Effect of Postconditioning on Myocardial 99mTc-Annexin-V Uptake: Comparison with Ischemic Preconditioning and Caspase Inhibitor Treatment

The Relevance, Predictability, and Utility of Annexin A5 for Human Physiopathology

As an important functional protein molecule in the human body, human annexin A5 (hAnxA5) is widely found in human cells and body fluids. hAnxA5, the smallest type of annexin, performs a variety of biological functions by reversibly and specifically binding phosphatidylserine (PS) in a calcium-dependent manner and plays an important role in many human physiological and pathological processes. The free state hAnxA5 exists in the form of monomers and usually forms a polymer in a specific self-assembly manner when exerting biological activity. This review systematically discusses the current knowledge and understanding of hAnxA5 from three perspectives: physiopathological relevance, diagnostic value, and therapeutic utility. hAnxA5 affects the occurrence and development of many physiopathological processes. Moreover, hAnxA5 can be used independently or in combination as a biomarker of physiopathological phenomena for the diagnosis of certain diseases. Importantly, based on the properties of hAnxA5, many novel drug candidates have been designed and prepared for application in actual medical practice. However, there are also some gaps and shortcomings in hAnxA5 research. This in-depth study will not only expand the understanding of structural and functional relationships but also promote the application of hAnxA5 in the field of biomedicine.

Postconditioning Accelerates Myocardial Inflammatory Resolution Demonstrated by 14C-Methionine Imaging and Attenuates Ventricular Remodeling After Ischemia and Reperfusion

BACKGROUND

Methionine uptake after myocardial infarction has been proven to reflect myocardial inflammation. The effect of postconditioning on the post-infarction inflammatory process, however, remains to be elucidated.Methods and Results:In control (n=22) and postconditioning rats (n=23), the left coronary artery was occluded for 30 min, followed by reperfusion for 1, 3, 7, and 14 days. Postconditioning was performed immediately following the reperfusion. ¹⁴C-methinine (0.74 MBq) and ²⁰¹Tl (14.8 MBq) were injected 20 and 10 min prior to sacrifice, respectively. One minute before sacrifice, 150-180 MBq of ^{99 m}Tc-MIBI was injected immediately following the re-occlusion of the left coronary artery to verify the area at risk, and left ventricular triple-tracer autoradiography was performed. To examine the ventricular remodeling, echocardiography was performed 2 months after reperfusion in both groups (n=6 each). In the control rats, the methionine uptake ratios on days 1, 3, 7, and 14 were 0.74±0.12, 1.85±0.16, 1.48±0.10, 1.25±0.04, respectively. With postconditioning, methionine uptake was similar on day 3 (1.90±0.21), but was lower on day 7 (1.23±0.22, P<0.05) and day 14 (1.08±0.09, P<0.005). Echocardiography revealed that postconditioning reduced the ventricular end-diastolic (0.97±0.16 to 0.78±0.12 cm, P<0.05) and systolic (0.85±0.21 to 0.55±0.23 cm, P<0.05) dimensions and improved ventricular percentage fractional shortening (12±6.2 to 29±12 %, P=0.01).

CONCLUSIONS

¹⁴C-methinine imaging revealed that postconditioning accelerated resolution of inflammation and attenuated ventricular remodeling.

The Role of (99m)Tc-Annexin V Apoptosis Scintigraphy in Visualizing Early Stage Glucocorticoid-Induced Femoral Head Osteonecrosis in the Rabbit

OBJECTIVE

To validate the ability of (99m)Tc-Annexin V to visualize early stage of glucocorticoid-induced femoral head necrosis by comparing with (99m)Tc-MDP bone scanning.

METHODS

Femoral head necrosis was induced in adult New Zealand white rabbits by intramuscular injection of methylprednisolone. (99m)Tc-Annexin scintigraphy and (99m)Tc-MDP scans were performed before and 5, 6, and 8 weeks after methylprednisolone administration. Rabbits were sacrificed at various time points and conducted for TUNEL and H&E staining.

RESULTS

All methylprednisolone treated animals developed femoral head necrosis; at 8 weeks postinjection, destruction of bone structure was evident in H&E staining, and apoptosis was confirmed by the TUNEL assay. This was matched by (99m)Tc-Annexin V images, which showed a significant increase in signal over baseline. Serial (99m)Tc-Annexin V scans revealed that increased (99m)Tc-Annexin V uptake could be observed in 5 weeks. In contrast, there was no effect on (99m)Tc-MDP signal until 8 weeks. The TUNEL assay revealed that bone cell apoptosis occurred at 5 weeks.

CONCLUSION

(99m)Tc-Annexin V is superior to (99m)Tc-MDP for the early detection of glucocorticoid-induced femoral head necrosis in the rabbit and may be a better strategy for the early detection of glucocorticoid-induced femoral head necrosis in patients.

Paracrine Engineering of Human Cardiac Stem Cells With Insulin-Like Growth Factor 1 Enhances Myocardial Repair

BACKGROUND

Insulin-like growth factor 1 (IGF-1) activates prosurvival pathways and improves postischemic cardiac function, but this key cytokine is not robustly expressed by cultured human cardiac stem cells. We explored the influence of an enhanced IGF-1 paracrine signature on explant-derived cardiac stem cell-mediated cardiac repair.

METHODS AND RESULTS

Receptor profiling demonstrated that IGF-1 receptor expression was increased in the infarct border zones of experimentally infarcted mice by 1 week after myocardial infarction. Human explant-derived cells underwent somatic gene transfer to overexpress human IGF-1 or the green fluorescent protein reporter alone. After culture in hypoxic reduced-serum media, overexpression of IGF-1 enhanced proliferation and expression of prosurvival transcripts and prosurvival proteins and decreased expression of apoptotic markers in both explant-derived cells and cocultured neonatal rat ventricular cardiomyocytes. Transplant of explant-derived cells genetically engineered to overexpress IGF-1 into immunodeficient mice 1 week after infarction boosted IGF-1 content within infarcted tissue and long-term engraftment of transplanted cells while reducing apoptosis and long-term myocardial scarring.

CONCLUSIONS

Paracrine engineering of explant-derived cells to overexpress IGF-1 provided a targeted means of improving cardiac stem cell-mediated repair by enhancing the long-term survival of transplanted cells and surrounding myocardium.

Imaging the myocardium at risk with ⁹⁹mTc-lactadherin administered after reperfusion in a porcine model

INTRODUCTION

Phosphatidylserine is translocated from the inner to the outer leaflet of the plasma membrane in the early stages of apoptosis and necrosis and in reversibly injured cells. In rabbit hearts, ischemia followed by reperfusion results in exposure of phosphatidylserine on myocytes unaffected by apoptosis or necrosis. Lactadherin was recently introduced as a highly sensitive phosphatidylserine ligand. We hypothesized that ischemic myocardial cell damage can be identified by radio-labeled lactadherin and that the ischemic area at risk (AAR) can be visualized retrospectively after reperfusion.

METHODS

Left anterior descending coronary artery in pigs was occluded for 20 minutes, 45 minutes or 45 minutes preceded by ischemic preconditioning. In all three groups, (99m)Tc-lactadherin was injected intravenously 30 minutes after reperfusion. The AAR was demarcated by Evans blue and the infarct size by 2,3,5,-triphenyltetrazodium chloride staining.

RESULTS

The regional myocardial uptake of (99m)Tc-lactadherin closely correlated with the AAR (r=.83, P = .001). The area of (99m)Tc-lactadherin uptake was unaltered by a shorter duration of ischemia and ischemic preconditioning (P=.23) despite significantly different infarct development (P=.001).

CONCLUSION

The results suggest that (99m)Tc-lactadherin can be used as a sensitive marker for AAR imaging when injected 30 minutes after reperfusion following acute ischemia.

Image-guided therapies for myocardial repair: concepts and practical implementation

Cell- and molecule-based therapeutic strategies to support wound healing and regeneration after myocardial infarction (MI) are under development. These emerging therapies aim at sustained preservation of ventricular function by enhancing tissue repair after myocardial ischaemia and reperfusion. Such therapies will benefit from guidance with regard to timing, regional targeting, suitable candidate selection, and effectiveness monitoring. Such guidance is effectively obtained by non-invasive tomographic imaging. Infarct size, tissue characteristics, muscle mass, and chamber geometry can be determined by magnetic resonance imaging and computed tomography. Radionuclide imaging can be used for the tracking of therapeutic agents and for the interrogation of molecular mechanisms such as inflammation, angiogenesis, and extracellular matrix activation. This review article portrays the hypothesis that an integrated approach with an early implementation of structural and molecular tomographic imaging in the development of novel therapies will provide a framework for achieving the goal of improved tissue repair after MI.

Pharmacokinetics of the phosphatidylserine tracers 99mTc-lactadherin and 99mTc-annexin V in pigs

Background

Phosphatidylserine (PS) is a phospholipid normally located in the inner leaflet of the cell membrane. PS is translocated from the inner to the outer leaflet of the plasma membrane during the early stages of apoptosis and in necrosis. In cell and animal studies, reversible PS externalisation to the outer membrane leaflet has been observed in viable cells. Hence, PS markers have been proposed as markers of both reversibly and irreversibly damaged cells. The purpose of this experimental study in pigs was to investigate the kinetics of the newly introduced PS marker technetium-99m-labelled lactadherin (^99mTc-lactadherin) in comparison with the well-known PS tracer ^99mTc-annexin V with special reference to the renal handling of the tracers. The effective dose for humans was estimated from the biodistribution in 24 mice.

Methods

Nine anaesthetised pigs randomly allocated into two treatment groups were administered a single injection of either ^99mTc-lactadherin or ^99mTc-annexin V. Renal perfusion was assessed by simultaneous injection of ⁵¹Cr-EDTA. Throughout the examinations, planar, dynamic scintigraphy of the trunk was performed, urine was collected and arterial and renal vein blood was sampled. The effective dose was estimated using the adult male phantom from the RADAR website.

Results

^99mTc-lactadherin was cleared four times faster from plasma than ^99mTc-annexin V, 57 ± 13 ml/min (mean ± SD) versus 14 ± 2 ml/min. ^99mTc-lactadherin had a predominant uptake in the liver, whereas ^99mTc-annexin V was primarily taken up by the kidneys. The estimated effective human dose after single injection of ^99mTc-lactadherin and ^99mTc-annexin V was 5.8 and 11 μSv/MBq, respectively.

Conclusions

The high hepatic uptake of ^99mTc-lactadherin compromises the use of ^99mTc-lactadherin for imaging PS externalisation in the liver. Due to scatter from the liver, the use of in vivo visualisation of PS externalisation in the lower thorax and upper abdomen by ^99mTc-lactadherin is challenged, but not precluded. In contrast to ^99mTc-annexin, ^99mTc-lactadherin has a low renal uptake and may be the preferred tracer for imaging PS externalisation in the kidneys. The effective dose after injection of ^99mTc-lactadherin and ^99mTc-annexin was low. Recommendations regarding the clinical use of ^99mTc-lactadherin must await tracer kinetic studies in patients.

14C-Methionine uptake as a potential marker of inflammatory processes after myocardial ischemia and reperfusion

A relationship between l-[methyl-(11)C]methionine ((11)C-methionine) uptake and angiogenesis has been suggested in gliomas. However, methionine uptake in myocardial ischemia and reperfusion has received little attention. We investigated the serial changes and mechanisms of (14)C-methionine uptake in a rat model of myocardial ischemia and reperfusion.

METHODS

The left coronary artery was occluded for 30 min, followed by reperfusion for 1-28 d. At the time of the study, (14)C-methionine (0.74 MBq) and (201)Tl (14.8 MBq) were injected intravenously at 20 and 10 min before sacrifice, respectively. One minute before sacrifice, the left coronary artery was reoccluded, and (99m)Tc-hexakis-2-methoxyisobutylisonitrile (150-180 MBq) was injected to verify the area at risk. Histologic sections of the heart were immunohistochemically analyzed using anti-CD68, anti-smooth-muscle α-actin (SMA), and antitroponin I and compared with the autoradiography findings.

RESULTS

Both (14)C-methionine (uptake ratio, 0.71 ± 0.13) and (201)Tl uptake were reduced in the area at risk at 1 d after reperfusion. However, 3 d after reperfusion, an increased (14)C-methionine uptake (1.79 ± 0.23) was observed corresponding to the area of still-reduced (201)Tl uptake, and the (14)C-methionine uptake gradually declined until 28 d. The increased (14)C-methionine uptake area at 3 and 7 d corresponded well to the macrophage infiltrations demonstrated by positive CD68 staining. Anti-SMA staining appeared at 7 d, after which CD68 staining was gradually replaced by the SMA staining, suggesting that methionine uptake in the early phase after ischemia and reperfusion might reflect inflammatory activity.

CONCLUSION

(14)C-methionine accumulated in the infarcted area, and its uptake corresponded closely to macrophage infiltration at 3-7 d after reperfusion. Methionine imaging may be useful for inflammatory imaging early after myocardial infarction.

Endogenous cardioprotection by ischaemic postconditioning and remote conditioning

Persistent myocardial ischaemia causes cell death if not rescued by early reperfusion. Millions of years in nature's laboratory have evolved protective responses that 'condition' the heart (and other tissues) to adapt to stressors, and these responses are applicable to the relatively new societal stress of myocardial ischaemia and reperfusion injury. Conditioning can be applied before (preconditioning), during (perconditioning), or after (postconditioning) the ischaemic stressor by imposing short periods of non-lethal ischaemia separated by brief periods of reperfusion. This conditioning protects multiple cell types and induces or rebalances a number of physiological and molecular pathways that ultimately attenuate necrosis and apoptosis. The seemingly disparate pathways may converge directly or indirectly on the mitochondria as a final effector, but other pathways not affecting mitochondria broaden the mechanisms of cardioprotection. The potential downsides of imposing even brief ischaemia directly on the heart somewhat tempered the enthusiasm for applying conditioning stimuli to the heart, but this hurdle was surmounted by applying ischaemia to remote organs and tissues in pre-, per-, and postconditioning. Although the clinical translation of remote per- and postconditioning has been rapid compared with classical preconditioning, there are numerous basic questions that require further investigation, and wider adoption awaits large-scale randomized clinical trials. Pharmacological mimetics may provide another important therapeutic approach by which to treat evolving myocardial infarction.

Tetramethylphenylenediamine protects the isolated heart against ischaemia-induced apoptosis and reperfusion-induced necrosis

BACKGROUND AND PURPOSE

Cytochrome c when released from mitochondria into cytosol triggers assembly of the apoptosome resulting in caspase activation. Recent evidence suggests that reduced cytochrome c is unable to activate the caspase cascade. In this study, we investigated whether a chemical reductant of cytochrome c, N,N,N',N'-tetramethylphenylene-1,4-diamine (TMPD), which we have previously shown to block cytochrome c-induced caspase activation, could prevent ischaemia-induced apoptosis in the rat perfused heart.

EXPERIMENTAL APPROACH

The Langendorff-perfused rat hearts were pretreated with TMPD and subjected to stop-flow ischaemia or ischaemia/reperfusion. The activation of caspases (measured as DEVD-p-nitroanilide-cleaving activity), nuclear apoptosis of cardiomyocytes (measured by dUTP nick end labelling assay), mitochondrial and cytosolic levels of cytochrome c (measured spectrophotometrically and by elisa), and reperfusion-induced necrosis (measured as the activity of creatine kinase released into perfusate) were assessed.

KEY RESULTS

We found that perfusion of the hearts with TMPD strongly inhibited ischaemia- or ischaemia/reperfusion-induced activation of caspases and partially prevented nuclear apoptosis in cardiomyocytes. TMPD did not prevent ischaemia- or ischaemia/reperfusion-induced release of cytochrome c from mitochondria into cytosol. TMPD also inhibited ischaemia/reperfusion-induced necrosis.

CONCLUSIONS AND IMPLICATIONS

These results suggest that TMPD or related molecules might be used to protect the heart against damage induced by ischaemia/reperfusion. The mechanism of this protective effect of TMPD probably involves electron reduction of cytochrome c (without decreasing its release) which then inhibits the activation of caspases.

The multidimensional physiological responses to postconditioning

Reperfusion is the definitive treatment to reduce infarct size and other manifestations of postischemic injury. However, reperfusion contributes to postischemic injury, and, therefore, reperfusion therapies do not achieve the optimal salvage of myocardium. Other tissues as well undergo injury after reperfusion, notably, the coronary vascular endothelium. Postconditioning has been shown to have salubrious effects on different tissue types within the heart (cardiomyocytes, endothelium) and to protect against various pathologic processes, including necrosis, apoptosis, contractile dysfunction, arrhythmias, and microvascular injury or "no-reflow." The mechanisms by which postconditioning alters the pathophysiology of reperfusion injury is exceedingly complex and involves physiological mechanisms (e.g., delaying re-alkalinization of tissue pH, triggering release of autacoids, and opening and closing of various channels) and molecular mechanisms (activation of kinases) that affect cellular and subcellular targets or effectors. The physiologic responses to postconditioning are not isolated or mutually exclusive, but are interactive, with one response affecting another in an integrated manner. This integrated response on multiple targets differs from the monotherapy approach by drugs that have failed to reduce reperfusion injury on a consistent basis and may underlie the efficacy of this therapeutic approach across species and in human trials.

Dynamic expression of tenascin-C after myocardial ischemia and reperfusion: assessment by 125I-anti-tenascin-C antibody imaging

Tenascin-C, an extracellular matrix glycoprotein, appears only in the early stages of embryonic development. It is not normally expressed in the adult heart but does reappear transiently in distinct areas in association with active tissue remodeling. The aim of this study was to explore serial changes in the expression of tenascin-C after myocardial ischemia and reperfusion, using (125)I-labeled anti-tenascin-C antibody ((125)I-TNC-Ab) in a rat model of acute ischemia and reperfusion.

METHODS

The left coronary artery was occluded for 20 or 30 min, followed by reperfusion for 1, 3, or 7 d in rats with 20 min of ischemia and for 1, 3, 7, 14, or 28 d in rats with 30 min of ischemia. At the time of the study, (125)I-TNC-Ab (1.0-2.5 MBq) was injected. Three to 5 h later, to verify the area at risk, (99m)Tc-methoxyisobutylisonitrile (100-200 MBq) was injected intravenously just after the left coronary artery reocclusion and the rats were sacrificed 1 min later. Dual-tracer autoradiography was performed to assess (125)I-TNC-Ab uptake and the area at risk.

RESULTS

In rats with 20 min of ischemia, (125)I-TNC-Ab uptake peaked at 3 d after reperfusion, followed by faint uptake after 7 d (uptake ratios at 1, 3, and 7 d after reperfusion were 1.81 +/- 0.53, 2.46 +/- 0.79, and 1.23 +/- 0.17, respectively [P < 0.05 vs. 3 d]). In rats with 30 min of ischemia, uptake was high at 1 and 3 d after reperfusion (2.99 +/- 0.90 and 2.71 +/- 0.80, respectively), decreased at 7 and 14 d (1.94 +/- 0.23 and 2.06 +/- 0.37, respectively), and was weak at 28 d (1.47 +/- 0.27, P < 0.005 vs. 1 d, P < 0.05 vs. 3 d).

CONCLUSION

These data indicate that (125)I-TNC-Ab imaging may be a way to monitor myocardial injury and its repair process after ischemia and reperfusion by visualizing tenascin-C expression.

Imaging the molecular signatures of apoptosis and injury with radiolabeled annexin V

Annexin V is a ubiquitous intracellular protein in humans that has a variety of intriguing characteristics, including a nanomolar affinity for the membrane-bound constitutive anionic phospholipid known as phosphatidylserine (PS). PS is selectively expressed on the surface of apoptotic or physiologically stressed cells. As such, radiolabeled forms of annexin V have been used in both animal models and human Phase I and Phase II trials to determine if this tracer can be employed as an early surrogate marker of therapeutic efficacy in NSCLC and non-Hodgkin's lymphoma. Many other pulmonary imaging applications of radiolabeled annexin V are also possible, including the detection and monitoring of active pulmonary inflammation and other pathophysiologic stressors in a variety of diseases. In this article, the salient molecular features of apoptosis (and other forms of cell death) that permits imaging with radiolabeled annexin V will be discussed. The latest results from Phase II imaging trials with NSCLC and non-Hodgkin's lymphoma will be also be detailed. Finally, the potential future application of this tracer for the imaging of other pulmonary pathologies will be outlined.

Fundamentals of molecular imaging: rationale and applications with relevance for radiation oncology

Molecular imaging allows for the visualization and quantification biologic processes at cellular levels. This article focuses on positron emission tomography as one readily available tool for clinical molecular imaging. To prove its clinical utility in oncology, molecular imaging will ultimately have to provide valuable information in the following 4 pertinent areas: staging; assessment of extent of disease; target delineation for radiation therapy planning; response prediction and assessment and differentiation between treatment sequelae and recurrent disease. These issues are addressed in other contributions in this issue of Seminars in Nuclear Medicine. In contrast, this article will focus on the biochemical principles of cancer metabolism that provide the rationale for positron emission tomography imaging in radiation oncology.