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Bartolucci C, Mesirca P, Ricci E, Sales-Bellés C, Torre E, Louradour J, Mangoni ME, Severi S. Computational modelling of mouse atrio ventricular node action potential and automaticity. J Physiol 2024. [PMID: 39269369 DOI: 10.1113/jp285950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 08/08/2024] [Indexed: 09/15/2024] Open
Abstract
The atrioventricular node (AVN) is a crucial component of the cardiac conduction system. Despite its pivotal role in regulating the transmission of electrical signals between atria and ventricles, a comprehensive understanding of the cellular electrophysiological mechanisms governing AVN function has remained elusive. This paper presents a detailed computational model of mouse AVN cell action potential (AP). Our model builds upon previous work and introduces several key refinements, including accurate representation of membrane currents and exchangers, calcium handling, cellular compartmentalization, dynamic update of intracellular ion concentrations, and calcium buffering. We recalibrated and validated the model against existing and unpublished experimental data. In control conditions, our model reproduces the AVN AP experimental features, (e.g. rate = 175 bpm, experimental range [121, 191] bpm). Notably, our study sheds light on the contribution of L-type calcium currents, through both Cav1.2 and Cav1.3 channels, in AVN cells. The model replicates several experimental observations, including the cessation of firing upon block of Cav1.3 or INa,r current. If block induces a reduction in beating rate of 11%. In summary, this work presents a comprehensive computational model of mouse AVN cell AP, offering a valuable tool for investigating pacemaking mechanisms and simulating the impact of ionic current blockades. By integrating calcium handling and refining formulation of ionic currents, our model advances understanding of this critical component of the cardiac conduction system, providing a platform for future developments in cardiac electrophysiology. KEY POINTS: This paper introduces a comprehensive computational model of mouse atrioventricular node (AVN) cell action potentials (APs). Our model is based on the electrophysiological data from isolated mouse AVN cells and exhibits an action potential and calcium transient that closely match the experimental records. By simulating the effects of blocking specific ionic currents, the model effectively predicts the roles of L-type Cav1.2 and Cav1.3 channels, T-type calcium channels, sodium currents (TTX-sensitive and TTX-resistant), and the funny current (If) in AVN pacemaking. The study also emphasizes the significance of other ionic currents, including IKr, Ito, IKur, in regulating AP characteristics and cycle length in AVN cells. The model faithfully reproduces the rate dependence of action potentials under pacing, opening the possibility of use in impulse propagation models. The population-of-models approach showed the robustness of this new AP model in simulating a wide spectrum of cellular pacemaking in AVN.
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Affiliation(s)
- Chiara Bartolucci
- Computational Physiopathology Unit, Department of Electrical, Electronic and Information Engineering 'Guglielmo Marconi,', University of Bologna, Cesena, Italy
| | - Pietro Mesirca
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
- LabEx Ion Channels Science and Therapeutics (ICST), Montpellier, France
| | - Eugenio Ricci
- Computational Physiopathology Unit, Department of Electrical, Electronic and Information Engineering 'Guglielmo Marconi,', University of Bologna, Cesena, Italy
| | - Clara Sales-Bellés
- BSICoS group, I3A Institute, University of Zaragoza, IIS Aragón, Zaragoza, Spain
| | - Eleonora Torre
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
- LabEx Ion Channels Science and Therapeutics (ICST), Montpellier, France
| | - Julien Louradour
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
- LabEx Ion Channels Science and Therapeutics (ICST), Montpellier, France
| | - Matteo Elia Mangoni
- Institut de Génomique Fonctionnelle, Université de Montpellier, CNRS, INSERM, Montpellier, France
- LabEx Ion Channels Science and Therapeutics (ICST), Montpellier, France
| | - Stefano Severi
- Computational Physiopathology Unit, Department of Electrical, Electronic and Information Engineering 'Guglielmo Marconi,', University of Bologna, Cesena, Italy
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2
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Giles WR. The zebrafish atrioventricular canal: A model for mammalian AV node conduction and secondary or follower pacemaker activity. Acta Physiol (Oxf) 2024; 240:e14105. [PMID: 38270514 DOI: 10.1111/apha.14105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Affiliation(s)
- W R Giles
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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3
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Shima N, Yamamura A, Fujiwara M, Amano T, Matsumoto K, Sekine T, Okano H, Kondo R, Suzuki Y, Yamamura H. Up-regulated expression of two-pore domain K + channels, KCNK1 and KCNK2, is involved in the proliferation and migration of pulmonary arterial smooth muscle cells in pulmonary arterial hypertension. Front Cardiovasc Med 2024; 11:1343804. [PMID: 38410243 PMCID: PMC10894933 DOI: 10.3389/fcvm.2024.1343804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/29/2024] [Indexed: 02/28/2024] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is a severe and rare disease in the cardiopulmonary system. Its pathogenesis involves vascular remodeling of the pulmonary artery, which results in progressive increases in pulmonary arterial pressure. Chronically increased pulmonary arterial pressure causes right ventricular hypertrophy and subsequent right heart failure. Pulmonary vascular remodeling is attributed to the excessive proliferation and migration of pulmonary arterial smooth muscle cells (PASMCs), which are induced by enhanced Ca2+ signaling following the up-/down-regulation of ion channel expression. Objectives In the present study, the functional expression of two-pore domain potassium KCNK channels was investigated in PASMCs from idiopathic PAH (IPAH) patients and experimental pulmonary hypertensive (PH) animals. Results In IPAH-PASMCs, the expression of KCNK1/TWIK1 and KCNK2/TREK1 channels was up-regulated, whereas that of KCNK3/TASK1 and KCNK6/TWIK2 channels was down-regulated. The similar up-regulated expression of KCNK1 and KCNK2 channels was observed in the pulmonary arterial smooth muscles of monocrotaline-induced PH rats, Sugen 5416/hypoxia-induced PH rats, and hypoxia-induced PH mice. The facilitated proliferation of IPAH-PASMCs was suppressed by the KCNK channel blockers, quinine and tetrapentylammonium. The migration of IPAH-PASMCs was also suppressed by these channel blockers. Furthermore, increases in the proliferation and migration were inhibited by the siRNA knockdown of KCNK1 or KCNK2 channels. The siRNA knockdown also caused membrane depolarization and subsequent decrease in cytosolic [Ca2+]. The phosphorylated level of c-Jun N-terminal kinase (JNK) was elevated in IPAH-PASMCs compared to normal-PASMCs. The increased phosphorylation was significantly reduced by the siRNA knockdown of KCNK1 or KCNK2 channels. Conclusion Collectively, these findings indicate that the up-regulated expression of KCNK1 and KCNK2 channels facilitates the proliferation and migration of PASMCs via enhanced Ca2+ signaling and JNK signaling pathway, which is associated with vascular remodeling in PAH.
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Affiliation(s)
- Natsumi Shima
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Aya Yamamura
- Department of Physiology, Aichi Medical University, Nagakute, Japan
| | - Moe Fujiwara
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Taiki Amano
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Kazuyuki Matsumoto
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Taiga Sekine
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Haruka Okano
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Rubii Kondo
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Yoshiaki Suzuki
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
| | - Hisao Yamamura
- Department of Molecular and Cellular Pharmacology, Graduate School of Pharmaceutical Sciences, Nagoya City University, Nagoya, Japan
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4
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Chinnappa S, Maqbool A, Viswambharan H, Mooney A, Denby L, Drinkhill M. Beta Blockade Prevents Cardiac Morphological and Molecular Remodelling in Experimental Uremia. Int J Mol Sci 2023; 25:373. [PMID: 38203544 PMCID: PMC10778728 DOI: 10.3390/ijms25010373] [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: 11/21/2023] [Revised: 12/18/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
Heart failure and chronic kidney disease (CKD) share several mediators of cardiac pathological remodelling. Akin to heart failure, this remodelling sets in motion a vicious cycle of progressive pathological hypertrophy and myocardial dysfunction in CKD. Several decades of heart failure research have shown that beta blockade is a powerful tool in preventing cardiac remodelling and breaking this vicious cycle. This phenomenon remains hitherto untested in CKD. Therefore, we set out to test the hypothesis that beta blockade prevents cardiac pathological remodelling in experimental uremia. Wistar rats had subtotal nephrectomy or sham surgery and were followed up for 10 weeks. The animals were randomly allocated to the beta blocker metoprolol (10 mg/kg/day) or vehicle. In vivo and in vitro cardiac assessments were performed. Cardiac tissue was extracted, and protein expression was quantified using immunoblotting. Histological analyses were performed to quantify myocardial fibrosis. Beta blockade attenuated cardiac pathological remodelling in nephrectomised animals. The echocardiographic left ventricular mass and the heart weight to tibial length ratio were significantly lower in nephrectomised animals treated with metoprolol. Furthermore, beta blockade attenuated myocardial fibrosis associated with subtotal nephrectomy. In addition, the Ca++- calmodulin-dependent kinase II (CAMKII) pathway was shown to be activated in uremia and attenuated by beta blockade, offering a potential mechanism of action. In conclusion, beta blockade attenuated hypertrophic signalling pathways and ameliorated cardiac pathological remodelling in experimental uremia. The study provides a strong scientific rationale for repurposing beta blockers, a tried and tested treatment in heart failure, for the benefit of patients with CKD.
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Affiliation(s)
- Shanmugakumar Chinnappa
- Department of Nephrology, Doncaster and Bassetlaw Teaching Hospitals NHS Trust, Doncaster DN2 5LT, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds LS2 9JT, UK; (A.M.); (H.V.)
| | - Azhar Maqbool
- Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds LS2 9JT, UK; (A.M.); (H.V.)
| | - Hema Viswambharan
- Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds LS2 9JT, UK; (A.M.); (H.V.)
| | - Andrew Mooney
- Department of Nephrology, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK;
| | - Laura Denby
- Centre for Cardiovascular Science, The Queen’s Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, UK;
| | - Mark Drinkhill
- Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds LS2 9JT, UK; (A.M.); (H.V.)
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5
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Saint-Martin Willer A, Santos-Gomes J, Adão R, Brás-Silva C, Eyries M, Pérez-Vizcaino F, Capuano V, Montani D, Antigny F. Physiological and pathophysiological roles of the KCNK3 potassium channel in the pulmonary circulation and the heart. J Physiol 2023; 601:3717-3737. [PMID: 37477289 DOI: 10.1113/jp284936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/04/2023] [Indexed: 07/22/2023] Open
Abstract
Potassium channel subfamily K member 3 (KCNK3), encoded by the KCNK3 gene, is part of the two-pore domain potassium channel family, constitutively active at resting membrane potentials in excitable cells, including smooth muscle and cardiac cells. Several physiological and pharmacological mediators, such as intracellular signalling pathways, extracellular pH, hypoxia and anaesthetics, regulate KCNK3 channel function. Recent studies show that modulation of KCNK3 channel expression and function strongly influences pulmonary vascular cell and cardiomyocyte function. The altered activity of KCNK3 in pathological situations such as atrial fibrillation, pulmonary arterial hypertension and right ventricular dysfunction demonstrates the crucial role of KCNK3 in cardiovascular homeostasis. Furthermore, loss of function variants of KCNK3 have been identified in patients suffering from pulmonary arterial hypertension and atrial fibrillation. This review focuses on current knowledge of the role of the KCNK3 channel in pulmonary circulation and the heart, in healthy and pathological conditions.
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Affiliation(s)
- Anaïs Saint-Martin Willer
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 'Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique', Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Joana Santos-Gomes
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rui Adão
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
- CIBER Enfermedades Respiratorias (Ciberes), Madrid, Spain
| | - Carmen Brás-Silva
- Cardiovascular R&D Centre-UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mélanie Eyries
- Département de génétique, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
- INSERM UMRS1166, ICAN - Institute of CardioMetabolism and Nutrition, Sorbonne Université, Paris, France
| | - Francisco Pérez-Vizcaino
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
- CIBER Enfermedades Respiratorias (Ciberes), Madrid, Spain
| | - Véronique Capuano
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 'Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique', Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - David Montani
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 'Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique', Hôpital Marie Lannelongue, Le Plessis-Robinson, France
- Assistance Publique - Hôpitaux de Paris (AP-HP), Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Fabrice Antigny
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999 'Hypertension Pulmonaire: Physiopathologie et Innovation Thérapeutique', Hôpital Marie Lannelongue, Le Plessis-Robinson, France
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6
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Keefe JA, Wehrens XHT. Anti-Ro/SSA Antibodies in Atrioventricular Block: Innocent Bystander or Mechanistic Driver? JACC Clin Electrophysiol 2023; 9:1649-1651. [PMID: 37354190 DOI: 10.1016/j.jacep.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/10/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Joshua A Keefe
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA; Department of Integrative Physiology, Baylor College of Medicine, Houston, Texas, USA
| | - Xander H T Wehrens
- Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA; Department of Integrative Physiology, Baylor College of Medicine, Houston, Texas, USA; Department of Medicine (Division of Cardiology), Baylor College of Medicine, Houston, Texas, USA; Department of Neuroscience, Baylor College of Medicine, Houston, Texas, USA; Department of Pediatrics (Division of Cardiology), Baylor College of Medicine, Houston, Texas, USA; Center for Space Medicine, Baylor College of Medicine, Houston, Texas, USA.
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7
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Deng J, Jiang Y, Chen ZB, Rhee JW, Deng Y, Wang ZV. Mitochondrial Dysfunction in Cardiac Arrhythmias. Cells 2023; 12:679. [PMID: 36899814 PMCID: PMC10001005 DOI: 10.3390/cells12050679] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/14/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
Electrophysiological and structural disruptions in cardiac arrhythmias are closely related to mitochondrial dysfunction. Mitochondria are an organelle generating ATP, thereby satisfying the energy demand of the incessant electrical activity in the heart. In arrhythmias, the homeostatic supply-demand relationship is impaired, which is often accompanied by progressive mitochondrial dysfunction leading to reduced ATP production and elevated reactive oxidative species generation. Furthermore, ion homeostasis, membrane excitability, and cardiac structure can be disrupted through pathological changes in gap junctions and inflammatory signaling, which results in impaired cardiac electrical homeostasis. Herein, we review the electrical and molecular mechanisms of cardiac arrhythmias, with a particular focus on mitochondrial dysfunction in ionic regulation and gap junction action. We provide an update on inherited and acquired mitochondrial dysfunction to explore the pathophysiology of different types of arrhythmias. In addition, we highlight the role of mitochondria in bradyarrhythmia, including sinus node dysfunction and atrioventricular node dysfunction. Finally, we discuss how confounding factors, such as aging, gut microbiome, cardiac reperfusion injury, and electrical stimulation, modulate mitochondrial function and cause tachyarrhythmia.
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Affiliation(s)
- Jielin Deng
- Department of Diabetes and Cancer Metabolism, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Yunqiu Jiang
- Department of Diabetes and Cancer Metabolism, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
- Irell and Manella Graduate School of Biological Sciences, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Zhen Bouman Chen
- Irell and Manella Graduate School of Biological Sciences, City of Hope National Medical Center, Duarte, CA 91010, USA
- Department of Diabetes Complications and Metabolism, Arthur Riggs Diabetes and Metabolism Research Institute, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
- City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
| | - June-Wha Rhee
- Irell and Manella Graduate School of Biological Sciences, City of Hope National Medical Center, Duarte, CA 91010, USA
- City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
- Department of Medicine, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Yingfeng Deng
- Department of Diabetes and Cancer Metabolism, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
- Irell and Manella Graduate School of Biological Sciences, City of Hope National Medical Center, Duarte, CA 91010, USA
| | - Zhao V. Wang
- Department of Diabetes and Cancer Metabolism, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA 91010, USA
- Irell and Manella Graduate School of Biological Sciences, City of Hope National Medical Center, Duarte, CA 91010, USA
- City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA
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8
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Perez-Vizcaino F, Cogolludo A, Mondejar-Parreño G. Transcriptomic profile of cationic channels in human pulmonary arterial hypertension. Sci Rep 2021; 11:15829. [PMID: 34349187 PMCID: PMC8338963 DOI: 10.1038/s41598-021-95196-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/19/2021] [Indexed: 12/27/2022] Open
Abstract
The dysregulation of K+ channels is a hallmark of pulmonary arterial hypertension (PAH). Herein, the channelome was analyzed in lungs of patients with PAH in a public transcriptomic database. Sixty six (46%) mRNA encoding cationic channels were dysregulated in PAH with most of them downregulated (83%). The principal component analysis indicated that dysregulated cationic channel expression is a signature of the disease. Changes were very similar in idiopathic, connective tissue disease and congenital heart disease associated PAH. This analysis 1) is in agreement with the widely recognized pathophysiological role of TASK1 and KV1.5, 2) supports previous preliminary reports pointing to the dysregulation of several K+ channels including the downregulation of KV1.1, KV1.4, KV1.6, KV7.1, KV7.4, KV9.3 and TWIK2 and the upregulation of KCa1.1 and 3) points to other cationic channels dysregulated such as Kv7.3, TALK2, CaV1 and TRPV4 which might play a pathophysiological role in PAH. The significance of other changes found in Na+ and TRP channels remains to be investigated.
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Affiliation(s)
- Francisco Perez-Vizcaino
- Department of Pharmacology and Toxicology. School of Medicine, Universidad Complutense de Madrid, Madrid, Spain. .,Ciber Enfermedades Respiratorias (Ciberes), Madrid, Spain. .,Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain.
| | - Angel Cogolludo
- Department of Pharmacology and Toxicology. School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,Ciber Enfermedades Respiratorias (Ciberes), Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
| | - Gema Mondejar-Parreño
- Department of Pharmacology and Toxicology. School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,Ciber Enfermedades Respiratorias (Ciberes), Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón (IISGM), Madrid, Spain
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9
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Zaky A, Zafar I, Masjoan-Juncos JX, Husain M, Mariappan N, Morgan CJ, Hamid T, Frölich MA, Ahmad S, Ahmad A. Echocardiographic, Biochemical, and Electrocardiographic Correlates Associated With Progressive Pulmonary Arterial Hypertension. Front Cardiovasc Med 2021; 8:705666. [PMID: 34355033 PMCID: PMC8329095 DOI: 10.3389/fcvm.2021.705666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 06/09/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Pulmonary arterial hypertension (PAH) is a progressive proliferative vasculopathy associated with mechanical and electrical changes, culminating in increased vascular resistance, right ventricular (RV) failure, and death. With a main focus on invasive tools, there has been an underutilization of echocardiography, electrocardiography, and biomarkers to non-invasively assess the changes in myocardial and pulmonary vascular structure and function during the course of PAH. Methods: A SU5416-hypoxia rat model was used for inducing PAH. Biventricular functions were measured using transthoracic two-dimensional (2D) echocardiography/Doppler (echo/Doppler) at disease onset (0 week), during progression (3 weeks), and establishment (5 weeks). Similarly, electrocardiography was performed at 0, 3, and 5 weeks. Invasive hemodynamic measurements and markers of cardiac injury in plasma were assessed at 0, 3, and 5 weeks. Results: Increased RV systolic pressure (RVSP) and rate of isovolumic pressure rise and decline were observed at 0, 3, and 5 weeks in PAH animals. EKG showed a steady increase in QT-interval with progression of PAH, whereas P-wave height and RS width were increased only during the initial stages of PAH progression. Echocardiographic markers of PAH progression and severity were also identified. Three echocardiographic patterns were observed: a steady pattern (0-5 weeks) in which echo parameter changed progressively with severity [inferior vena cava (IVC) expiratory diameter and pulmonary artery acceleration time (PAAT)], an early pattern (0-3 weeks) where there is an early change in parameters [RV fractional area change (RV-FAC), transmitral flow, left ventricle (LV) output, estimated mean PA pressure, RV performance index, and LV systolic eccentricity index], and a late pattern (3-5 weeks) in which there is only a late rise at advanced stages of PAH (LV diastolic eccentricity index). RVSP correlated with PAAT, PAAT/PA ejection times, IVC diameters, RV-FAC, tricuspid systolic excursion, LV systolic eccentricity and output, and transmitral flow. Plasma myosin light chain (Myl-3) and cardiac troponin I (cTnI) increased progressively across the three time points. Cardiac troponin T (cTnT) and fatty acid-binding protein-3 (FABP-3) were significantly elevated only at the 5-week time point. Conclusion: Distinct electrocardiographic and echocardiographic patterns along with plasma biomarkers were identified as useful non-invasive tools for monitoring PAH progression.
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Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Iram Zafar
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Juan Xavier Masjoan-Juncos
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Maroof Husain
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Nithya Mariappan
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Charity J. Morgan
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tariq Hamid
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael A. Frölich
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Shama Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Aftab Ahmad
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
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10
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Mesirca P, Nakao S, Nissen SD, Forte G, Anderson C, Trussell T, Li J, Cox C, Zi M, Logantha S, Yaar S, Cartensen H, Bidaud I, Stuart L, Soattin L, Morris GM, da Costa Martins PA, Cartwright EJ, Oceandy D, Mangoni ME, Jespersen T, Buhl R, Dobrzynski H, Boyett MR, D'Souza A. Intrinsic Electrical Remodeling Underlies Atrioventricular Block in Athletes. Circ Res 2021; 129:e1-e20. [PMID: 33849278 DOI: 10.1161/circresaha.119.316386] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Pietro Mesirca
- IGF, Université de Montpellier, CNRS, INSERM, France (P.M., I.B., M.E.M.)
| | - Shu Nakao
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
- Department of Biomedical Sciences, Ritsumeikan University, Japan (S.N.)
| | - Sarah Dalgas Nissen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences (S.D.N., H.C., R.B.), University of Copenhagen, Denmark
| | - Gabriella Forte
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Cali Anderson
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Tariq Trussell
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Jue Li
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Charlotte Cox
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Min Zi
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Sunil Logantha
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
- Liverpool Centre for Cardiovascular Sciences, University of Liverpool, United Kingdom (S.L.)
| | - Sana Yaar
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Helena Cartensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences (S.D.N., H.C., R.B.), University of Copenhagen, Denmark
| | - Isabelle Bidaud
- IGF, Université de Montpellier, CNRS, INSERM, France (P.M., I.B., M.E.M.)
| | - Luke Stuart
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | | | - Gwilym M Morris
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | | | - Elizabeth J Cartwright
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Delvac Oceandy
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
| | - Matteo E Mangoni
- IGF, Université de Montpellier, CNRS, INSERM, France (P.M., I.B., M.E.M.)
| | - Thomas Jespersen
- Department of Biomedical Sciences (T.J., M.R.B.), University of Copenhagen, Denmark
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences (S.D.N., H.C., R.B.), University of Copenhagen, Denmark
| | - Halina Dobrzynski
- Department of Anatomy, Jagiellonian University Medical College, Poland (H.D.)
| | - Mark R Boyett
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
- Department of Biomedical Sciences (T.J., M.R.B.), University of Copenhagen, Denmark
| | - Alicia D'Souza
- Division of Cardiovascular Sciences, University of Manchester, United Kingdom (S.N., G.F., C.A., T.T., J.L., C.C., M.Z., S.L., S.Y., L. Stuart, L. Soattin, G.M.M., E.J.C., D.O., H.D., M.R.B., A.D.)
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11
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Amuzescu B, Airini R, Epureanu FB, Mann SA, Knott T, Radu BM. Evolution of mathematical models of cardiomyocyte electrophysiology. Math Biosci 2021; 334:108567. [PMID: 33607174 DOI: 10.1016/j.mbs.2021.108567] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/10/2021] [Accepted: 02/04/2021] [Indexed: 12/16/2022]
Abstract
Advanced computational techniques and mathematical modeling have become more and more important to the study of cardiac electrophysiology. In this review, we provide a brief history of the evolution of cardiomyocyte electrophysiology models and highlight some of the most important ones that had a major impact on our understanding of the electrical activity of the myocardium and associated transmembrane ion fluxes in normal and pathological states. We also present the use of these models in the study of various arrhythmogenesis mechanisms, particularly the integration of experimental pharmacology data into advanced humanized models for in silico proarrhythmogenic risk prediction as an essential component of the Comprehensive in vitro Proarrhythmia Assay (CiPA) drug safety paradigm.
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Affiliation(s)
- Bogdan Amuzescu
- Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, 91-95 Splaiul Independentei, Bucharest 050095, Romania; Life, Environmental and Earth Sciences Division, Research Institute of the University of Bucharest (ICUB), 91-95 Splaiul Independentei, Bucharest 050095, Romania.
| | - Razvan Airini
- Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, 91-95 Splaiul Independentei, Bucharest 050095, Romania; Life, Environmental and Earth Sciences Division, Research Institute of the University of Bucharest (ICUB), 91-95 Splaiul Independentei, Bucharest 050095, Romania
| | - Florin Bogdan Epureanu
- Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, 91-95 Splaiul Independentei, Bucharest 050095, Romania; Life, Environmental and Earth Sciences Division, Research Institute of the University of Bucharest (ICUB), 91-95 Splaiul Independentei, Bucharest 050095, Romania
| | - Stefan A Mann
- Cytocentrics Bioscience GmbH, Nattermannallee 1, 50829 Cologne, Germany
| | - Thomas Knott
- CytoBioScience Inc., 3463 Magic Drive, San Antonio, TX 78229, USA
| | - Beatrice Mihaela Radu
- Department of Anatomy, Animal Physiology and Biophysics, Faculty of Biology, University of Bucharest, 91-95 Splaiul Independentei, Bucharest 050095, Romania; Life, Environmental and Earth Sciences Division, Research Institute of the University of Bucharest (ICUB), 91-95 Splaiul Independentei, Bucharest 050095, Romania
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12
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Boengler K, Rohrbach S, Weissmann N, Schulz R. Importance of Cx43 for Right Ventricular Function. Int J Mol Sci 2021; 22:ijms22030987. [PMID: 33498172 PMCID: PMC7863922 DOI: 10.3390/ijms22030987] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
In the heart, connexins form gap junctions, hemichannels, and are also present within mitochondria, with connexin 43 (Cx43) being the most prominent connexin in the ventricles. Whereas the role of Cx43 is well established for the healthy and diseased left ventricle, less is known about the importance of Cx43 for the development of right ventricular (RV) dysfunction. The present article focusses on the importance of Cx43 for the developing heart. Furthermore, we discuss the expression and localization of Cx43 in the diseased RV, i.e., in the tetralogy of Fallot and in pulmonary hypertension, in which the RV is affected, and RV hypertrophy and failure occur. We will also introduce other Cx molecules that are expressed in RV and surrounding tissues and have been reported to be involved in RV pathophysiology. Finally, we highlight therapeutic strategies aiming to improve RV function in pulmonary hypertension that are associated with alterations of Cx43 expression and function.
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13
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Alghamdi AM, Boyett MR, Hancox JC, Zhang H. Cardiac Pacemaker Dysfunction Arising From Different Studies of Ion Channel Remodeling in the Aging Rat Heart. Front Physiol 2020; 11:546508. [PMID: 33343378 PMCID: PMC7744970 DOI: 10.3389/fphys.2020.546508] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 11/13/2020] [Indexed: 12/19/2022] Open
Abstract
The function of the sinoatrial node (SAN), the pacemaker of the heart, declines with age, resulting in increased incidence of sinoatrial node dysfunction (SND) in older adults. The present study assesses potential ionic mechanisms underlying age associated SND. Two group studies have identified complex and various changes in some of membrane ion channels in aged rat SAN, the first group (Aging Study-1) indicates a considerable changes of gene expression with up-regulation of mRNA in ion channels of Cav1.2, Cav1.3 and KvLQT1, Kv4.2, and the Ca2+ handling proteins of SERCA2a, and down-regulation of Cav3.1, NCX, and HCN1 and the Ca2+-clock proteins of RYR2. The second group (Aging Study-2) suggests a different pattern of changes, including down regulation of Cav1.2, Cav1.3 and HCN4, and RYR2, and an increase of NCX and SERCA densities and proteins. Although both data sets shared a similar finding for some specific ion channels, such as down regulation of HCN4, NCX, and RYR2, there are contradictory changes for some other membrane ion channels, such as either up-regulation or down-regulation of Cav1.2, NCX and SERCA2a in aged rat SAN. The present study aims to test a hypothesis that age-related SND may arise from different ionic and molecular remodeling patterns. To test this hypothesis, a mathematical model of the electrical action potential of rat SAN myocytes was modified to simulate the functional impact of age-induced changes on membrane ion channels and intracellular Ca2+ handling as observed in Aging Study-1 and Aging Study-2. The role and relative importance of each individually remodeled ion channels and Ca2+-handling in the two datasets were evaluated. It was shown that the age-induced changes in ion channels and Ca2+-handling, based on either Aging Study-1 or Aging Study-2, produced similar bradycardic effects as manifested by a marked reduction in the heart rate (HR) that matched experimental observations. Further analysis showed that although the SND arose from an integrated action of all remodeling of ion channels and Ca2+-handling in both studies, it was the change to I CaL that played the most important influence.
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Affiliation(s)
- Aaazh M Alghamdi
- Biological Physics Group, Department of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom.,Department of Physics, Faculty of Science, University of Jeddah, Jeddah, Saudi Arabia
| | - Mark R Boyett
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jules C Hancox
- Biological Physics Group, Department of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom.,School of Physiology, Pharmacology and Neuroscience, and Cardiovascular Research Laboratories, Faculty of Life Sciences, University of Bristol, Bristol, United Kingdom
| | - Henggui Zhang
- Biological Physics Group, Department of Physics and Astronomy, The University of Manchester, Manchester, United Kingdom.,Peng Cheng Laboratory, Shenzhen, China.,Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
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14
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Clauss S, Bleyer C, Schüttler D, Tomsits P, Renner S, Klymiuk N, Wakili R, Massberg S, Wolf E, Kääb S. Animal models of arrhythmia: classic electrophysiology to genetically modified large animals. Nat Rev Cardiol 2020; 16:457-475. [PMID: 30894679 DOI: 10.1038/s41569-019-0179-0] [Citation(s) in RCA: 123] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Arrhythmias are common and contribute substantially to cardiovascular morbidity and mortality. The underlying pathophysiology of arrhythmias is complex and remains incompletely understood, which explains why mostly only symptomatic therapy is available. The evaluation of the complex interplay between various cell types in the heart, including cardiomyocytes from the conduction system and the working myocardium, fibroblasts and cardiac immune cells, remains a major challenge in arrhythmia research because it can be investigated only in vivo. Various animal species have been used, and several disease models have been developed to study arrhythmias. Although every species is useful and might be ideal to study a specific hypothesis, we suggest a practical trio of animal models for future use: mice for genetic investigations, mechanistic evaluations or early studies to identify potential drug targets; rabbits for studies on ion channel function, repolarization or re-entrant arrhythmias; and pigs for preclinical translational studies to validate previous findings. In this Review, we provide a comprehensive overview of different models and currently used species for arrhythmia research, discuss their advantages and disadvantages and provide guidance for researchers who are considering performing in vivo studies.
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Affiliation(s)
- Sebastian Clauss
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians University Munich (LMU), Munich, Germany. .,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.
| | - Christina Bleyer
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians University Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
| | - Dominik Schüttler
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians University Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
| | - Philipp Tomsits
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians University Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
| | - Simone Renner
- Institute of Molecular Animal Breeding and Biotechnology, Ludwig-Maximilians University Munich (LMU), Munich, Germany.,DZD (German Centre for Diabetes Research), Neuherberg, Germany
| | - Nikolai Klymiuk
- Institute of Molecular Animal Breeding and Biotechnology, Ludwig-Maximilians University Munich (LMU), Munich, Germany
| | - Reza Wakili
- Universitätsklinikum Essen, Westdeutsches Herz- und Gefäßzentrum Essen, Essen, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians University Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
| | - Eckhard Wolf
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany.,Institute of Molecular Animal Breeding and Biotechnology, Ludwig-Maximilians University Munich (LMU), Munich, Germany.,DZD (German Centre for Diabetes Research), Neuherberg, Germany
| | - Stefan Kääb
- Department of Medicine I, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians University Munich (LMU), Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Munich, Germany
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15
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Antigny F, Mercier O, Humbert M, Sabourin J. Excitation-contraction coupling and relaxation alteration in right ventricular remodelling caused by pulmonary arterial hypertension. Arch Cardiovasc Dis 2020; 113:70-84. [DOI: 10.1016/j.acvd.2019.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 10/18/2019] [Accepted: 10/23/2019] [Indexed: 02/09/2023]
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16
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D’Souza A, Trussell T, Morris GM, Dobrzynski H, Boyett MR. Supraventricular Arrhythmias in Athletes: Basic Mechanisms and New Directions. Physiology (Bethesda) 2019; 34:314-326. [DOI: 10.1152/physiol.00009.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Athletes are prone to supraventricular rhythm disturbances including sinus bradycardia, heart block, and atrial fibrillation. Mechanistically, this is attributed to high vagal tone and cardiac electrical and structural remodeling. Here, we consider the supporting evidence for these three pro-arrhythmic mechanisms in athletic human cohorts and animal models, featuring current controversies, emerging data, and future directions of relevance to the translational research agenda.
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Affiliation(s)
- Alicia D’Souza
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Tariq Trussell
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Gwilym M. Morris
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Halina Dobrzynski
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Mark R. Boyett
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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17
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Simvastatin causes pulmonary artery relaxation by blocking smooth muscle ROCK and calcium channels: Evidence for an endothelium-independent mechanism. PLoS One 2019; 14:e0220473. [PMID: 31369604 PMCID: PMC6675113 DOI: 10.1371/journal.pone.0220473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/16/2019] [Indexed: 01/13/2023] Open
Abstract
Simvastatin reduces pulmonary arterial pressure and right ventricular hypertrophy in animal models of pulmonary arterial hypertension (PAH) and is thought to restore endothelial dysfunction. In vivo effects of drugs are complicated by several factors and little is known of the direct effects of statins on pulmonary arteries. This study investigated the direct effects of simvastatin on pulmonary arteries isolated from rats with or without monocrotaline-induced PAH. Simvastatin suppressed contractions evoked by the thromboxane A2 receptor agonist U46619 (30 nM), the α1–adrenergic agonist phenylephrine (5 μM) and KCl (50 mM) by ~50% in healthy and diseased arteries, but did not reduce contraction evoked by sarco/endoplasmic reticulum ATPase blockers. It relaxed hypertensive arteries in the absence of stimulation. Removing the endothelium or inhibiting eNOS did not prevent the inhibition by simvastatin. Inhibiting RhoA/rho kinase (ROCK) with Y27632 (10 μM) suppressed contractions to U46619 and phenylephrine by ~80% and prevented their inhibition by simvastatin. Y27632 reduced KCl-induced contraction by ~30%, but did not prevent simvastatin inhibition. Simvastatin suppressed Ca2+ entry into smooth muscle cells, as detected by Mn2+ quench of fura-2 fluorescence. The calcium antagonist, nifedipine (1 μM), almost abolished K+-induced contraction with less effect against U46619 and phenylephrine. We conclude that simvastatin relaxes pulmonary arteries by acting on smooth muscle to interfere with signalling through G-protein coupled receptors and voltage-dependent Ca2+ entry. Its actions likely include inhibition of ROCK-dependent Ca2+ sensitisation and voltage-gated Ca2+ channels. These are likely to contribute to the beneficial effects of simvastatin in animal models of PAH.
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18
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Strauss B, Sassi Y, Bueno-Beti C, Ilkan Z, Raad N, Cacheux M, Bisserier M, Turnbull IC, Kohlbrenner E, Hajjar RJ, Hadri L, Akar FG. Intra-tracheal gene delivery of aerosolized SERCA2a to the lung suppresses ventricular arrhythmias in a model of pulmonary arterial hypertension. J Mol Cell Cardiol 2018; 127:20-30. [PMID: 30502350 DOI: 10.1016/j.yjmcc.2018.11.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/21/2018] [Accepted: 11/24/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) results in right ventricular (RV) failure, electro-mechanical dysfunction and heightened risk of sudden cardiac death (SCD), although exact mechanisms and predisposing factors remain unclear. Because impaired chronotropic response to exercise is a strong predictor of early mortality in patients with PAH, we hypothesized that progressive elevation in heart rate can unmask ventricular tachyarrhythmias (VT) in a rodent model of monocrotaline (MCT)-induced PAH. We further hypothesized that intra-tracheal gene delivery of aerosolized AAV1.SERCA2a (AAV1.S2a), an approach which improves pulmonary vascular remodeling in PAH, can suppress VT in this model. OBJECTIVE To determine the efficacy of pulmonary AAV1.S2a in reversing electrophysiological (EP) remodeling and suppressing VT in PAH. METHODS Male rats received subcutaneous injection of MCT (60 mg/kg) leading to advanced PAH. Three weeks following MCT, rats underwent intra-tracheal delivery of aerosolized AAV1.S2a (MCT + S2a, N = 8) or saline (MCT, N = 9). Age-matched rats served as controls (CTRL, N = 7). The EP substrate and risk of VT were determined using high-resolution optical action potential (AP) mapping ex vivo. The expression levels of key ion channel subunits, fibrosis markers and hypertrophy indices were measured by RT-PCR and histochemical analyses. RESULTS Over 80% of MCT but none of the CTRL hearts were prone to sustained VT by rapid pacing (P < .01). Aerosolized gene delivery of AAV1.S2a to the lung suppressed the incidence of VT to <15% (P < .05). Investigation of the EP substrate revealed marked prolongation of AP duration (APD), increased APD heterogeneity, a reversal in the trans-epicardial APD gradient, and marked conduction slowing in untreated MCT compared to CTRL hearts. These myocardial EP changes coincided with major remodeling in the expression of K and Ca channel subunits, decreased expression of Cx43 and increased expression of pro-fibrotic and pro-hypertrophic markers. Intra-tracheal gene delivery of aerosolized AAV1 carrying S2a but not luciferase resulted in selective upregulation of the human isoform of SERCA2a in the lung but not the heart. This pulmonary intervention, in turn, ameliorated MCT-induced APD prolongation, reversed spatial APD heterogeneity, normalized myocardial conduction, and suppressed the incidence of pacing-induced VT. Comparison of the minimal conduction velocity (CV) generated at the fastest pacing rate before onset of VT or at the end of the protocol revealed significantly lower values in untreated compared to AAV1.S2a treated PAH and CTRL hearts. Reversal of EP remodeling by pulmonary AAV1.S2a gene delivery was accompanied by restored expression of key ion channel transcripts. Restored expression of Cx43 and collagen but not the pore-forming Na channel subunit Nav1.5 likely ameliorated VT by improving CV at rapid rates in PAH. CONCLUSION Aerosolized AAV1.S2a gene delivery selectively to the lungs ameliorates myocardial EP remodeling and VT susceptibility at rapid heart rates. Our findings highlight for the first time the utility of a non-cardiac gene therapy approach for arrhythmia suppression.
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Affiliation(s)
- Benjamin Strauss
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Yassine Sassi
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Carlos Bueno-Beti
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Zeki Ilkan
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Nour Raad
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Marine Cacheux
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Malik Bisserier
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Irene C Turnbull
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Erik Kohlbrenner
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Roger J Hajjar
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Lahouaria Hadri
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Fadi G Akar
- Cardiovascular Research Center, Icahn School of Medicine at Mount Sinai, NY, New York, USA.
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19
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Saeed Y, Temple IP, Borbas Z, Atkinson A, Yanni J, Maczewski M, Mackiewicz U, Aly M, Logantha SJRJ, Garratt CJ, Dobrzynski H. Structural and functional remodeling of the atrioventricular node with aging in rats: The role of hyperpolarization-activated cyclic nucleotide-gated and ryanodine 2 channels. Heart Rhythm 2018; 15:752-760. [PMID: 29288034 PMCID: PMC5934612 DOI: 10.1016/j.hrthm.2017.12.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Aging is associated with an increased incidence of atrioventricular nodal (AVN) dysfunction. OBJECTIVE The aim of this study was to investigate the structural and functional remodeling in the atrioventricular junction (AVJ) with aging. METHODS Electrophysiology, histology, and immunohistochemistry experiments on male Wistar Hannover rats aged 3 months (n = 24) and 2 years (n = 15) were performed. Atrio-His (AH) interval, Wenkebach cycle length (WBCL), and AVN effective refractory period (AVNERP) were measured. Cesium (2 mM) was used to block hyperpolarization-activated cyclic nucleotide-gated (HCN) channels, while ryanodine (2 μM) was used to block ryanodine 2 (RyR2) channels. Protein expression from different regions of the AVJ was studied using immunofluorescence. The expression of connexins (connexin 43 and connexin 40), ion channels (Hyperpolarization-activated cyclic nucleotide-gated channel 4 (HCN4), voltage sensitive sodium channel (Nav1.5), and L-Type calcium channel (Cav1.3)), and calcium handling proteins (RyR2 and sarco/endoplasmic reticulum calcium ATPaset type 2a (SERCA2a)) were measured. Morphological characteristics were studied with histology. RESULTS Without drugs to block HCN and RyR2 channels, there was prolongation of the AH interval, WBCL, and AVNERP (P < .05) with aging. In young rats only, cesium prolonged the AH interval, WBCL, and AVNERP (P < .01). Ryanodine prolonged the AH interval and WBCL (P < .01) in both young and old rats. Immunofluorescence revealed that with aging, connexin 43, HCN4, Nav1.5, and RyR2 downregulate in the regions of the AVJ and connexin 40, SERCA2a, and Cav1.3 upregulate (P < .05). Aging results in cellular hypertrophy, loosely packed cells, a decrease in the number of nuclei, and an increase in collagen content. CONCLUSION Heterogeneous ion channel expression changes were observed in the AVJ with aging. For the first time, we have shown that HCN and RyR2 play an important role in AVN dysfunction with aging.
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Affiliation(s)
- Yawer Saeed
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Ian P Temple
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Zoltan Borbas
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Andrew Atkinson
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Joseph Yanni
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Michal Maczewski
- Department of Clinical Physiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Urszula Mackiewicz
- Department of Clinical Physiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariam Aly
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Sunil Jit R J Logantha
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Clifford J Garratt
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom; Manchester Heart Centre, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Halina Dobrzynski
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom.
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20
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Lambert M, Boet A, Rucker-Martin C, Mendes-Ferreira P, Capuano V, Hatem S, Adão R, Brás-Silva C, Hautefort A, Michel JB, Dorfmuller P, Fadel E, Kotsimbos T, Price L, Jourdon P, Montani D, Humbert M, Perros F, Antigny F. Loss of KCNK3 is a hallmark of RV hypertrophy/dysfunction associated with pulmonary hypertension. Cardiovasc Res 2018; 114:880-893. [DOI: 10.1093/cvr/cvy016] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 01/18/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mélanie Lambert
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - Angèle Boet
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
- Réanimation des Cardiopathies Congénitales, Univ. Paris-Sud, Hôpital-Marie-Lannelongue, Le Plessis-Robinson, France
| | - Catherine Rucker-Martin
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - Pedro Mendes-Ferreira
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research Centre, University of Porto, 4200-319 Porto, Portugal
| | - Véronique Capuano
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - Stéphane Hatem
- Département de Cardiologie, INSERM UMR_S1166, ICAN, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié-Salpêtrière 75013, France
| | - Rui Adão
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research Centre, University of Porto, 4200-319 Porto, Portugal
| | - Carmen Brás-Silva
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research Centre, University of Porto, 4200-319 Porto, Portugal
| | - Aurélie Hautefort
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - Jean-Baptiste Michel
- INSERM UMR_S1148, Paris7, Denis Diderot University, Xavier Bichat Hospital, 75018, Paris, France
| | - Peter Dorfmuller
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - Elie Fadel
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
- Service de Chirurgie Thoracique, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Tom Kotsimbos
- Department of Respiratory Medicine, Alfred Hospital, Monash University, Melbourne, VIC 3181, Australia
| | - Laura Price
- National Pulmonary Hypertension Service, Royal Brompton Hospital, London SW3 6NP, UK
| | - Philippe Jourdon
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - David Montani
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - Marc Humbert
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - Frédéric Perros
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
| | - Fabrice Antigny
- Univ. Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre 94270, France
- Assistance Publique Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Le Kremlin Bicêtre 94270, France
- Inserm UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson 92350, France
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21
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Neto-Neves EM, Frump AL, Vayl A, Kline JA, Lahm T. Isolated heart model demonstrates evidence of contractile and diastolic dysfunction in right ventricles from rats with sugen/hypoxia-induced pulmonary hypertension. Physiol Rep 2017; 5:5/19/e13438. [PMID: 29038355 PMCID: PMC5641930 DOI: 10.14814/phy2.13438] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/31/2017] [Accepted: 08/16/2017] [Indexed: 01/29/2023] Open
Abstract
Although extensively used for the study of left ventricular function, limited experience exists with the isolated heart model in the evaluation of right ventricular (RV) function. In particular, no published experience exists with this tool in sugen/hypoxia‐induced pulmonary hypertension (SuHx‐PH), a frequently used model of severe and progressive PH. We sought to characterize markers of RV contractile and diastolic function in SuHx‐PH and to establish their relationship with markers of maladaptive RV remodeling. Hearts were excised from anesthetized Sprague Dawley rats with or without SuHx‐PH and perfused via the aorta using a Langendorff preparation. We explored the Frank–Starling relationship of RV function (RV developed pressure, dP/dtmax, and dP/dtmin; all normalized to RV mass) by increasing RV end‐diastolic pressure (RVEDP) from 0 to 40 mmHg. Functional studies were complemented by quantification of RV pro‐apoptotic signaling (bcl2/bax), procontractile signaling (apelin), and stress response signaling (p38MAPK activation). Pearson's correlation analysis was performed for functional and biochemical parameters. SuHx‐RVs exhibited severe RV dysfunction with marked hypertrophy and decreased echocardiographic cardiac output. For any given RVEDP, SuHx‐RVs demonstrated less developed pressure and lower dP/dtmax, as well as less pronounced dP/dtmin, suggestive of decreased contractile and diastolic function. SuHx‐RVs exhibited decreased bcl2/bax ratios, apelin expression, and p38MAPK activation. Bcl2/bax and apelin RNA abundance correlated positively with RV developed pressure and dP/dtmax and negatively with dP/dtmin. p38MAPK activation correlated positively with RV developed pressure. We conclude that SuHx‐RVs exhibit severe contractile and diastolic dysfunction. Increased pro‐apoptotic signaling and attenuated procontractile and stress response signaling may contribute to these functional alterations.
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Affiliation(s)
- Evandro M Neto-Neves
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrea L Frump
- Department of Medicine, Division of Pulmonary, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alexandra Vayl
- Department of Medicine, Division of Pulmonary, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana.,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Critical Care, Occupational and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana .,Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
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