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Dandel M. Cardiological Challenges Related to Long-Term Mechanical Circulatory Support for Advanced Heart Failure in Patients with Chronic Non-Ischemic Cardiomyopathy. J Clin Med 2023; 12:6451. [PMID: 37892589 PMCID: PMC10607800 DOI: 10.3390/jcm12206451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
Long-term mechanical circulatory support by a left ventricular assist device (LVAD), with or without an additional temporary or long-term right ventricular (RV) support, is a life-saving therapy for advanced heart failure (HF) refractory to pharmacological treatment, as well as for both device and surgical optimization therapies. In patients with chronic non-ischemic cardiomyopathy (NICM), timely prediction of HF's transition into its end stage, necessitating life-saving heart transplantation or long-term VAD support (as a bridge-to-transplantation or destination therapy), remains particularly challenging, given the wide range of possible etiologies, pathophysiological features, and clinical presentations of NICM. Decision-making between the necessity of an LVAD or a biventricular assist device (BVAD) is crucial because both unnecessary use of a BVAD and irreversible right ventricular (RV) failure after LVAD implantation can seriously impair patient outcomes. The pre-operative or, at the latest, intraoperative prediction of RV function after LVAD implantation is reliably possible, but necessitates integrative evaluations of many different echocardiographic, hemodynamic, clinical, and laboratory parameters. VADs create favorable conditions for the reversal of structural and functional cardiac alterations not only in acute forms of HF, but also in chronic HF. Although full cardiac recovery is rather unusual in VAD recipients with pre-implant chronic HF, the search for myocardial reverse remodelling and functional improvement is worthwhile because, for sufficiently recovered patients, weaning from VADs has proved to be feasible and capable of providing survival benefits and better quality of life even if recovery remains incomplete. This review article aimed to provide an updated theoretical and practical background for those engaged in this highly demanding and still current topic due to the continuous technical progress in the optimization of long-term VADs, as well as due to the new challenges which have emerged in conjunction with the proof of a possible myocardial recovery during long-term ventricular support up to levels which allow successful device explantation.
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Affiliation(s)
- Michael Dandel
- German Centre for Heart and Circulatory Research (DZHK), 10785 Berlin, Germany
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2
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Zhi X, Shi S, Li Y, Ma M, Long Y, Li C, Hao H, Liu H, Wang X, Wang L. S100a9 inhibits Atg9a transcription and participates in suppression of autophagy in cardiomyocytes induced by β 1-adrenoceptor autoantibodies. Cell Mol Biol Lett 2023; 28:74. [PMID: 37723445 PMCID: PMC10506287 DOI: 10.1186/s11658-023-00486-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/31/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Cardiomyocyte death induced by autophagy inhibition is an important cause of cardiac dysfunction. In-depth exploration of its mechanism may help to improve cardiac dysfunction. In our previous study, we found that β1-adrenergic receptor autoantibodies (β1-AAs) induced a decrease in myocardial autophagy and caused cardiomyocyte death, thus resulting in cardiac dysfunction. Through tandem mass tag (TMT)-based quantitative proteomics, autophagy-related S100a9 protein was found to be significantly upregulated in the myocardial tissue of actively immunized mice. However, whether S100a9 affects the cardiac function in the presence of β1-AAs through autophagy and the specific mechanism are currently unclear. METHODS In this study, the active immunity method was used to establish a β1-AA-induced mouse cardiac dysfunction model, and RT-PCR and western blot were used to detect changes in gene and protein expression in cardiomyocytes. We used siRNA to knockdown S100a9 in cardiomyocytes. An autophagy PCR array was performed to screen differentially expressed autophagy-related genes in cells transfected with S100a9 siRNA and negative control siRNA. Cytoplasmic nuclear separation, co-immunoprecipitation (Co-IP), and immunofluorescence were used to detect the binding of S100a9 and hypoxia inducible factor-1α (HIF-1α). Finally, AAV9-S100a9-RNAi was injected into mice via the tail vein to knockdown S100a9 in cardiomyocytes. Cardiac function was detected via ultrasonography. RESULTS The results showed that β1-AAs induced S100a9 expression. The PCR array indicated that Atg9a changed significantly in S100a9siRNA cells and that β1-AAs increased the binding of S100a9 and HIF-1α in cytoplasm. Knockdown of S100a9 significantly improved autophagy levels and cardiac dysfunction. CONCLUSION Our research showed that β1-AAs increased S100a9 expression in cardiomyocytes and that S100a9 interacted with HIF-1α, which prevented HIF-1α from entering the nucleus normally, thus inhibiting the transcription of Atg9a. This resulted in autophagy inhibition and cardiac dysfunction.
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Affiliation(s)
- Xiaoyan Zhi
- Department of Pathology, Shanxi Medical University, No.56 Xinjian South Road, Taiyuan, Shanxi, 030001, People's Republic of China
| | - Shu Shi
- Department of Pathology, Shanxi Medical University, No.56 Xinjian South Road, Taiyuan, Shanxi, 030001, People's Republic of China
| | - Yang Li
- Department of Pathology, Shanxi Medical University, No.56 Xinjian South Road, Taiyuan, Shanxi, 030001, People's Republic of China
| | - Mingxia Ma
- Department of Pathology, Shanxi Medical University, No.56 Xinjian South Road, Taiyuan, Shanxi, 030001, People's Republic of China
| | - Yaolin Long
- Department of Pathology, Shanxi Medical University, No.56 Xinjian South Road, Taiyuan, Shanxi, 030001, People's Republic of China
| | - Chen Li
- Department of Pathology, Shanxi Medical University, No.56 Xinjian South Road, Taiyuan, Shanxi, 030001, People's Republic of China
| | - Haihu Hao
- Department of Orthopaedics, Shanxi Bethune Hospital, Shanxi Academy of Medical Science, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, People's Republic of China
| | - Huirong Liu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, People's Republic of China
| | - Xiaohui Wang
- Department of Pathology, Shanxi Medical University, No.56 Xinjian South Road, Taiyuan, Shanxi, 030001, People's Republic of China
| | - Li Wang
- Department of Pathology, Shanxi Medical University, No.56 Xinjian South Road, Taiyuan, Shanxi, 030001, People's Republic of China.
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Sun Y, Feng L, Hu B, Dong J, Zhang L, Huang X, Yuan Y. Prognostic Value of β1 Adrenergic Receptor Autoantibody and Soluble Suppression of Tumorigenicity-2 in Patients With Acutely Decompensated Heart Failure. Front Cardiovasc Med 2022; 9:821553. [PMID: 35224052 PMCID: PMC8866312 DOI: 10.3389/fcvm.2022.821553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Both β1 adrenergic receptor autoantibody (β1-AA) and soluble suppression of tumorigenicity-2 (sST2) take a role in the pathological remodeling of heart failure. However, limited studies investigated the correlation between the expression of β1-AA and sST2 in patients with acutely decompensated heart failure (ADHF). Objective To explore the correlation between β1-AA and sST2, and evaluate their prognostic value in patients with ADHF. Methods Patients who were admitted for ADHF were included. The N-terminal pro-brain natriuretic peptide (NT-proBNP), sST2, and β1-AA in blood samples were tested at hospital admission and then followed up for assessing the outcomes. Pearson correlation analysis was used to explore the correlation between β1-AA and sST2. The effects of β1-AA, sST2, or the combination of them on the all-cause mortality of patients with ADHF were assessed by Multivariate Cox regression analysis. Results There were 96 patients with ADHF and 96 control populations enrolled. The β1-AA was significantly higher in ADHF than in the control group (0.321 ± 0.06 vs. 0.229 ± 0.04, P = 0.000). Pearson correlation analysis showed that β1-AA was positively correlated with sST2 (r = 0.593), NT-proBNP (r = 0.557), Procalcitonin (r = 0.176), and left ventricular end-diastolic diameter (r = 0.315), but negatively correlated with triglycerides (r = −0.323), and left ventricular ejection fraction (r = −0.430) (all P < 0.05) in ADHF. Patients with ADHF, complicated with both high β1-AA and sST2, showed the highest all-cause mortality during an average of 25.5 months of follow-up. Multivariate Cox regression showed the combination of both high β1-AA and sST2 independently correlated with the all-cause mortality after adjustment for other risk factors (hazard ratio 3.348, 95% CI 1.440 to 7.784, P = 0.005). After adding with β1-AA and sST2, the area under the curves for the prognostic all-cause mortality could increase from 0.642 to 0.748 (P = 0.011). Conclusion The β1-AA is positively correlated with sST2 in patients with ADHF. Elevated plasma β1-AA and sST2 level in patients with ADHF are associated with poorer prognoses.
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Freitag H, Szklarski M, Lorenz S, Sotzny F, Bauer S, Philippe A, Kedor C, Grabowski P, Lange T, Riemekasten G, Heidecke H, Scheibenbogen C. Autoantibodies to Vasoregulative G-Protein-Coupled Receptors Correlate with Symptom Severity, Autonomic Dysfunction and Disability in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. J Clin Med 2021; 10:3675. [PMID: 34441971 PMCID: PMC8397061 DOI: 10.3390/jcm10163675] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/12/2021] [Accepted: 08/16/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is an acquired complex disease with patients suffering from the cardinal symptoms of fatigue, post-exertional malaise (PEM), cognitive impairment, pain and autonomous dysfunction. ME/CFS is triggered by an infection in the majority of patients. Initial evidence for a potential role of natural regulatory autoantibodies (AAB) to beta-adrenergic (AdR) and muscarinic acetylcholine receptors (M-AChR) in ME/CFS patients comes from a few studies. METHODS Here, we analyzed the correlations of symptom severity with levels of AAB to vasoregulative AdR, AChR and Endothelin-1 type A and B (ETA/B) and Angiotensin II type 1 (AT1) receptor in a Berlin cohort of ME/CFS patients (n = 116) by ELISA. The severity of disease, symptoms and autonomic dysfunction were assessed by questionnaires. RESULTS We found levels of most AABs significantly correlated with key symptoms of fatigue and muscle pain in patients with infection-triggered onset. The severity of cognitive impairment correlated with AT1-R- and ETA-R-AAB and severity of gastrointestinal symptoms with alpha1/2-AdR-AAB. In contrast, the patients with non-infection-triggered ME/CFS showed fewer and other correlations. CONCLUSION Correlations of specific AAB against G-protein-coupled receptors (GPCR) with symptoms provide evidence for a role of these AAB or respective receptor pathways in disease pathomechanism.
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Affiliation(s)
- Helma Freitag
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Marvin Szklarski
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Sebastian Lorenz
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Franziska Sotzny
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Sandra Bauer
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Aurélie Philippe
- Department of Nephrology and Critical Care Medicine, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Claudia Kedor
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Patricia Grabowski
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
| | - Tanja Lange
- Department of Rheumatology and Clinical Immunology, University of Lübeck, 23538 Lübeck, Germany; (T.L.); (G.R.)
| | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Lübeck, 23538 Lübeck, Germany; (T.L.); (G.R.)
| | | | - Carmen Scheibenbogen
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany; (M.S.); (S.L.); (F.S.); (S.B.); (C.K.); (P.G.); (C.S.)
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
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Targeting Adrenergic Receptors in Metabolic Therapies for Heart Failure. Int J Mol Sci 2021; 22:ijms22115783. [PMID: 34071350 PMCID: PMC8198887 DOI: 10.3390/ijms22115783] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 12/14/2022] Open
Abstract
The heart has a reduced capacity to generate sufficient energy when failing, resulting in an energy-starved condition with diminished functions. Studies have identified numerous changes in metabolic pathways in the failing heart that result in reduced oxidation of both glucose and fatty acid substrates, defects in mitochondrial functions and oxidative phosphorylation, and inefficient substrate utilization for the ATP that is produced. Recent early-phase clinical studies indicate that inhibitors of fatty acid oxidation and antioxidants that target the mitochondria may improve heart function during failure by increasing compensatory glucose oxidation. Adrenergic receptors (α1 and β) are a key sympathetic nervous system regulator that controls cardiac function. β-AR blockers are an established treatment for heart failure and α1A-AR agonists have potential therapeutic benefit. Besides regulating inotropy and chronotropy, α1- and β-adrenergic receptors also regulate metabolic functions in the heart that underlie many cardiac benefits. This review will highlight recent studies that describe how adrenergic receptor-mediated metabolic pathways may be able to restore cardiac energetics to non-failing levels that may offer promising therapeutic strategies.
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IgG stimulated β2 adrenergic receptor activation is attenuated in patients with ME/CFS. Brain Behav Immun Health 2020; 3:100047. [PMID: 34589837 PMCID: PMC8474590 DOI: 10.1016/j.bbih.2020.100047] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/03/2020] [Indexed: 11/22/2022] Open
Abstract
Background There is emerging evidence of a network of natural autoantibodies against GPCR which is dysregulated in various diseases. β2 adrenergic and M3 and M4 cholinergic receptor (β2 AdR and M3/4 mAChR) antibodies were found to be elevated in a subset of ME/CFS patients. Methods We comparatively analyzed the effects of polyclonal IgG on β2 AdR signaling and immune cell function in vitro. 16 IgG fractions were isolated from serum of 5 ME/CFS patients with elevated (CFS AABhigh) and 5 with normal levels (CFS AABnorm) of β2 AdR autoantibodies, and from 6 healthy controls (HC). The effect of each IgG on β-arrestin recruitment and cAMP production in β2 AdR and M3/4R reporter cell lines was studied. Further effect of each IgG on human monocyte cytokine production and on T cell proliferation in vitro was analyzed. In addition, studies on cytokine production in β2 AdR wild type and knockout mice splenocytes incubated with IgG fractions were performed. Results We found that IgGs from HC could stimulate β-arrestin recruitment and cAMP production in β2 AdR reporter cell lines whereas IgGs from CFS AABhigh had no effect. The IgG-mediated activation of β2 AdR was confirmed in β2 AdR wt and ko mice. In accordance with previous studies IgG fractions from HC inhibited LPS-induced TNFα and stimulated LPS-induced IL-10 production of monocytes. Further IgG fractions from HC enhanced proliferation of T-cells stimulated with anti-CD3/CD28. IgG fractions from CFS AABhigh patients had no significant effect on both cytokine production and T cell proliferation, while IgGs from CFS AABnorm had an intermediate effect. We could also observe that IgG can modulate the signaling of β2 AdR ligands isoprenline and propranolol. Conclusions We provide evidence that IgG can activate β2 AdR. The β2 AdR activation by IgG is attenuated in ME/CFS patients. A dysregulation of β2 AdR function could explain many symptoms of ME/CFS.
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Düngen HD, Dordevic A, Felix SB, Pieske B, Voors AA, McMurray JJV, Butler J. β 1-Adrenoreceptor Autoantibodies in Heart Failure: Physiology and Therapeutic Implications. Circ Heart Fail 2020; 13:e006155. [PMID: 31957469 DOI: 10.1161/circheartfailure.119.006155] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antibodies that activate the β1-AR (β1-adrenoreceptor) can induce heart failure in animal models. These antibodies are often found in patients with heart failure secondary to varying etiologies. Their binding to the β1 receptor leads to prolonged receptor activation with subsequent induction of cellular dysfunction, apoptosis, and arrhythmias. β-blocker therapy while highly effective for heart failure, may not be sufficient treatment for patients who have β1 receptor autoantibodies. Removal of these autoantibodies by immunoadsorption has been shown to improve heart failure in small studies. However, immunoadsorption is costly, time consuming, and carries potential risks. An alternative to immunoadsorption is neutralization of autoantibodies through the intravenous application of small soluble molecules, such as peptides or aptamers, which specifically target and neutralize β1-AR autoantibodies. Peptides may induce immunogenicity. Animal as well as early phase human studies with aptamers have not shown safety concerns to date and have demonstrated effectiveness in reducing autoantibody levels. Novel aptamers have the potential advantage of having a wide spectrum of action, neutralizing a variety of known circulating G-protein coupled receptor autoantibodies. These aptamers, therefore, have the potential to be novel therapeutic option for patients with heart failure who have positive for β1-AR autoantibodies. However, clinical outcomes trials are needed to assess the clinical utility of this novel approach to treat heart failure.
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Affiliation(s)
- Hans-Dirk Düngen
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charite-Universitätsmedizin, Berlin, Germany (H.-D.D., A.D., B.P.)
| | - Aleksandar Dordevic
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charite-Universitätsmedizin, Berlin, Germany (H.-D.D., A.D., B.P.)
| | - Stephan B Felix
- Department of Internal Medicine B, University Medicine Greifswald, Germany (S.B.F.).,DZHK (German Center for Cardiovascular Research), partner site Greifswald, Germany (S.B.F.)
| | - Burkert Pieske
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Germany (B.P.).,Berlin Institute of Health (BIH), Germany (B.P.)
| | - Adriaan A Voors
- Department of Internal Medicine and Cardiology, German Heart Center Berlin, Germany (B.P.)
| | - John J V McMurray
- Department of Cardiology, University Medical Center Groningen, University of Groningen, the Netherlands (A.A.V.)
| | - Javed Butler
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (J.J.V.M.)
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Affiliation(s)
| | | | - M. Tiess
- Dialysegemeinschaft Nord e.V., Rostock, Germany
| | - W. Ramlow
- Dialysegemeinschaft Nord e.V., Rostock, Germany
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Jünemann A, Hohberger B, Rech J, Sheriff A, Fu Q, Schlötzer-Schrehardt U, Voll RE, Bartel S, Kalbacher H, Hoebeke J, Rejdak R, Horn F, Wallukat G, Kunze R, Herrmann M. Agonistic Autoantibodies to the β2-Adrenergic Receptor Involved in the Pathogenesis of Open-Angle Glaucoma. Front Immunol 2018; 9:145. [PMID: 29483909 PMCID: PMC5816038 DOI: 10.3389/fimmu.2018.00145] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 01/17/2018] [Indexed: 11/21/2022] Open
Abstract
Glaucoma is a frequent ocular disease that may lead to blindness. Primary open-angle glaucoma (POAG) and ocular hypertension (OHT) are common diseases with increased intraocular pressure (IOP), which are mainly responsible for these disorders. Their pathogenesis is widely unknown. We screened the sera of patients with POAG and OHT for the prevalence of autoantibodies (AAb) against G protein-coupled receptors (GPCRs) in comparison to controls. Employing frequency modulation of spontaneously contracting neonatal rat cardiomyocytes in vitro, agonistic GPCR AAb were to be detected in roughly 75% of the patients with POAG and OHT, however, not in controls. Using inhibitory peptides the AAb’ target was identified as β2 adrenergic receptor (β2AR). The AAb interact with the second extracellular loop of β2AR. The peptides 181–187 and 186–192 were identified as binding sites of the AAb within the extracellular loop II. The binding of the AAb to β2ARs was verified by surface-plasmon-resonance analysis. The isotype of the AAb was (immunoglobulin) IgG3. In an additional pilot principal-of-proof study, including four patients with POAG, the removal of the AAb against the β2AR and other immunoglobulins G by immunoadsorption resulted in a transient reduction of IOP. These findings might indicate a possible role of agonistic AAb directed against β2ARs in the dynamics of aqueous humor and might support a contribution of adaptive autoimmunity in the etiopathogenesis of POAG and OHT.
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Affiliation(s)
- Anselm Jünemann
- Department of Ophthalmology, University of Rostock, Rostock, Germany
| | - Bettina Hohberger
- Department of Ophthalmology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Jürgen Rech
- Department of Internal Medicine III, Institute of Clinical Immunology and Rheumatology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Ahmed Sheriff
- Department of Internal Medicine III, Institute of Clinical Immunology and Rheumatology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Qin Fu
- Department of Pharmacology, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | | | - Reinhard Edmund Voll
- IZKF Research Group 2, Nikolaus-Fiebiger-Center of Molecular Medicine, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Sabine Bartel
- Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Hubert Kalbacher
- IFIB - Institute of Biochemistry, University of Tübingen, Tübingen, Germany
| | - Johan Hoebeke
- C.N.R.S. UPR 9021 «Chimie et Immunologie Thérapeutiques», Strasbourg, France
| | - Robert Rejdak
- Department of General Ophthalmology, Medical University of Lublin, Lublin, Poland
| | - Folkert Horn
- Department of Ophthalmology, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - Gerd Wallukat
- Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Rudolf Kunze
- Science Office, Berlin-Buch, Campus Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Martin Herrmann
- Department of Internal Medicine III, Institute of Clinical Immunology and Rheumatology, University of Erlangen-Nürnberg, Erlangen, Germany
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Lv T, Du Y, Cao N, Zhang S, Gong Y, Bai Y, Wang W, Liu H. Proliferation in cardiac fibroblasts induced by β1-adrenoceptor autoantibody and the underlying mechanisms. Sci Rep 2016; 6:32430. [PMID: 27577254 PMCID: PMC5006240 DOI: 10.1038/srep32430] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 08/09/2016] [Indexed: 12/25/2022] Open
Abstract
Chronic sustained stimulation of β-adrenoceptor is closely related to cardiac fibrosis which is bad for cardiac function. Growing evidence showed that the high prevalence of β1-adrenoceptor autoantibody (β1-AA) in the sera of patients with various types of cardiovascular diseases decreased cardiac function. In the current study, we demonstrated that β1-AA impaired the cardiac function evaluated by echocardiography and that β1-AA triggered cardiac fibrosis in terms of increased expression of α-smooth muscle actin as the marker of myofibroblast and collagen deposition in a passive β1-AA immunized mice model during 16 weeks. Further, we showed that β1-AA activated β1-AR/cAMP/PKA pathway and promoted proliferation in primary cardiac fibroblasts through specific binding to β1-AR but not to β2-AR. Moreover, β1-AA was also likely to promote proliferation in cardiac fibroblasts through activating p38MAPK and ERK1/2 as p38MAPK inhibitor SB203580 and ERK1/2 inhibitor PD98059 partially reversed the proliferative effect. The persistent activating signalling of PKA and P38MAPK in 1 h induced by β1-AA was associated with lacking agonist-induced desensitization phenomena. The conditioned medium from β1-AA-stimulated cardiac fibroblasts induced cardiomyocyte apoptosis, which indicated that β1-AA changed the secretion of cardiac fibroblasts contributing to cardiac injury. These findings will contribute to our understanding of the pathological mechanisms of β1-AA.
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Affiliation(s)
- Tingting Lv
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, PR China
| | - Yunhui Du
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, PR China.,Beijing Key Laboratory of Metabolic Disorders Related Cardiovascular Disease, Capital Medical University, Beijing 100069, PR China
| | - Ning Cao
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, PR China
| | - Suli Zhang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, PR China.,Beijing Key Laboratory of Metabolic Disorders Related Cardiovascular Disease, Capital Medical University, Beijing 100069, PR China
| | - Yulin Gong
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, PR China
| | - Yan Bai
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, PR China
| | - Wen Wang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, PR China.,Beijing Key Laboratory of Metabolic Disorders Related Cardiovascular Disease, Capital Medical University, Beijing 100069, PR China
| | - Huirong Liu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing 100069, PR China.,Beijing Key Laboratory of Metabolic Disorders Related Cardiovascular Disease, Capital Medical University, Beijing 100069, PR China
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Zhao L, Xu C, Xu J. Autoantibodies against β1 Receptor and AT1 Receptor in Type 2 Diabetes Patients with Left Ventricular Dilatation. Cardiology 2014; 129:191-6. [DOI: 10.1159/000365782] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 07/04/2014] [Indexed: 11/19/2022]
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Dandel M, Wallukat G, Englert A, Lehmkuhl HB, Knosalla C, Hetzer R. Long-term benefits of immunoadsorption in β1
-adrenoceptor autoantibody-positive transplant candidates with dilated cardiomyopathy. Eur J Heart Fail 2014; 14:1374-88. [DOI: 10.1093/eurjhf/hfs123] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Michael Dandel
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; D-3353 Germany
| | | | - Angela Englert
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; D-3353 Germany
| | - Hans B. Lehmkuhl
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; D-3353 Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; D-3353 Germany
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; D-3353 Germany
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13
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Abstract
Hypertensive disorders are life-threatening diseases with high morbidity and mortality, affecting billions of individuals worldwide. A multitude of underlying conditions may contribute to hypertension, thus the need for a plethora of treatment options to identify the approach that best meets the needs of individual patients. A growing body of evidence indicates that (1) autoantibodies that bind to and activate the major angiotensin II type I (AT₁) receptor exist in the circulation of patients with hypertensive disorders, (2) these autoantibodies contribute to disease pathophysiology, (3) antibody titers correlate to the severity of the disease, and (4) efforts to block or remove these pathogenic autoantibodies have therapeutic potential. These autoantibodies, termed AT₁ agonistic autoantibodies have been extensively characterized in preeclampsia, a life-threatening hypertensive condition of pregnancy. As reviewed here, these autoantibodies cause symptoms of preeclampsia when injected into pregnant mice. Somewhat surprisingly, these auto antibodies also appear in 3 animal models of preeclampsia. However, the occurrence of AT₁ agonistic autoantibodies is not restricted to pregnancy. These autoantibodies are prevalent among kidney transplant recipients who develop severe transplant rejection and malignant hypertension during the first week after transplantation. AT₁ agonistic autoantibodies are also highly abundant among a group of patients with essential hypertension that are refractory to standard therapy. More recently these autoantibodies have been seen in patients with the autoimmune disease, systemic sclerosis. These 3 examples extend the clinical impact of AT₁ agonistic autoantibodies beyond pregnancy. Research reviewed here raises the intriguing possibility that preeclampsia and other hypertensive conditions are autoimmune diseases characterized by the presence of pathogenic autoantibodies that activate the major angiotensin receptor, AT₁. These pathogenic autoantibodies could serve as presymptomatic biomarkers and therapeutic targets, thereby providing improved medical management for these conditions.
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Affiliation(s)
- Yang Xia
- Department of Biochemistry and Molecular Biology, The University of Texas Medical School at Houston, Houston, TX 77030, USA.
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14
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Dandel M, Wallukat G, Englert A, Hetzer R. Immunoadsorption therapy for dilated cardiomyopathy and pulmonary arterial hypertension. ATHEROSCLEROSIS SUPP 2013; 14:203-11. [DOI: 10.1016/j.atherosclerosissup.2012.10.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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15
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Du Y, Yan L, Wang J, Zhan W, Song K, Han X, Li X, Cao J, Liu H. β1-Adrenoceptor autoantibodies from DCM patients enhance the proliferation of T lymphocytes through the β1-AR/cAMP/PKA and p38 MAPK pathways. PLoS One 2012; 7:e52911. [PMID: 23300817 PMCID: PMC3534136 DOI: 10.1371/journal.pone.0052911] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 11/21/2012] [Indexed: 11/21/2022] Open
Abstract
Background Autoantibodies against the second extracellular loop of the β1-adrenergic receptor (β1-AA) not only contribute to increased susceptibility to heart failure, but also play a causative role in myocardial remodeling through their sympathomimetic-like effects that are induced upon binding to the β1-adrenergic receptor. However, their role in the function of T lymphocytes has never been previously investigated. Our present study was designed to determine whether β1-AA isolated from the sera of dilated cardiomyopathy (DCM) patients caused the proliferation of T cells and the secretion of cytokines. Methods Blood samples were collected from 95 DCM patients as well as 95 healthy subjects, and β1-AA was detected using ELISA. The CD3+T lymphocytes were selected separately through flow cytometry and the effect of β1-AA on T lymphocyte proliferation was examined by CCK-8 kits and CFSE assay. Western blotting was used to analyze the expressions of phospho-VASP and phospho-p38 MAPK. Results β1-AA enhanced the proliferation of T lymphocytes. This effect could be blocked by the selective β1-adrenergic receptor antagonist metoprolol, PKA inhibitor H89, and p38 MAPK inhibitor SB203580. Furthermore, the expression of the phosphorylated forms of phospho-VASP and phospho-p38 MAPK were markedly increased in the presence of β1-AA. β1-AA also inhibited the secretion of interferon-γ (IFN-γ) while promoting an increase in interleukin-4 (IL-4) levels. Conclusions These results demonstrate that β1-AA isolated from DCM patients binds to β1-AR on the surface of T cells, causing changes in T-cell proliferation and secretion through the β1-AR/cAMP/PKA and p38 MAPK pathways.
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Affiliation(s)
- Yunhui Du
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
- Department of Marine Bioengineering, Marine College, Shandong University, Weihai, Shandong, China
| | - Li Yan
- Department of Physiology and Pathophysiology, Institute of Basic Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jin Wang
- Department of Physiology, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wenzhang Zhan
- Department of Internal Medicine, General Hospital of Tonghua Mining Group CO. LTD, Baishan, Jilin, China
| | - Kai Song
- Department of Internal Medicine, A Peace Hospital Attached to Changzhi Medical College, Changzhi, Shanxi, China
| | - Xue Han
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Xiao Li
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
| | - Jimin Cao
- Department of Physiology and Pathophysiology, Institute of Basic Medical Sciences, Peking Union Medical College, Beijing, China
| | - Huirong Liu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Capital Medical University, Beijing, China
- The Key Laboratory of Remodeling-related Cardiovascular Diseases, Capital Medical University, Ministry of Education, Beijing, China
- * E-mail:
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16
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Du Y, Yan L, Du H, Wang L, Ding F, Quan L, Cheng X, Song K, Liu H. β1-adrenergic receptor autoantibodies from heart failure patients enhanced TNF-α secretion in RAW264.7 macrophages in a largely PKA-dependent fashion. J Cell Biochem 2012; 113:3218-28. [DOI: 10.1002/jcb.24198] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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17
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Dandel M, Wallukat G, Potapov E, Hetzer R. Role of β1-adrenoceptor autoantibodies in the pathogenesis of dilated cardiomyopathy. Immunobiology 2012; 217:511-20. [DOI: 10.1016/j.imbio.2011.07.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 07/05/2011] [Indexed: 10/18/2022]
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18
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Torre-Amione G, Orrego CM, Khalil N, Kottner-Assad C, Leveque C, Celis R, Youker KA, Estep JD. Therapeutic plasma exchange a potential strategy for patients with advanced heart failure. J Clin Apher 2010; 25:323-30. [DOI: 10.1002/jca.20264] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 07/19/2010] [Indexed: 11/11/2022]
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19
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Gesinde MO, Tan LB, Gooi HC. Plasma exchange treatment to reduce anti-beta1-adrenergic receptor antibody in a patient with dilated cardiomyopathy. J Clin Apher 2007; 22:241-2. [PMID: 17385717 DOI: 10.1002/jca.20127] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- M O Gesinde
- National Blood Service, Leeds, West Yorkshire, United Kingdom.
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20
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Gao Y, Liu HR, Zhao RR, Zhi JM. Autoantibody against cardiac beta1-adrenoceptor induces apoptosis in cultured neonatal rat cardiomyocytes. Acta Biochim Biophys Sin (Shanghai) 2006; 38:443-9. [PMID: 16820859 DOI: 10.1111/j.1745-7270.2006.00185.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
To clarify whether apoptosis is involved in the injury processes induced by autoantibody against cardiac beta1-adrenoceptor, we investigated the biological and apoptotic effects of antibodies on cultured neonatal rat cardiomyocytes. Wistar rats were immunized with peptides corresponding to the second extracellular loop of the beta1-adrenoceptor to induce the production of anti-beta1-adrenoceptor antibodies in the sera. Immunoglobulin (Ig) G in the sera was detected using synthetic antigen enzyme-linked immunosorbent assay and purified using the diethylaminoethyl cellulose ion exchange technique. Apoptosis of cardiomyocytes was evaluated using agarose gel electrophoresis and flow cytometry. Our results showed that the positive serum IgG greatly increased the beating rates of cardiomyocytes and showed an agonist-like activity. Furthermore, positive serum IgG induced cardiomyocyte apoptosis after treatment with beta1-adrenoceptor overstimulation for 48 h. The effects of monoclonal antibody against beta1-adrenoceptor were also found to be similar to those of positive serum IgG. It was suggested that the autoantibody could induce cardiomyocyte apoptosis by excessive stimulation of beta1-adrenoceptor.
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MESH Headings
- Animals
- Animals, Newborn
- Apoptosis
- Autoantibodies/immunology
- Cells, Cultured
- DNA Fragmentation
- Flow Cytometry
- Heart Rate/drug effects
- Humans
- Immunoglobulin G/pharmacology
- Isoproterenol/pharmacology
- Models, Cardiovascular
- Myocytes, Cardiac/cytology
- Myocytes, Cardiac/drug effects
- Myocytes, Cardiac/immunology
- Peptides/chemistry
- Peptides/immunology
- Protein Structure, Tertiary
- Rats
- Rats, Wistar
- Receptors, Adrenergic, beta-1/chemistry
- Receptors, Adrenergic, beta-1/immunology
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Affiliation(s)
- Yan Gao
- Department of Cardiovascular Physiology, Shanxi Medical University, Taiyuan 030001, China
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21
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von Haehling S, Doehner W, Anker SD. The roles of immunity and autoimmunity in chronic heart failure. ERNST SCHERING RESEARCH FOUNDATION WORKSHOP 2005:155-68. [PMID: 16329662 DOI: 10.1007/3-540-30822-9_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Chronic heart failure (CHF) represents a major public health burden in developed countries. The introduction of new treatments has helped to improve its prognosis in recent years. However, it is still not possible to directly target the immunological aspects of the disease. In fact, chronic immune activation with the up-regulation of pro-inflammatory substances in the plasma remains an important feature of the disease, independently of its aetiology. Autoimmune mechanisms play a significant role in a subgroup of patients with dilated cardiomyopathy. The interplay between the two systems has not been established so far. This review briefly summarizes immune and autoimmune mechanisms in CHF.
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Affiliation(s)
- S von Haehling
- Department of Clinical Cardiology, Imperial College School of Medicine, National Heart & Lung Institute, London, UK.
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22
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Brette F, Leroy J, Le Guennec JY, Sallé L. Ca2+ currents in cardiac myocytes: Old story, new insights. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2005; 91:1-82. [PMID: 16503439 DOI: 10.1016/j.pbiomolbio.2005.01.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Calcium is a ubiquitous second messenger which plays key roles in numerous physiological functions. In cardiac myocytes, Ca2+ crosses the plasma membrane via specialized voltage-gated Ca2+ channels which have two main functions: (i) carrying depolarizing current by allowing positively charged Ca2+ ions to move into the cell; (ii) triggering Ca2+ release from the sarcoplasmic reticulum. Recently, it has been suggested than Ca2+ channels also participate in excitation-transcription coupling. The purpose of this review is to discuss the physiological roles of Ca2+ currents in cardiac myocytes. Next, we describe local regulation of Ca2+ channels by cyclic nucleotides. We also provide an overview of recent studies investigating the structure-function relationship of Ca2+ channels in cardiac myocytes using heterologous system expression and transgenic mice, with descriptions of the recently discovered Ca2+ channels alpha(1D) and alpha(1E). We finally discuss the potential involvement of Ca2+ currents in cardiac pathologies, such as diseases with autoimmune components, and cardiac remodeling.
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Affiliation(s)
- Fabien Brette
- School of Biomedical Sciences, University of Leeds, Worsley Building Leeds, LS2 9NQ, UK.
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23
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Matoba Y, Okubo H, Nosé Y. Therapeutic left ventricular assist device and apheresis on dilated cardiomyopathy. Artif Organs 2004; 28:171-81. [PMID: 14961957 DOI: 10.1111/j.1525-1594.2004.47338.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pathogenesis and therapies of dilated cardiomyopathy (DCM) have been discussed for a long time, but both of the ultimate answers are still unknown. In the last decade, the pathogenic role of immunological factors, such as cardiac autoimmune antibodies and cytokines, have been discussed attentively. This has led to one possible new therapy, immunoadsorption, which removes antibodies, and it has made a remarkable effect. However, there are other factors to remove. For the removal of cytokines and neurohormones, the most effective method is hemofiltration (HF). Also, double-filtration plasmapheresis (DFPP) removes immunoglobulin as well as low-density lipoprotein (LDL) and coagulation factors that may improve blood circulation, including the coronary arteries. Therefore, to eliminate all deteriorative factors, both apheresis therapies, HF and DFPP, should be performed. Due to the shortage of donor hearts, left ventricular assist systems (LVAD) have been used as a bridge to transplantation. It has now been reported that the total unloading of the left ventricle does not only maintain, but also recovers, the cardiac function, even from end-stage heart failure. However, the patients who have obtained a long-lasting recovery of cardiac function from an LVAD are still in a minority. To make this the majority, therapeutic LVAD should be combined with the apheresis therapies, DFPP and HF. We believe that this concept, a combination of HF and DFPP with therapeutic LVAD, will be the next generation of treatment that has a potential to postpone, or even avoid, heart transplantation.
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Affiliation(s)
- Yoshica Matoba
- Michael E. DeBakey Department of Surgery, Artificial Organ Research Center, Baylor College of Medicine, Houston, TX 77030, USA.
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Wallukat G, Neichel D, Nissen E, Homuth V, Luft FC. Agonistic autoantibodies directed against the angiotensin II AT1 receptor in patients with preeclampsia. Can J Physiol Pharmacol 2003; 81:79-83. [PMID: 12710518 DOI: 10.1139/y02-160] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We showed that sera from patients with preeclampsia contain autoantibodies directed against the angiotensin II AT1 receptor. The antibodies recognize an epitope on the second extracellular loop of the receptor and are immunoglobulins of the IgG3 subclass. The antibodies accelerate the beating rate of neonatal rat cardiomyocytes. The agonistic effect can be blocked with the AT1 receptor blocker losartan and can be neutralized by a peptide corresponding to the AT1 receptor's second extracellular loop. In further studies we shown that the autoantibodies recognize a specific conformation of the AT1 receptor. Cleavage of the external disulfide bond with dithiothreitol caused an inactivation of the receptor when stimulated either with Ang II or the autoantibodies in a system of cultured neonatal rat cardiomyocytes. Long-term stimulation of the AT1 receptor with either agonists down-regulated the AT1 receptor-mediated response to a second Ang II stimulation. These observations show that the agonistic autoantibodies behave pharmacologically in a similar fashion to Ang II. We have found the autoantibodies in all women meeting the clinical criteria of preeclampsia and suggest that they may be important to the pathogenesis of the disease.
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Affiliation(s)
- Gerd Wallukat
- Max Delbrück Center for Molecular Medicine and Franz Volhard Clinic HELIOS Klinikum-Berlin, Medical Faculty of the Charit,é Humboldt University of Berlin, Germany.
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25
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Affiliation(s)
- P D Booker
- Paediatric Anaesthesia, University of Liverpool, Alder Hey Children's Hospital, Liverpool, UK.
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26
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Halfmann RH. Immunoadsorption as a new treatment option for patients with idiopathic dilated cardiomyopathy. Perfusion 2000; 15:333-6. [PMID: 10926416 DOI: 10.1177/026765910001500408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- R H Halfmann
- Edwards Lifesciences Germany, GMbH, Unterschleissheim
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