SERCA2a upregulation ameliorates cellular alternans induced by metabolic inhibition

The 'Reverse FDUF' Mechanism of Atrial Excitation-Contraction Coupling Sustains Calcium Alternans-A Hypothesis

Cardiac calcium alternans is defined as beat-to-beat alternations of Ca transient (CaT) amplitude and has been linked to cardiac arrhythmia, including atrial fibrillation. We investigated the mechanism of atrial alternans in isolated rabbit atrial myocytes using high-resolution line scan confocal Ca imaging. Alternans was induced by increasing the pacing frequency until stable alternans was observed (1.6-2.5 Hz at room temperature). In atrial myocytes, action potential-induced Ca release is initiated in the cell periphery and subsequently propagates towards the cell center by Ca-induced Ca release (CICR) in a Ca wave-like fashion, driven by the newly identified 'fire-diffuse-uptake-fire' (FDUF) mechanism. The development of CaT alternans was accompanied by characteristic changes of the spatio-temporal organization of the CaT. During the later phase of the CaT, central [Ca]_i exceeded peripheral [Ca]_i that was indicative of a reversal of the subcellular [Ca]_i gradient from centripetal to centrifugal. This gradient reversal resulted in a reversal of CICR propagation, causing a secondary Ca release during the large-amplitude alternans CaT, thereby prolonging the CaT, enhancing Ca-release refractoriness and reducing Ca release on the subsequent beat, thus enhancing the degree of CaT alternans. Here, we propose the 'reverse FDUF' mechanism as a novel cellular mechanism of atrial CaT alternans, which explains how the uncoupling of central from peripheral Ca release leads to the reversal of propagating CICR and to alternans.

CaMKII inhibition has dual effects on spontaneous Ca2+ release and Ca2+ alternans in ventricular cardiomyocytes from mice with a gain-of-function RyR2 mutation

In conditions with abnormally increased activity of the cardiac ryanodine receptor (RyR2), Ca²⁺/calmodulin-dependent protein kinase II (CaMKII) can contribute to a further destabilization of RyR2 that results in triggered arrhythmias. Therefore, inhibition of CaMKII in such conditions has been suggested as a strategy to suppress RyR2 activity and arrhythmias. However, suppression of RyR2 activity can lead to the development of arrhythmogenic Ca²⁺ alternans. The aim of this study was to test whether the suppression of RyR2 activity caused by inhibition of CaMKII increases propensity for Ca²⁺ alternans. We studied spontaneous Ca²⁺ release events and Ca²⁺ alternans in isolated left ventricular cardiomyocytes from mice carrying the gain-of-function RyR2 mutation RyR2-R2474S and from wild-type mice. CaMKII inhibition by KN-93 effectively decreased the frequency of spontaneous Ca²⁺ release events in RyR2-R2474S cardiomyocytes exposed to the β-adrenoceptor agonist isoprenaline. However, KN-93-treated RyR2-R2474S cardiomyocytes also showed increased propensity for Ca²⁺ alternans and increased Ca²⁺ alternans ratio compared with both an inactive analog of KN-93 and with vehicle-treated controls. This increased propensity for Ca²⁺ alternans was explained by prolongation of Ca²⁺ release refractoriness. Importantly, the increased propensity for Ca²⁺ alternans in KN-93-treated RyR2-R2474S cardiomyocytes did not surpass that of wild type. In conclusion, inhibition of CaMKII efficiently reduces spontaneous Ca²⁺ release but promotes Ca²⁺ alternans in RyR2-R2474S cardiomyocytes with a gain-of-function RyR2 mutation. The dominant effect in RyR2-R2474S is to reduce spontaneous Ca²⁺ release, which supports this intervention as a therapeutic strategy in this specific condition. However, future studies on CaMKII inhibition in conditions with increased propensity for Ca²⁺ alternans should include investigation of both phenomena.NEW & NOTEWORTHY Genetically increased RyR2 activity promotes arrhythmogenic Ca²⁺ release. Inhibition of CaMKII suppresses RyR2 activity and arrhythmogenic Ca²⁺ release. Suppression of RyR2 activity prolongs refractoriness of Ca²⁺ release. Prolonged refractoriness of Ca²⁺ release leads to arrhythmogenic Ca²⁺ alternans. CaMKII inhibition promotes Ca²⁺ alternans by prolonging Ca²⁺ release refractoriness.

Clinical Potential of Beat-to-Beat Diastolic Interval Control in Preventing Cardiac Arrhythmias

Life‐threatening ventricular arrhythmias and sudden cardiac death are often preceded by cardiac alternans, a beat‐to‐beat oscillation in the T‐wave morphology or duration. However, given the spatiotemporal and structural complexity of the human heart, designing algorithms to effectively suppress alternans and prevent fatal rhythms is challenging. Recently, an antiarrhythmic constant diastolic interval pacing protocol was proposed and shown to be effective in suppressing alternans in 0‐, 1‐, and 2‐dimensional in silico studies as well as in ex vivo whole heart experiments. Herein, we provide a systematic review of the electrophysiological conditions and mechanisms that enable constant diastolic interval pacing to be an effective antiarrhythmic pacing strategy. We also demonstrate a successful translation of the constant diastolic interval pacing protocol into an ECG‐based real‐time control system capable of modulating beat‐to‐beat cardiac electrical activity and preventing alternans. Furthermore, we present evidence of the clinical utility of real‐time alternans suppression in reducing arrhythmia susceptibility in vivo. We provide a comprehensive overview of this promising pacing technique, which can potentially be translated into a clinically viable device that could radically improve the quality of life of patients experiencing abnormal cardiac rhythms.

Blockade of sodium‑calcium exchanger via ORM-10962 attenuates cardiac alternans

Repolarization alternans, a periodic oscillation of long-short action potential duration, is an important source of arrhythmogenic substrate, although the mechanisms driving it are insufficiently understood. Despite its relevance as an arrhythmia precursor, there are no successful therapies able to target it specifically. We hypothesized that blockade of the sodium‑calcium exchanger (NCX) could inhibit alternans. The effects of the selective NCX blocker ORM-10962 were evaluated on action potentials measured with microelectrodes from canine papillary muscle preparations, and calcium transients measured using Fluo4-AM from isolated ventricular myocytes paced to evoke alternans. Computer simulations were used to obtain insight into the drug's mechanisms of action. ORM-10962 attenuated cardiac alternans, both in action potential duration and calcium transient amplitude. Three morphological types of alternans were observed, with differential response to ORM-10962 with regards to APD alternans attenuation. Analysis of APD restitution indicates that calcium oscillations underlie alternans formation. Furthermore, ORM-10962 did not markedly alter APD restitution, but increased post-repolarization refractoriness, which may be mediated by indirectly reduced L-type calcium current. Computer simulations reproduced alternans attenuation via ORM-10962, suggesting that it is acts by reducing sarcoplasmic reticulum release refractoriness. This results from the ORM-10962-induced sodium‑calcium exchanger block accompanied by an indirect reduction in L-type calcium current. Using a computer model of a heart failure cell, we furthermore demonstrate that the anti-alternans effect holds also for this disease, in which the risk of alternans is elevated. Targeting NCX may therefore be a useful anti-arrhythmic strategy to specifically prevent calcium driven alternans.

Mitochondrial depolarization promotes calcium alternans: Mechanistic insights from a ventricular myocyte model

Mitochondria are vital organelles inside the cell and contribute to intracellular calcium (Ca2+) dynamics directly and indirectly via calcium exchange, ATP generation, and production of reactive oxygen species (ROS). Arrhythmogenic Ca2+ alternans in cardiac myocytes has been observed in experiments under abnormal mitochondrial depolarization. However, complex signaling pathways and Ca2+ cycling between mitochondria and cytosol make it difficult in experiments to reveal the underlying mechanisms of Ca2+ alternans under abnormal mitochondrial depolarization. In this study, we use a newly developed spatiotemporal ventricular myocyte computer model that integrates mitochondrial Ca2+ cycling and complex signaling pathways to investigate the mechanisms of Ca2+ alternans during mitochondrial depolarization. We find that elevation of ROS in response to mitochondrial depolarization plays a critical role in promoting Ca2+ alternans. Further examination reveals that the redox effect of ROS on ryanodine receptors and sarco/endoplasmic reticulum Ca2+-ATPase synergistically promote alternans. Upregulation of mitochondrial Ca2+ uniporter promotes Ca2+ alternans via Ca2+-dependent mitochondrial permeability transition pore opening. Due to their relatively slow kinetics, oxidized Ca2+/calmodulin-dependent protein kinase II activation and ATP do not play significant roles acutely in the genesis of Ca2+ alternans after mitochondrial depolarization, but their roles can be significant in the long term, mainly through their effects on sarco/endoplasmic reticulum Ca2+-ATPase activity. In conclusion, mitochondrial depolarization promotes Ca2+ alternans acutely via the redox effect of ROS and chronically by ATP reduction. It suppresses Ca2+ alternans chronically through oxidized Ca2+/calmodulin-dependent protein kinase II activation.

A Spatiotemporal Ventricular Myocyte Model Incorporating Mitochondrial Calcium Cycling

Intracellular calcium (Ca2+) cycling dynamics in cardiac myocytes are spatiotemporally generated by stochastic events arising from a spatially distributed network of coupled Ca2+ release units that interact with an intertwined mitochondrial network. In this study, we developed a spatiotemporal ventricular myocyte model that integrates mitochondria-related Ca2+ cycling components into our previously developed ventricular myocyte model consisting of a three-dimensional Ca2+ release unit network. Mathematical formulations of mitochondrial membrane potential, mitochondrial Ca2+ cycling, mitochondrial permeability transition pore stochastic opening and closing, intracellular reactive oxygen species signaling, and oxidized Ca2+/calmodulin-dependent protein kinase II signaling were incorporated into the model. We then used the model to simulate the effects of mitochondrial depolarization on mitochondrial Ca2+ cycling, Ca2+ spark frequency, and Ca2+ amplitude, which agree well with experimental data. We also simulated the effects of the strength of mitochondrial Ca2+ uniporters and their spatial localization on intracellular Ca2+ cycling properties, which substantially affected diastolic and systolic Ca2+ levels in the mitochondria but exhibited only a small effect on sarcoplasmic reticulum and cytosolic Ca2+ levels under normal conditions. We show that mitochondrial depolarization can cause Ca2+ waves and Ca2+ alternans, which agrees with previous experimental observations. We propose that this new, to our knowledge, spatiotemporal ventricular myocyte model, incorporating properties of mitochondrial Ca2+ cycling and reactive-oxygen-species-dependent signaling, will be useful for investigating the effects of mitochondria on intracellular Ca2+ cycling and action potential dynamics in ventricular myocytes.

Exploring Impaired SERCA Pump-Caused Alternation Occurrence in Ischemia

Impaired sarcoplasmic reticulum (SR) calcium transport ATPase (SERCA) gives rise to Ca²⁺ alternans and changes of the Ca2+release amount. These changes in Ca²⁺ release amount can reveal the mechanism underlying how the interaction between Ca²⁺ release and Ca²⁺ uptake induces Ca²⁺ alternans. This study of alternans by calculating the values of Ca²⁺ release properties with impaired SERCA has not been explored before. Here, we induced Ca²⁺ alternans by using an impaired SERCA pump under ischemic conditions. The results showed that the recruitment and refractoriness of the Ca²⁺ release increased as Ca²⁺ alternans occurred. This indicates triggering Ca waves. As the propagation of Ca waves is linked to the occurrence of Ca²⁺ alternans, the “threshold” for Ca waves reflects the key factor in Ca²⁺ alternans development, and it is still controversial nowadays. We proposed the ratio between the diastolic network SR (NSR) Ca content (Ca_nsr) and the cytoplasmic Ca content (Ca_i) (Ca_nsr/Ca_i) as the “threshold” of Ca waves and Ca²⁺ alternans. Diastolic Ca_nsr, Ca_i, and their ratio were recorded at the onset of Ca²⁺ alternans. Compared with certain Ca_nsr and Ca_i, the “threshold” of the ratio can better explain the comprehensive effects of the Ca²⁺ release and the Ca²⁺ uptake on Ca²⁺ alternans onset. In addition, these ratios are related with the function of SERCA pumps, which vary with different ischemic conditions. Thus, values of these ratios could be used to differentiate Ca²⁺ alternans from different ischemic cases. This agrees with some experimental results. Therefore, the certain value of diastolic Ca_nsr/Ca_i can be the better “threshold” for Ca waves and Ca²⁺ alternans.

Proarrhythmic Remodeling of Calcium Homeostasis in Cardiac Disease; Implications for Diabetes and Obesity

A rapid growth in the incidence of diabetes and obesity has transpired to a major heath issue and economic burden in the postindustrial world, with more than 29 million patients affected in the United States alone. Cardiovascular defects have been established as the leading cause of mortality and morbidity of diabetic patients. Over the last decade, significant progress has been made in delineating mechanisms responsible for the diminished cardiac contractile function and enhanced propensity for malignant cardiac arrhythmias characteristic of diabetic disease. Rhythmic cardiac contractility relies upon the precise interplay between several cellular Ca²⁺ transport protein complexes including plasmalemmal L-type Ca²⁺ channels (LTCC), Na⁺-Ca²⁺ exchanger (NCX1), Sarco/endoplasmic Reticulum (SR) Ca²⁺-ATPase (SERCa2a) and ryanodine receptors (RyR2s), the SR Ca²⁺ release channels. Here we provide an overview of changes in Ca²⁺ homeostasis in diabetic ventricular myocytes and discuss the therapeutic potential of targeting Ca²⁺ handling proteins in the prevention of diabetes-associated cardiomyopathy and arrhythmogenesis.

Proarrhythmic Remodeling of Calcium Homeostasis in Cardiac Disease; Implications for Diabetes and Obesity

A rapid growth in the incidence of diabetes and obesity has transpired to a major heath issue and economic burden in the postindustrial world, with more than 29 million patients affected in the United States alone. Cardiovascular defects have been established as the leading cause of mortality and morbidity of diabetic patients. Over the last decade, significant progress has been made in delineating mechanisms responsible for the diminished cardiac contractile function and enhanced propensity for malignant cardiac arrhythmias characteristic of diabetic disease. Rhythmic cardiac contractility relies upon the precise interplay between several cellular Ca²⁺ transport protein complexes including plasmalemmal L-type Ca²⁺ channels (LTCC), Na⁺-Ca²⁺ exchanger (NCX1), Sarco/endoplasmic Reticulum (SR) Ca²⁺-ATPase (SERCa2a) and ryanodine receptors (RyR2s), the SR Ca²⁺ release channels. Here we provide an overview of changes in Ca²⁺ homeostasis in diabetic ventricular myocytes and discuss the therapeutic potential of targeting Ca²⁺ handling proteins in the prevention of diabetes-associated cardiomyopathy and arrhythmogenesis.

Proarrhythmic Remodeling of Calcium Homeostasis in Cardiac Disease; Implications for Diabetes and Obesity

A rapid growth in the incidence of diabetes and obesity has transpired to a major heath issue and economic burden in the postindustrial world, with more than 29 million patients affected in the United States alone. Cardiovascular defects have been established as the leading cause of mortality and morbidity of diabetic patients. Over the last decade, significant progress has been made in delineating mechanisms responsible for the diminished cardiac contractile function and enhanced propensity for malignant cardiac arrhythmias characteristic of diabetic disease. Rhythmic cardiac contractility relies upon the precise interplay between several cellular Ca²⁺ transport protein complexes including plasmalemmal L-type Ca²⁺ channels (LTCC), Na⁺-Ca²⁺ exchanger (NCX1), Sarco/endoplasmic Reticulum (SR) Ca²⁺-ATPase (SERCa2a) and ryanodine receptors (RyR2s), the SR Ca²⁺ release channels. Here we provide an overview of changes in Ca²⁺ homeostasis in diabetic ventricular myocytes and discuss the therapeutic potential of targeting Ca²⁺ handling proteins in the prevention of diabetes-associated cardiomyopathy and arrhythmogenesis.

Modulation of Cardiac Alternans by Altered Sarcoplasmic Reticulum Calcium Release: A Simulation Study

Background: Cardiac alternans is an important precursor to arrhythmia, facilitating formation of conduction block, and re-entry. Diseased hearts were observed to be particularly vulnerable to alternans, mainly in heart failure or after myocardial infarction. Alternans is typically linked to oscillation of calcium cycling, particularly in the sarcoplasmic reticulum (SR). While the role of SR calcium reuptake in alternans is well established, the role of altered calcium release by ryanodine receptors has not yet been studied extensively. At the same time, there is strong evidence that calcium release is abnormal in heart failure and other heart diseases, suggesting that these changes might play a pro-alternans role.

Aims: To demonstrate how changes to intracellular calcium release dynamics and magnitude affect alternans vulnerability.

Methods: We used the state-of-the-art Heijman–Rudy and O’Hara–Rudy computer models of ventricular myocyte, given their detailed representation of calcium handling and their previous utility in alternans research. We modified the models to obtain precise control over SR release dynamics and magnitude, allowing for the evaluation of these properties in alternans formation and suppression.

Results: Shorter time to peak SR release and shorter release duration decrease alternans vulnerability by improved refilling of releasable calcium within junctional SR; conversely, slow release promotes alternans. Modulating the total amount of calcium released, we show that sufficiently increased calcium release may surprisingly prevent alternans via a mechanism linked to the functional depletion of junctional SR during release. We show that this mechanism underlies differences between “eye-type” and “fork-type” alternans, which were observed in human in vivo and in silico. We also provide a detailed explanation of alternans formation in the given computer models, termed “sarcoplasmic reticulum calcium cycling refractoriness.” The mechanism relies on the steep SR load–release relationship, combined with relatively limited rate of junctional SR refilling.

Conclusion: Both altered dynamics and magnitude of SR calcium release modulate alternans vulnerability. In particular, slow dynamics of SR release, such as those observed in heart failure, promote alternans. Therefore, acceleration of intracellular calcium release, e.g., via synchronization of calcium sparks, may inhibit alternans in failing hearts and reduce arrhythmia occurrence.

The cardiac ryanodine receptor, but not sarcoplasmic reticulum Ca2+-ATPase, is a major determinant of Ca2+ alternans in intact mouse hearts

Sarcoplasmic reticulum (SR) Ca²⁺ cycling is governed by the cardiac ryanodine receptor (RyR2) and SR Ca²⁺-ATPase (SERCA2a). Abnormal SR Ca²⁺ cycling is thought to be the primary cause of Ca²⁺ alternans that can elicit ventricular arrhythmias and sudden cardiac arrest. Although alterations in either RyR2 or SERCA2a function are expected to affect SR Ca²⁺ cycling, whether and to what extent altered RyR2 or SERCA2a function affects Ca²⁺ alternans is unclear. Here, we employed a gain-of-function RyR2 variant (R4496C) and the phospholamban-knockout (PLB-KO) mouse model to assess the effect of genetically enhanced RyR2 or SERCA2a function on Ca²⁺ alternans. Confocal Ca²⁺ imaging revealed that RyR2-R4496C shortened SR Ca²⁺ release refractoriness and markedly suppressed rapid pacing-induced Ca²⁺ alternans. Interestingly, despite enhancing RyR2 function, intact RyR2-R4496C hearts exhibited no detectable spontaneous SR Ca²⁺ release events during pacing. Unlike for RyR2, enhancing SERCA2a function by ablating PLB exerted a relatively minor effect on Ca²⁺ alternans in intact hearts expressing RyR2 WT or a loss-of-function RyR2 variant, E4872Q, that promotes Ca²⁺ alternans. Furthermore, partial SERCA2a inhibition with 3 μm 2,5-di-tert-butylhydroquinone (tBHQ) also had little impact on Ca²⁺ alternans, whereas strong SERCA2a inhibition with 10 μm tBHQ markedly reduced the amplitude of Ca²⁺ transients and suppressed Ca²⁺ alternans in intact hearts. Our results demonstrate that enhanced RyR2 function suppresses Ca²⁺ alternans in the absence of spontaneous Ca²⁺ release and that RyR2, but not SERCA2a, is a key determinant of Ca²⁺ alternans in intact working hearts, making RyR2 an important therapeutic target for cardiac alternans.

Alternans in atria: Mechanisms and clinical relevance

Atrial fibrillation is the most common sustained arrhythmia and its prevalence is rapidly rising with the aging of the population. Cardiac alternans, defined as cyclic beat-to-beat alternations in contraction force, action potential (AP) duration and intracellular Ca²⁺ release at constant stimulation rate, has been associated with the development of ventricular arrhythmias. Recent clinical data also provide strong evidence that alternans plays a central role in arrhythmogenesis in atria. The aim of this article is to review the mechanisms that are responsible for repolarization alternans and contribute to the transition from spatially concordant alternans to the more arrhythmogenic spatially discordant alternans in atria.

Functional Implications of Cardiac Mitochondria Clustering

The spatio-temporal organization of mitochondria in cardiac myocytes facilitates myocyte-wide, cluster-bound, mitochondrial inner membrane potential oscillatory depolarizations, commonly triggered by metabolic or oxidative stressors. Local intermitochondrial coupling can be mediated by reactive oxygen species (ROS) that activate inner membrane pores to initiate a ROS-induced-ROS-release process that produces synchronized limit cycle oscillations of mitochondrial clusters within the whole mitochondrial network. The network's dynamic organization, structure and function can be assessed by quantifying dynamic local coupling constants and dynamic functional clustering coefficients, both providing information about the network's response to external stimuli. In addition to its special organization, the mitochondrial network of cardiac myocytes exhibits substrate-sensitive coupling constants and clustering coefficients. The myocyte's ability to form functional clusters of synchronously oscillating mitochondria is sensitive to conditions such as substrate availability (e.g., glucose, pyruvate, β-hydroxybutyrate), antioxidant status, respiratory chain activity, or history of oxidative challenge (e.g., ischemia-reperfusion). This underscores the relevance of quantitative methods to characterize the network's functional status as a way to assess the myocyte's resilience to pathological stressors.