptake. Conclusions: 68Ga-PRGD2 uptake was observed around the ischemic region in both MI and stroke patients, which was correlated with the disease phase and severity. The different image patterns and uptake levels in MI and stroke patients warrant further investigations.
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Abstract
In almost all cardiac diseases, an increase in extracellular matrix (ECM) deposition or fibrosis occurs, mostly consisting of collagen I. Whereas replacement fibrosis follows cardiomyocyte loss in myocardial infarction, reactive fibrosis is triggered by myocardial stress or inflammatory mediators and often results in ventricular stiffening, functional deterioration, and development of heart failure. Given the importance of ECM deposition in cardiac disease, ECM imaging could be a valuable clinical tool. Molecular imaging of ECM may help understand pathology, evaluate impact of novel therapy, and may eventually find a role in predicting the extent of ECM expansion and development of personalized treatment. In the current review, we provide an overview of ECM imaging including the assessment of ECM volume and molecular targeting of key players involved in ECM deposition and degradation. The targets comprise myofibroblasts, intracardiac renin-angiotensin axis, matrix metalloproteinases, and matricellular proteins.
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Affiliation(s)
- Hans J de Haas
- From Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (H.J.d.H., V.F., J.N.); Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, the Netherlands (H.J.d.H.); Centre for Inherited Cardiovascular Diseases, IRCCS Policlinico San Matteo, Pavia, Italy (E.A.); Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain (V.F.); and Departments of Medicine and Radiology, University of Virginia Health System, Charlottesville, VA (C.M.K.)
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Capitanio S, Marini C, Bauckneht M, Sambuceti G. Nuclear Cardiology in Heart Failure. CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-013-9256-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
PURPOSE OF REVIEW Myocardial fibrosis is a common feature of many cardiomyopathies, including hypertrophic cardiomyopathy. Myocardial fibrosis has been shown to be reversible and treatable with timely intervention. Although early detection and assessment of fibrosis is crucial, adequate diagnostics are still in development. Recent studies have shown progress on noninvasive imaging methods of fibrosis using cardiovascular magnetic resonance (CMR) and nuclear imaging modalities. RECENT FINDINGS T1 mapping and extracellular volume mapping (ECV) combined with CMR imaging are cutting edge methods that have the potential to assess interstitial myocardial fibrosis. Recent findings show that ECV measurement can be correlated to the extent of diffuse fibrosis. Comparatively, molecular imaging targets specific biomarkers in the fibrosis formation pathway and provides enhanced sensitivity for imaging early disease. Biomarkers include molecules involved in angiogenesis, ventricular remodeling, and fibrotic tissue formation, whereas collagen targeted agents can directly identify fibrotic tissue in the heart. SUMMARY This review introduces novel methods of fibrosis imaging that utilize properties of extracellular matrix and its biomarkers. Changes in characteristics and cellular biomarkers of the extracellular space can provide significant information regarding fibrosis formation and its role in cardiomyopathy. Ultimately, these findings may improve detection and monitoring of disease and improve efficiency and effectiveness of the treatment.
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Abstract
Despite declines in heart failure morbidity and mortality with current therapies, rehospitalization rates remain distressingly high, substantially affecting individuals, society, and the economy. As a result, the need for new therapeutic advances and novel medical devices is urgent. Disease-related left ventricular remodeling is a complex process involving cardiac myocyte growth and death, vascular rarefaction, fibrosis, inflammation, and electrophysiological remodeling. Because these events are highly interrelated, targeting a single molecule or process may not be sufficient. Here, we review molecular and cellular mechanisms governing pathological ventricular remodeling.
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Bengel FM, George RT, Schuleri KH, Lardo AC, Wollert KC. Image-guided therapies for myocardial repair: concepts and practical implementation. Eur Heart J Cardiovasc Imaging 2013; 14:741-51. [PMID: 23720377 DOI: 10.1093/ehjci/jet038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Cell- and molecule-based therapeutic strategies to support wound healing and regeneration after myocardial infarction (MI) are under development. These emerging therapies aim at sustained preservation of ventricular function by enhancing tissue repair after myocardial ischaemia and reperfusion. Such therapies will benefit from guidance with regard to timing, regional targeting, suitable candidate selection, and effectiveness monitoring. Such guidance is effectively obtained by non-invasive tomographic imaging. Infarct size, tissue characteristics, muscle mass, and chamber geometry can be determined by magnetic resonance imaging and computed tomography. Radionuclide imaging can be used for the tracking of therapeutic agents and for the interrogation of molecular mechanisms such as inflammation, angiogenesis, and extracellular matrix activation. This review article portrays the hypothesis that an integrated approach with an early implementation of structural and molecular tomographic imaging in the development of novel therapies will provide a framework for achieving the goal of improved tissue repair after MI.
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Affiliation(s)
- Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany.
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Gray GA, White CI, Thomson A, Kozak A, Moran C, Jansen MA. Imaging the healing murine myocardial infarct in vivo: ultrasound, magnetic resonance imaging and fluorescence molecular tomography. Exp Physiol 2012; 98:606-13. [PMID: 23064510 DOI: 10.1113/expphysiol.2012.064741] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Improved understanding of the processes involved in infarct healing is required for identification of novel therapeutic targets to limit infarct expansion and consequent long-term ventricular remodelling after myocardial infarction. Infarct healing can be modelled effectively in murine models of coronary artery ligation. While imaging the murine heart is challenging due to its size and high rate of contraction, advances in preclinical imaging now permit accurate assessment of myocardial structure and function in vivo after myocardial infarction. Furthermore, rapid development of a range of molecular probes for use in a number of imaging modalities allows more detailed in vivo analysis of processes, including inflammation, fibrosis and angiogenesis. Here we consider the practical application of in vivo imaging by magnetic resonance imaging, ultrasound and fluorescence molecular tomography for assessment of infarct healing in the mouse.
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Affiliation(s)
- Gillian A Gray
- British Heart Foundation/University Centre for Cardiovascular Science, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK.
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de Haas HJ, van den Borne SW, Boersma HH, Slart RH, Fuster V, Narula J. Evolving role of molecular imaging for new understanding: targeting myofibroblasts to predict remodeling. Ann N Y Acad Sci 2012; 1254:33-41. [DOI: 10.1111/j.1749-6632.2012.06476.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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A randomized study of the beneficial effects of aldosterone antagonism on LV function, structure, and fibrosis markers in metabolic syndrome. JACC Cardiovasc Imaging 2012; 4:1239-49. [PMID: 22172779 DOI: 10.1016/j.jcmg.2011.08.014] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 08/31/2011] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The purpose of this study was to identify the effects of spironolactone on left ventricular (LV) structure and function, and serological fibrosis markers in patients with metabolic syndrome (MS) taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. BACKGROUND Myocardial fibrosis may be an important contributor to myocardial impairment in MS, and aldosterone antagonism may reduce fibrosis. METHODS Eighty patients (age 59 ± 11 years) with MS, already being treated with angiotensin II inhibition, were randomized to spironolactone 25 mg/day or placebo for 6 months. Each patient underwent baseline and follow-up conventional echocardiography and color tissue Doppler imaging. Raw data files were used to measure calibrated integrated backscatter and to calculate radial and longitudinal strain. Blood was obtained at baseline and follow-up to measure fibrosis markers (procollagen type III amino-terminal propeptide and procollagen type I carboxy-terminal propeptide [PICP]). RESULTS The spironolactone group showed significant improvement of LV function, myocardial reflectivity, and LV hypertrophy, with a parallel decrease in levels of PICP and procollagen type III amino-terminal propeptide. No analogous changes were seen in the placebo group. Baseline strain (β = 0.47, p < 0.0001), spironolactone therapy (β = -0.38, p < 0.0001), and change in PICP level (β = -0.19, p < 0.03) were independently associated with LV systolic function improvement (increase in strain). Correlates of LV diastolic function improvement (increase in early diastolic mitral annular velocity) were baseline early diastolic mitral annular velocity (β = 0.47, p < 0.0001), spironolactone therapy (β = -0.21, p < 0.03), change in PICP level (β = -0.23, p < 0.02), and age (β = 0.22, p < 0.04). Favorable effects of spironolactone on cardiac function were not demonstrated in patients with less fibrosis (the lower baseline PICP tertile) or preserved function (the upper baseline strain tertile). CONCLUSIONS Addition of spironolactone to standard angiotensin II inhibition improved myocardial abnormalities and decreased fibrotic markers in MS. The magnitude of benefit on cardiac performance is determined mainly by baseline LV dysfunction and collagen turnover as well its response to intervention.
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Dilsizian V, Zynda TK, Petrov A, Ohshima S, Tahara N, Haider N, Donohue A, Aras O, Femia FJ, Hillier SM, Joyal JL, Wong ND, Coleman T, Babich JW, Narula J. Molecular Imaging of Human ACE-1 Expression in Transgenic Rats. JACC Cardiovasc Imaging 2012; 5:409-18. [DOI: 10.1016/j.jcmg.2011.10.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 10/03/2011] [Indexed: 11/30/2022]
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Pitt B, Zannad F. The detection of myocardial fibrosis: an opportunity to reduce cardiovascular risk in patients with diabetes mellitus? Circ Cardiovasc Imaging 2012; 5:9-11. [PMID: 22253334 DOI: 10.1161/circimaging.111.971143] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Barallobre-Barreiro J, Didangelos A, Schoendube FA, Drozdov I, Yin X, Fernández-Caggiano M, Willeit P, Puntmann VO, Aldama-López G, Shah AM, Doménech N, Mayr M. Proteomics Analysis of Cardiac Extracellular Matrix Remodeling in a Porcine Model of Ischemia/Reperfusion Injury. Circulation 2012; 125:789-802. [DOI: 10.1161/circulationaha.111.056952] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
After myocardial ischemia, extracellular matrix (ECM) deposition occurs at the site of the focal injury and at the border region.
Methods and Results—
We have applied a novel proteomic method for the analysis of ECM in cardiovascular tissues to a porcine model of ischemia/reperfusion injury. ECM proteins were sequentially extracted and identified by liquid chromatography tandem mass spectrometry. For the first time, ECM proteins such as cartilage intermediate layer protein 1, matrilin-4, extracellular adipocyte enhancer binding protein 1, collagen α-1(XIV), and several members of the small leucine-rich proteoglycan family, including asporin and prolargin, were shown to contribute to cardiac remodeling. A comparison in 2 distinct cardiac regions (the focal injury in the left ventricle and the border region close to the occluded coronary artery) revealed a discordant regulation of protein and mRNA levels; although gene expression for selected ECM proteins was similar in both regions, the corresponding protein levels were much higher in the focal lesion. Further analysis based on >100 ECM proteins delineated a signature of early- and late-stage cardiac remodeling with transforming growth factor-β1 signaling at the center of the interaction network. Finally, novel cardiac ECM proteins identified by proteomics were validated in human left ventricular tissue acquired from ischemic cardiomyopathy patients at cardiac transplantation.
Conclusion—
Our findings reveal a biosignature of early- and late-stage ECM remodeling after myocardial ischemia/reperfusion injury, which may have clinical utility as a prognostic marker and modifiable target for drug discovery.
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Affiliation(s)
- Javier Barallobre-Barreiro
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Athanasios Didangelos
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Friedrich A. Schoendube
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Ignat Drozdov
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Xiaoke Yin
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Mariana Fernández-Caggiano
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Peter Willeit
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Valentina O. Puntmann
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Guillermo Aldama-López
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Ajay M. Shah
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Nieves Doménech
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
| | - Manuel Mayr
- From the Research Unit/INIBIC CHUAC (J.B.-B., M.F.-C., N.D.) and CHUAC Interventional Cardiology Unit (G.A.-L.), A Coruña, Spain; Cardiovascular Division, King's British Heart Foundation Centre (A.D., I.D., X.Y., V.O.P., A.M.S., M.M.) and Centre for Bioinformatics, School of Physical Sciences and Engineering (I.D.), King's College London, London, UK; Faculty of Medicine, University of Goettingen, Goettingen, Germany (F.A.S.); and Department of Public Health and Primary Care, University of Cambridge,
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Sado DM, Flett AS, Moon JC. Novel imaging techniques for diffuse myocardial fibrosis. Future Cardiol 2012; 7:643-50. [PMID: 21929344 DOI: 10.2217/fca.11.45] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Diffuse myocardial fibrosis (DMF) is an important marker in many cardiac diseases, but its utility has been limited by the need for biopsy for its assessment. An accurate noninvasive method for DMF assessment could transform cardiology. This review explores the basic biology of DMF and then discusses the ability of various cardiac imaging modalities to evaluate this variable, speculating on how this area of research may develop over the next few years.
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Affiliation(s)
- Daniel M Sado
- Department of Inherited Cardiac Disease, The Heart Hospital, 16-18 Westmoreland Street, London, W1G 8PH, UK
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Buxton DB, Antman M, Danthi N, Dilsizian V, Fayad ZA, Garcia MJ, Jaff MR, Klimas M, Libby P, Nahrendorf M, Sinusas AJ, Wickline SA, Wu JC, Bonow RO, Weissleder R. Report of the National Heart, Lung, and Blood Institute working group on the translation of cardiovascular molecular imaging. Circulation 2011; 123:2157-63. [PMID: 21576680 DOI: 10.1161/circulationaha.110.000943] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Denis B Buxton
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute/National Institutes of Health, 6701 Rockledge Dr, Room 8216, Bethesda, MD 20892, USA.
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Dash R, Chung J, Ikeno F, Hahn-Windgassen A, Matsuura Y, Bennett MV, Lyons JK, Teramoto T, Robbins RC, McConnell MV, Yeung AC, Brinton TJ, Harnish PP, Yang PC. Dual manganese-enhanced and delayed gadolinium-enhanced MRI detects myocardial border zone injury in a pig ischemia-reperfusion model. Circ Cardiovasc Imaging 2011; 4:574-82. [PMID: 21719779 DOI: 10.1161/circimaging.110.960591] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gadolinium (Gd)-based delayed-enhancement MRI (DEMRI) identifies nonviable myocardium but is nonspecific and may overestimate nonviable territory. Manganese (Mn(2+))-enhanced MRI (MEMRI) denotes specific Mn(2+) uptake into viable cardiomyocytes. We performed a dual-contrast myocardial assessment in a porcine ischemia-reperfusion (IR) model to test the hypothesis that combined DEMRI and MEMRI identifies viable infarct border zone (BZ) myocardium in vivo. METHODS AND RESULTS Sixty-minute left anterior descending coronary artery IR injury was induced in 13 adult swine. Twenty-one days post-IR, 3-T cardiac MRI was performed. MEMRI was obtained after injection of 0.7 mL/kg Mn(2+) contrast agent. DEMRI was then acquired after injection of 0.2 mmol/kg Gd. Left ventricular (LV) mass, infarct, and function were analyzed. Subtraction of MEMRI defect from DEMRI signal identified injured BZ myocardium. Explanted hearts were analyzed by 2,3,5-triphenyltetrazolium chloride stain and tissue electron microscopy to compare infarct, BZ, and remote myocardium. Average LV ejection fraction was reduced (30±7%). MEMRI and DEMRI infarct volumes correlated with 2,3,5-triphenyltetrazolium chloride stain analysis (MEMRI, r=0.78; DEMRI, r=0.75; P<0.004). MEMRI infarct volume percentage was significantly lower than that of DEMRI (14±4% versus 23±4%; P<0.05). BZ MEMRI signal-to-noise ratio (SNR) was intermediate to remote and core infarct SNR (7.5±2.8 versus 13.2±3.4 and 2.9±1.6; P<0.0001), and DEMRI BZ SNR tended to be intermediate to remote and core infarct SNR (8.4±5.4 versus 3.3±0.6 and 14.3±6.6; P>0.05). Tissue electron microscopy analysis exhibited preserved cell structure in BZ cardiomyocytes despite transmural DEMRI enhancement. CONCLUSIONS The dual-contrast MEMRI-DEMRI detects BZ viability within DEMRI infarct zones. This approach may identify injured, at-risk myocardium in ischemic cardiomyopathy.
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Affiliation(s)
- Rajesh Dash
- Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, CA 94305-5233, USA.
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Affiliation(s)
- Ian Y Chen
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305-5111, USA
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Osborn EA, Jaffer FA. The year in molecular imaging. JACC Cardiovasc Imaging 2011; 3:1181-95. [PMID: 21071007 DOI: 10.1016/j.jcmg.2010.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 08/26/2010] [Accepted: 09/07/2010] [Indexed: 11/26/2022]
Abstract
Molecular imaging aims to enable personalized medicine via imaging-specific molecular and cellular targets that are relevant to the diagnosis and treatment of disease. By providing in vivo readouts of biological detail, molecular imaging complements traditional anatomical imaging modalities to allow: 1) visualization of important disease-modulating molecules and cells in vivo; 2) serial investigations to image evolutionary changes in disease attributes; and 3) evaluation of the in vivo molecular effects of biotherapeutics. The added information garnered by molecular imaging can improve risk assessment and prognosticative studies, this is of particular benefit in the management of cardiovascular disease (CVD).
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Affiliation(s)
- Eric A Osborn
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Massare J, Berry JM, Luo X, Rob F, Johnstone JL, Shelton JM, Bassel-Duby R, Hill JA, Naseem RH. Diminished cardiac fibrosis in heart failure is associated with altered ventricular arrhythmia phenotype. J Cardiovasc Electrophysiol 2011; 21:1031-7. [PMID: 20233273 DOI: 10.1111/j.1540-8167.2010.01736.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We sought to define the role of interstitial fibrosis in the proarrhythmic phenotype of failing ventricular myocardium. BACKGROUND Multiple cellular events that occur during pathological remodeling of the failing ventricle are implicated in the genesis of ventricular tachycardia (VT), including interstitial fibrosis. Recent studies suggest that ventricular fibrosis is reversible, and current anti-remodeling therapies attenuate ventricular fibrosis. However, the role of interstitial fibrosis in the proarrhythmic phenotype of failing ventricular myocardium is currently not well defined. METHODS Class II histone deacetylases (HDACs) have been implicated in promoting collagen biosynthesis. As these enzymes are inhibited by protein kinase D1 (PKD1), we studied mice with cardiomyocyte-specific transgenic over-expression of a constitutively active mutant of PKD1 (caPKD). caPKD mice were compared with animals in which cardiomyopathy was induced by severe thoracic aortic banding (sTAB). Hearts were analyzed by echocardiographic and electrocardiographic means. Interstitial fibrosis was assessed by histology and quantified biochemically. Ventricular arrhythmias were induced by closed-chest, intracardiac pacing. RESULTS Similar degrees of hypertrophic growth, systolic dysfunction and mortality were observed in the two models. In sTAB mice, robust ventricular fibrosis was readily detected, but myocardial collagen content was significantly reduced in caPKD mice. As expected, VT was readily inducible by programmed stimulation in sTAB mice and VT was less inducible in caPKD mice. Surprisingly, episodes of VT manifested longer cycle lengths and longer duration in caPKD mice. CONCLUSION Attenuated ventricular fibrosis is associated with reduced VT inducibility, increased VT duration, and significantly longer arrhythmia cycle length.
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Affiliation(s)
- Jorge Massare
- Department of Internal Medicine (Cardiology), University of Texas Southwestern Medical Center, Dallas, Texas 75390-8573, USA
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Abstract
Heart failure is an important cause of morbidity and mortality in individuals of all ages. The many-faceted nature of the clinical heart failure syndrome has historically frustrated attempts to develop an overarching explanative theory. However, much useful information has been gained by basic and clinical investigation, even though a comprehensive understanding of heart failure has been elusive. Heart failure is a growing problem, in both adult and pediatric populations, for which standard medical therapy, as of 2010, can have positive effects, but these are usually limited and progressively diminish with time in most patients. If we want curative or near-curative therapy that will return patients to a normal state of health at a feasible cost, much better diagnostic and therapeutic technologies need to be developed. This review addresses the vexing group of heart failure etiologies that include cardiomyopathies and other ventricular dysfunctions of various types, for which current therapy is only modestly effective. Although there are many unique aspects to heart failure in patients with pediatric and congenital heart disease, many of the innovative approaches that are being developed for the care of adults with heart failure will be applicable to heart failure in childhood.
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Affiliation(s)
- Daniel J Penny
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA
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Verjans J, Wolters S, Laufer W, Schellings M, Lax M, Lovhaug D, Boersma H, Kemerink G, Schalla S, Gordon P, Teule J, Narula J, Hofstra L. Early molecular imaging of interstitial changes in patients after myocardial infarction: comparison with delayed contrast-enhanced magnetic resonance imaging. J Nucl Cardiol 2010; 17:1065-72. [PMID: 20658273 PMCID: PMC2990010 DOI: 10.1007/s12350-010-9268-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Accepted: 06/15/2010] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The clinical feasibility of noninvasive imaging of interstitial alterations after myocardial infarction (MI) was assessed using a technetium-99m-labeled RGD imaging peptide (RIP). In experimental studies, RIP has been shown to target integrins associated with collagen-producing myofibroblasts (MFB). METHODS AND RESULTS Ten patients underwent myocardial perfusion imaging (MPI) within the first week after MI. At 3 and 8 weeks after MI, RIP was administered intravenously and SPECT images acquired for interstitial imaging. RIP imaging was compared to initial MPI and to the extent of scar formation defined by late gadolinium-enhanced (LGE) cardiac magnetic resonance (CMR) imaging 1 year after MI. RIP uptake was observed in 7 of the 10 patients at both 3 and 8 weeks. Although, RIP uptake corresponded to areas of perfusion defects, it usually extended beyond the infarct zone to a variable extent; 2 of 7 patients showed tracer uptake throughout myocardium. In all positive cases, RIP uptake was similar to the extent of scar observed at 1 year by LGE-CMR imaging. CONCLUSION This study demonstrates that RGD-based imaging early after MI may predict the eventual extent of scar formation, which often exceeds initial MPI deficit but colocalizes with LGE in CMR imaging performed subsequently.
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Affiliation(s)
- Johan Verjans
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Sander Wolters
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Ward Laufer
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Mark Schellings
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | | | | | - Hendrikus Boersma
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Gerrit Kemerink
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Simon Schalla
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | | | - Jaap Teule
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Jagat Narula
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- University of California, Irvine, Irvine, CA USA
| | - Leonard Hofstra
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
- University of California, Irvine, Irvine, CA USA
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Dimas V, Ayers C, Daniels J, Joglar JA, Hill JA, Naseem RH. Spironolactone therapy is associated with reduced ventricular tachycardia rate in patients with cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 34:309-14. [PMID: 20946289 DOI: 10.1111/j.1540-8159.2010.02888.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Multiple pharmacological therapies currently in prevalent clinical use for cardiac diseases have antifibrotic properties. Spironolactone, a potent antifibrotic agent, is currently used for advanced heart failure. Therapies such as HMG-CoA reductase inhibitors (statins) and angiotensin-converting enzyme inhibitors (ACEi) also have antifibrotic properties. However, the effect of these medications on the ventricular arrhythmia phenotype is currently unknown. Therefore, we set out to define the ventricular arrhythmia rates in patients actively treated with such therapies. METHODS AND RESULTS We retrospectively evaluated the ventricular tachycardia (VT) rates in patients with structural heart disease actively treated with therapies with antifibrotic properties. VT rates were significantly diminished in patients treated with spironolactone (158 ± 26 beats per minute [bpm], n = 21) compared to patients on no medications (205 ± 22 bpm, n = 13) or those who were on similar heart-failure therapies but not on spironolactone (186 ± 32 bpm, n = 82). In addition, we observed that VT rates showed a significant trend toward lower rates in patients receiving either statins or ACEi, compared to patients on no medical therapy. In multivariate analysis, spironolactone therapy was identified as the single most significant variable for reduced VT rate. CONCLUSION Use of spironolactone in patients with heart failure is associated with reduced VT rate. Similar but less-significant reductions in VT rates were observed with use of other pharmacological agents with antifibrotic properties, such as statins and ACEi. Our findings, at least in part, could account for reduction in sudden cardiac death rates documented with use of these therapies.
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Affiliation(s)
- Vassilis Dimas
- Department of Internal Medicine (Cardiology), University of Texas Southwestern Medical Center, Dallas, Texas 75390-8573, USA
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Jellis C, Martin J, Narula J, Marwick TH. Assessment of Nonischemic Myocardial Fibrosis. J Am Coll Cardiol 2010; 56:89-97. [DOI: 10.1016/j.jacc.2010.02.047] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 01/19/2010] [Accepted: 02/01/2010] [Indexed: 01/19/2023]
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Muzard J, Sarda-Mantel L, Loyau S, Meulemans A, Louedec L, Bantsimba-Malanda C, Hervatin F, Marchal-Somme J, Michel JB, Le Guludec D, Billiald P, Jandrot-Perrus M. Non-invasive molecular imaging of fibrosis using a collagen-targeted peptidomimetic of the platelet collagen receptor glycoprotein VI. PLoS One 2009; 4:e5585. [PMID: 19440310 PMCID: PMC2680759 DOI: 10.1371/journal.pone.0005585] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 04/17/2009] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Fibrosis, which is characterized by the pathological accumulation of collagen, is recognized as an important feature of many chronic diseases, and as such, constitutes an enormous health burden. We need non-invasive specific methods for the early diagnosis and follow-up of fibrosis in various disorders. Collagen targeting molecules are therefore of interest for potential in vivo imaging of fibrosis. In this study, we developed a collagen-specific probe using a new approach that takes advantage of the inherent specificity of Glycoprotein VI (GPVI), the main platelet receptor for collagens I and III. METHODOLOGY/PRINCIPAL FINDINGS An anti-GPVI antibody that neutralizes collagen-binding was used to screen a bacterial random peptide library. A cyclic motif was identified, and the corresponding peptide (designated collagelin) was synthesized. Solid-phase binding assays and histochemical analysis showed that collagelin specifically bound to collagen (Kd 10(-7) M) in vitro, and labelled collagen fibers ex vivo on sections of rat aorta and rat tail. Collagelin is therefore a new specific probe for collagen. The suitability of collagelin as an in vivo probe was tested in a rat model of healed myocardial infarctions (MI). Injecting Tc-99m-labelled collagelin and scintigraphic imaging showed that uptake of the probe occurred in the cardiac area of rats with MI, but not in controls. Post mortem autoradiography and histological analysis of heart sections showed that the labeled areas coincided with fibrosis. Scintigraphic molecular imaging with collagelin provides high resolution, and good contrast between the fibrotic scars and healthy tissues. The capacity of collagelin to image fibrosis in vivo was confirmed in a mouse model of lung fibrosis. CONCLUSION/SIGNIFICANCE Collagelin is a new collagen-targeting agent which may be useful for non-invasive detection of fibrosis in a broad spectrum of diseases.
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Affiliation(s)
- Julien Muzard
- INSERM, U698, Hôpital Bichat, Paris, France
- Université Paris7, Paris, France
| | - Laure Sarda-Mantel
- INSERM, U773, CRB3, Faculté Xavier Bichat, Paris, France
- Université Paris7, Paris, France
- AP-HP, Hôpital Bichat, Paris, France
| | - Stéphane Loyau
- INSERM, U698, Hôpital Bichat, Paris, France
- Université Paris7, Paris, France
| | - Alain Meulemans
- INSERM, U773, CRB3, Faculté Xavier Bichat, Paris, France
- Université Paris7, Paris, France
- AP-HP, Hôpital Bichat, Paris, France
| | - Liliane Louedec
- INSERM, U698, Hôpital Bichat, Paris, France
- Université Paris7, Paris, France
| | | | | | - Joëlle Marchal-Somme
- INSERM, U700, Faculté Xavier Bichat, Paris, France
- Université Paris7, Paris, France
| | - Jean Baptiste Michel
- INSERM, U698, Hôpital Bichat, Paris, France
- Université Paris7, Paris, France
- AP-HP, Hôpital Bichat, Paris, France
| | - Dominique Le Guludec
- INSERM, U773, CRB3, Faculté Xavier Bichat, Paris, France
- Université Paris7, Paris, France
- AP-HP, Hôpital Bichat, Paris, France
| | | | - Martine Jandrot-Perrus
- INSERM, U698, Hôpital Bichat, Paris, France
- Université Paris7, Paris, France
- AP-HP, Hôpital Bichat, Paris, France
- * E-mail:
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Mann DL. Molecular Imaging and the Failing Heart. JACC Cardiovasc Imaging 2009; 2:199-201. [DOI: 10.1016/j.jcmg.2008.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 12/09/2008] [Indexed: 10/21/2022]
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