Evaluation of left ventricular filling pressure by echocardiography: incremental diagnostic information from left atrial strain

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority

Background

Elevated left ventricular (LV) filling pressure is an important diagnostic feature of heart failure.

Objectives

To investigate determinants of left atrial (LA) reservoir and pump strain and if these parameters may serve as markers of LV filling pressure.

Methods

In a multicenter study of 322 patients with cardiovascular disease of different etiologies, LA strain by speckle tracking echocardiography was compared to conventional echocardiographic markers using invasive pressure as reference.

Results

Left ventricular filling pressure correlated well with LA reservoir and pump strain (r-values

‑0.52 and ‑0.57, respectively) (Figure). However, LV global longitudinal strain (GLS) was the strongest determinant of LA reservoir strain (r = 0.64), and correlated well with LA pump strain (r = 0.51).  For both LA strains, association with filling pressure was strongest in patients with reduced LV ejection fraction. In patients with normal GLS (≥18%), atrial strains provided no information regarding filling pressure (Figure). Reservoir strain <18% and pump strain <8% predicted elevated LV filling pressure better (p < 0.05) than the conventional indices LA volume, ratio of mitral early filling velocity/annular velocity and tricuspid regurgitation velocity. Accuracy to classify filling pressure as normal or elevated was 75% for both LA strains . When any one of the conventional indices were missing, and were replaced by LA strains, the combination of indices had accuracy 82% to correctly classify filling pressure.

Conclusions

Left atrial reservoir and pump strain may serve as clinical markers of LV filling pressure, but will be useful predominantly in patients with reduced systolic function.  Due to limited diagnostic accuracy, LA strain should be used in combination with other indices.

Abstract Figure

1231 Left atrial septal and lateral wall strains contain different pressure information: Utility in pulmonary hypertension

Funding Acknowledgements

South-Eastern Norway Regional Health Authority

Background

Reduced left atrial (LA) reservoir strain is a marker of elevated LA pressure. Thus it could be a potential non-invasive marker to differentiate pre- and post-capillary pulmonary hypertension (PH) as the latter is defined by elevated pulmonary capillary wedge pressure (PCWP) > 15 mmHg. However, in pre-capillary PH patients with elevated right atrial pressure (RAP), the atrial septal geometry may be abnormal. This could lead to lower regional LA septal strain, making LA lateral wall strain more accurately reflect PCWP.

Purpose

We investigated if LA lateral wall strain can differentiate between pre- and post-capillary PH, and how LA lateral wall strain and LA septal strain are both affected by elevated RAP in pre-capillary PH. Furthermore we investigated if LA septal strain can be used in pre-capillary PH patients to identify those with elevated RAP.

Methods

We analysed 63 patients with PH, 28 pre-capillary and 35 post-capillary, who underwent right heart catheterisation. Echocardiography was performed simultaneously with or within 24 hours of the invasive pressure measurements. Regional LA septal strain and lateral wall strain were measured from the apical four chamber view.

Results

Pulmonary artery pressure was 39.5 ± 11.1 mmHg (mean ± SD) in the pre-capillary PH patients and 37.0 ± 10.1 mmHg in the post-capillary PH patients (p = ns). Mean PCWP was 9.9 ± 2.5 mmHg and 24.5 ± 6.0 mmHg (p < 0.001), respectively.

LA lateral wall strain was significantly lower in patients with post-capillary PH compared to pre-capillary PH (11.9 ± 7.7% vs 26.6 ± 9.9%, p < 0.001) (Fig. a,b). At a cut-off value of 18.0%, LA lateral wall strain could predict elevated PCWP > 15 mmHg with AUC = 0.88, sensitivity = 85.7% and specificity = 76.3%.

In the 28 patients with pre-capillary PH, we classified mean RAP ≥ 10 mmHg as elevated and < 10 mmHg as normal. Seven of these patients had elevated RAP and showed significantly reduced LA septal strain compared to the 21 patients with normal RAP (13.0 ± 6.2% vs 22.1 ± 7.6%, p < 0.01). LA lateral wall strain showed no difference in these groups of pre-capillary PH patients (25.8 ± 10.1% vs 28.9 ± 9.4%) (Fig. c).

Conclusions

LA lateral wall strain can be used for differentiating between pre- and post-capillary PH. In addition, LA septal strain may be used in pre-capillary PH patients to identify those with elevated RAP.

Abstract 1231 Figure

P4368Estimation of pulmonary artery pressure from right atrial strain and tricuspid regurgitation velocity

Background

Systolic pulmonary artery pressure (SPAP) can be estimated non-invasively as the sum of indices for right atrial (RA) pressure and tricuspid regurgitation (TR) pressure gradient. Although echocardiographic evaluation of inferior vena cava diameter and collapsibility is currently being used to estimate RA pressure (IVC method), RA strain may be an alternative since atrial strain is related to atrial pressure.

Objective

We tested if RA strain by speckle tracking echocardiography can be used as a surrogate of mean RA pressure (RA strain method), and by adding the TR pressure gradient, be used to estimate SPAP.

Methods

We retrospectively analyzed 91 patients (mean age, 58 years) referred to right heart catheterization due to unexplained dyspnea or suspected pulmonary hypertension. Echocardiography was performed within 24 hours of the invasive procedure. RA reservoir strain was calculated from apical four-chamber view. SPAP was calculated as the sum of peak TR pressure gradient and estimated RA pressure by the IVC or RA strain methods.

Results

Right heart catheterization showed SPAP and mean RA pressures of 51±20 mmHg and 9±6 mmHg, respectively. RA reservoir strain was inversely correlated with mean RA pressure (r=−0.61, p<0.01). Thus, we set mean RA pressure as 5, 10 and 15 mmHg depending on high (≥25%), middle (10–25%) and low (≤10%) values of RA reservoir strain. As shown in the figure, both the RA strain and IVC methods when combined with peak TR velocity, provided good estimates of invasively measured SPAP.

Conclusions

RA strain provides a semiquantitative measure of RA pressure, which can be used in combination with peak TR velocity to estimate SPAP. This approach can be used as an alternative when the IVC method is not available in cases with poor subcostal window.

P2452Application of left atrial strain for differentiation between pre- and post-capillary pulmonary hypertension

Background

Pulmonary hypertension (PH) is classified as pre- or post-capillary PH, and pulmonary capillary wedge pressure (PCWP) >15 mmHg is used as criterion for post-capillary PH. Elevated left atrial (LA) pressure is associated with reduced LA reservoir strain. Thus, LA strain may potentially serve to differentiate between these diagnoses.

Objectives

This study tested the hypothesis that LA strain can be used as a noninvasive parameter to differentiate between pre- and post-capillary PH.

Methods

We analyzed 103 patients (mean age: 58 years, 51 female) referred to right heart catheterization due to unexplained dyspnea or suspected heart failure. Echocardiography was performed within 24 hours of the invasive procedure. Mean pulmonary artery pressure (PAP) was noninvasively estimated from tricuspid regurgitation (TR) velocity and inferior vena cava (IVC) diameter and collapsibility. LA reservoir strain was calculated from apical four-chamber view by speckle tracking echocardiography, and was feasible in 101 patients.

Results

Twenty-eight patients were invasively confirmed with pre-capillary PH and 43 patients with post-capillary PH. The remaining 32 patients had no PH. LA reservoir strain was significantly lower in patients with post-capillary PH than patients with pre-capillary PH (9.9±5.5% vs. 24.6±8.2%, p<0.01). At a cut-off value of 15.4%, LA reservoir strain could predict elevated PCWP >15 mmHg with AUC=0.88, sensitivity=84.8% and specificity=81.8%. As shown in the figure, echocardiography with LA reservoir strain correctly differentiated 82% of patients into pre- and post-capillary PH.

Conclusions

These results suggest that LA reservoir strain can be used to predict elevated PCWP, thus allowing discrimination between pre- and post-capillary PH.

P1480Left atrial strain improves estimation of left ventricular filling pressure

Background

The current algorithm in the 2016 recommendations for echocardiographic estimation of left ventricular filling pressure (LVFP) as normal or elevated, combines traditional indices of mitral inflow velocities, tissue Doppler, left atrial volume and tricuspid regurgitation velocity (Figure A). Some of the patients remain unclassified by this algorithm. Left atrial (LA) strain is a novel index that correlates well with LVFP and may improve estimation of LVFP in these patients.

Purpose

We tested if LA strain can improve estimation of LVFP for the patients that are unclassified by the 2016 algorithm.

Methods

We analyzed data from 100 patients who were referred to right heart catheterization due to unexplained dyspnea or suspected heart failure. Echocardiography was performed simultaneously with or within 24 hours of right heart catheterization. Pulmonary capillary wedge pressure (PCWP) was used as an estimate for LVFP and defined as elevated if above 12 mmHg. Elevated LVFP was first estimated using the 2016 algorithm. In patients who were unclassified by the algorithm due to conflicting indices or unattainable indices, LA strain was subsequently used to detect elevated LVFP using a cut-off found from ROC analysis of the whole cohort.

Results

Six patients were unclassified by the 2016 algorithm. The ROC analysis of all 100 patients showed that at an LA strain cut-off of above or below 16.2%, LVFP was correctly classified as normal or elevated, respectively, with a sensitivity of 83% and specificity of 88%. All 6 unclassified patients by the 2016 algorithm were correctly classified using the LA strain cut-off, effectively increasing the accuracy of the algorithm by 6 percentage points.

Conclusions

LA strain may have a role in non-invasive estimation of LVFP, particularly in patients who remain unclassified when using the conventional echocardiographic indices.

Acknowledgement/Funding

South-Eastern Norway Regional Health Authority

P2458Restricted left atrial motion as a result of atrial stiffening in patients with cardiac amyloidosis

Background

Left atrial (LA) involvement of abnormal amyloid fibrils could induce LA dysfunction and stiffening in patients with cardiac amyloidosis (CA). Thus, the assessments of LA function and stiffness might be a potential approach to diagnose CA phenotype among patients with hypertrophied hearts.

Purpose

We sought to determine whether LA reservoir strain with speckle tracking echocardiography could be used a marker of LA stiffness in a derivation cohort. Furthermore, we tested to our hypothesis that LA reservoir strain could differentiate CA patients from hypertrophic cardiomyopathy (HCM) in an independent validation cohort.

Methods

In the derivation cohort, echocardiography was performed simultaneously with measurements of pulmonary capillary wedge pressure (PCWP) in 50 patients with suspected or established heart failure and relatively preserved left ventricular (LV) ejection fraction (56±10%). LA maximum and minimum volume index, and reservoir strain were measured from apical four-chamber view. LA stiffness index was computed as a pressure rise from x-trough to v-wave divided by an increase from minimum to maximum indexed LA volume (Figure A). In an independent validation group, we studied a total of 33 biopsy-proved CA patients and 127 HCM patients (LV ejection fraction: 57±11% vs. 66±10%, P<0.01) in sinus rhythm on the date of comprehensive echocardiographic study. Among them, cardiac magnetic resonance imaging (CMR) could be evaluated in 17 CA patients and 98 HCM patients. Furthermore, right heart catheterization was performed with 12 CA patients and 12 HCM patients in the CMR group.

Results

The derivation cohort study found that there was a significant curvilinear correlation of LA reservoir strain to LA stiffness index (Figure B). In the validation cohort, LA reservoir strain was reduced in patients with CA compared with HCM in all participants (11.6±5.6% vs. 18.5±6.9%, P<0.01), although there was no significant difference of LA maximal volume index between 2 groups (37±16 ml/m2 vs. 37±12 ml/m2, p=0.89). In the CMR group, the late gadolinium enhancement was observed in the LA wall in 16 patients with CA (94.1%) as shown in Figure C. In contrast, the LA enhancement revealed only in 1 patient with HCM (1.0%). Among patients with invasive measures, LA stiffness index [median (interquartile range)] was higher in patients with CA than that in patients with HCM [1.1 (0.4–2.8) vs. 0.2 (0.1–0.6), P=0.01].

Conclusions

LA reservoir function was fairly limited in patients with CA compared with HCM. Restricted LA motion might be related to atrial amyloid deposits or fibrosis, which potentially provokes atrial chamber stiffening.

Effects of glycine substitutions on the structure and function of gramicidin a channels

Tryptophan residues often are found at the lipid-aqueous interface region of membrane-spanning proteins, including ion channels, where they are thought to be important determinants of protein structure and function. To better understand how Trp residues modulate the function of membrane-spanning channels, we have examined the effects of Trp replacements on the structure and function of gramicidin A channels. Analogues of gramicidin A in which the Trp residues at positions 9, 11, 13, and 15 were sequentially replaced with Gly were synthesized, and the three-dimensional structure of each analogue was determined using a combination of two-dimensional NMR techniques and distance geometry-simulated annealing structure calculations. Though Trp --> Gly substitutions destabilize the beta6.3-helical gA channel structure, it is possible to determine the structure of analogues with Trp --> Gly substitutions at positions 11, 13, and 15, but not for the analogue with the Trp --> Gly substitution at position 9. The Gly11-, Gly13-, and Gly15-gA analogues form channels that adopt a backbone fold identical to that of native gramicidin A, with only small changes in the side chain conformations of the unsubstituted residues. Single-channel current measurements show that the channel function and lifetime of the analogues are significantly affected by the Trp --> Gly replacements. The conductance variations appear to be caused by sequential removal of the Trp dipoles, which alter the ion-dipole interactions that modulate ion movement. The lifetime variations did not appear to follow a clear pattern.

Capsaicin regulates voltage-dependent sodium channels by altering lipid bilayer elasticity

At submicromolar concentrations, capsaicin specifically activates the TRPV1 receptor involved in nociception. At micro- to millimolar concentrations, commonly used in clinical and in vitro studies, capsaicin also modulates the function of a large number of seemingly unrelated membrane proteins, many of which are similarly modulated by the capsaicin antagonist capsazepine. The mechanism(s) underlying this widespread regulation of protein function are not understood. We investigated whether capsaicin could regulate membrane protein function by changing the elasticity of the host lipid bilayer. This was done by studying capsaicin's effects on lipid bilayer stiffness, measured using gramicidin A (gA) channels as molecular force-transducers, and on voltage-dependent sodium channels (VDSC) known to be regulated by bilayer elasticity. Capsaicin and capsazepine (10-100 microM) increase gA channel appearance rate and lifetime without measurably altering bilayer thickness or channel conductance, meaning that the changes in bilayer elasticity are sufficient to alter the conformation of an embedded protein. Capsaicin and capsazepine promote VDSC inactivation, similar to other amphiphiles that decrease bilayer stiffness, producing use-dependent current inhibition. For capsaicin, the quantitative relation between the decrease in bilayer stiffness and the hyperpolarizing shift in inactivation conforms to that previously found for other amphiphiles. Capsaicin's effects on gA channels and VDSC are similar to those of Triton X-100, although these amphiphiles promote opposite lipid monolayer curvature. We conclude that capsaicin can regulate VDSC function by altering bilayer elasticity. This mechanism may underlie the promiscuous regulation of membrane protein function by capsaicin and capsazepine-and by amphiphilic drugs generally.

On the importance of atomic fluctuations, protein flexibility, and solvent in ion permeation

Proteins, including ion channels, often are described in terms of some average structure and pictured as rigid entities immersed in a featureless solvent continuum. This simplified view, which provides for a convenient representation of the protein's overall structure, incurs the risk of deemphasizing important features underlying protein function, such as thermal fluctuations in the atom positions and the discreteness of the solvent molecules. These factors become particularly important in the case of ion movement through narrow pores, where the magnitude of the thermal fluctuations may be comparable to the ion pore atom separations, such that the strength of the ion channel interactions may vary dramatically as a function of the instantaneous configuration of the ion and the surrounding protein and pore water. Descriptions of ion permeation through narrow pores, which employ static protein structures and a macroscopic continuum dielectric solvent, thus face fundamental difficulties. We illustrate this using simple model calculations based on the gramicidin A and KcsA potassium channels, which show that thermal atomic fluctuations lead to energy profiles that vary by tens of kcal/mol. Consequently, within the framework of a rigid pore model, ion-channel energetics is extremely sensitive to the choice of experimental structure and how the space-dependent dielectric constant is assigned. Given these observations, the significance of any description based on a rigid structure appears limited. Creating a conducting channel model from one single structure requires substantial and arbitrary engineering of the model parameters, making it difficult for such approaches to contribute to our understanding of ion permeation at a microscopic level.

Voltage-gated ion channels in nociceptors: modulation by cGMP

In tissue or nerve injury, proinflammatory mediators are released that can modulate a variety of ion channels found in nociceptors. The changes in channel activity, which primarily occurs through changes in intracellular pathways, may lead to the pathological states of hyperalgesia and allodynia. To understand further the regulatory mechanisms underlying the changes in channel activity, we used whole cell patch-clamp recordings from capsaicin-sensitive nociceptive neurons in rat trigeminal ganglion neurons to examine how the cGMP-dependent pathways may regulate ion channel function. Addition of the 8-(4-chlorophenylthio)-3',5' (CPT)-cGMP, a membrane permeant modulator of ion channels, decreased the number of evoked action potentials by 36% and inhibited the tetrodotoxin-resistant (TTX-R) sodium currents and IA potassium currents by 37 and 32%, respectively. Delayed rectifier potassium (IK) currents were unaffected, suggesting that the effects of CPT-cGMP are unlikely to arise from a nonspecific effect on channel activity as a consequence of the adsorption of amphipathic CPT-cGMP molecules to the membrane's bilayer component. This conclusion was reinforced by the lack of changes in gramicidin A channel function in the presence of CTP-cGMP. In summary, the activation of the cGMP-dependent pathways reduces nociceptor excitability, in part, by decreasing the activity of voltage-gated TTX-R sodium channels. This pathway may be a target for efforts to produce selective analgesics.

Cholesterol-induced protein sorting: an analysis of energetic feasibility

The mechanism(s) underlying the sorting of integral membrane proteins between the Golgi complex and the plasma membrane remain uncertain because no specific Golgi retention signal has been found. Moreover one can alter a protein's eventual localization simply by altering the length of its transmembrane domain (TMD). M. S. Bretscher and S. Munro (SCIENCE: 261:1280-1281, 1993) therefore proposed a physical sorting mechanism based on the hydrophobic match between the proteins' TMD and the bilayer thickness, in which cholesterol would regulate protein sorting by increasing the lipid bilayer thickness. In this model, Golgi proteins with short TMDs would be excluded from cholesterol-enriched domains (lipid rafts) that are incorporated into transport vesicles destined for the plasma membrane. Although attractive, this model remains unproven. We therefore evaluated the energetic feasibility of a cholesterol-dependent sorting process using the theory of elastic liquid crystal deformations. We show that the distribution of proteins between cholesterol-enriched and cholesterol-poor bilayer domains can be regulated by cholesterol-induced changes in the bilayer physical properties. Changes in bilayer thickness per se, however, have only a modest effect on sorting; the major effect arises because cholesterol changes also the bilayer material properties, which augments the energetic penalty for incorporating short TMDs into cholesterol-enriched domains. We conclude that cholesterol-induced changes in the bilayer physical properties allow for effective and accurate sorting which will be important generally for protein partitioning between different membrane domains.

The structure, cation binding, transport, and conductance of Gly15-gramicidin A incorporated into SDS micelles and PC/PG vesicles

To further investigate the effect of single amino acid substitution on the structure and function of the gramicidin channel, an analogue of gramicidin A (GA) has been synthesized in which Trp(15) is replaced by Gly in the critical aqueous interface and cation binding region. The structure of Gly(15)-GA incorporated into SDS micelles has been determined using a combination of 2D-NMR spectroscopy and molecular modeling. Like the parent GA, Gly(15)-GA forms a dimeric channel composed of two single-stranded, right-handed beta(6.3)-helices joined by hydrogen bonds between their N-termini. The replacement of Trp(15) by Gly does not have a significant effect on backbone structure or side chain conformations with the exception of Trp(11) in which the indole ring is rotated away from the channel axis. Measurement of the equilibrium binding constants and Delta G for the binding of monovalent cations to GA and Gly(15)-GA channels incorporated into PC vesicles using (205)Tl NMR spectroscopy shows that monovalent cations bind much more weakly to the Gly(15)-GA channel entrance than to GA channels. Utilizing the magnetization inversion transfer NMR technique, the transport of Na(+) ions through GA and Gly(15)-GA channels incorporated into PC/PG vesicles has been investigated. The Gly(15) substitution produces an increase in the activation enthalpy of transport and thus a significant decrease in the transport rate of the Na(+) ion is observed. The single-channel appearances show that the conducting channels have a single, well-defined structure. Consistent with the NMR results, the single-channel conductances are reduced by 30% and the lifetimes by 70%. It is concluded that the decrease in cation binding, transport, and conductance in Gly(15)-GA results from the removal of the Trp(15) dipole and, to a lesser extent, the change in orientation of Trp(11).

Design and characterization of gramicidin channels with side chain or backbone mutations

Mutations and chemical substitutions of amino acid side chains and backbone atoms have proved vital for understanding the folding, structure and function of gramicidin channels in phospholipid membranes. The channel's pore is lined by peptide backbone groups; their importance for channel structure and function is shown by a single amide-to-ester replacement within the backbone, which greatly reduces the resulting channel conductance and lifetime. The four tryptophans and the intervening leucines together govern the formation and dissociation of conducting channels from single-stranded subunits. Conducting double-stranded gramicidin conformations (channels) occur rarely in membranes--except when the sequence has been altered to permit special arrangements of tryptophans or (infrequently) in unusually thick membranes. The tryptophans anchor the single-stranded channels to the membrane/solution interface, and the indole dipoles promote cation transport through the channels. Removal of any indole dipole reduces ion conductance; whereas 5-fluorination of an indole, which increases its dipole moment, enhances ion conductance. Some sequence changes at the formyl-NH-terminus (in the membrane interior, away from the tryptophans), including fluorination of the formyl-NH-terminal valine, introduce voltage-dependent channel gating. Gramicidin channels are not just static conductors, but also dynamic entities whose structure and function can be manipulated by backbone and side chain modifications.

Design and characterization of gramicidin channels

This article summarizes methods for the chemical synthesis and biophysical characterization of gramicidins with varying sequences and labels. The family of gramicidin channels has developed into a powerful model system for understanding fundamental properties, interactions, and dynamics of proteins and lipids generally, and ion channels specifically, in biological membranes.

Peptide backbone chemistry and membrane channel function: effects of a single amide-to-ester replacement on gramicidin channel structure and function

To examine the structural and functional importance of backbone amide groups in ion channels for subunit folding, hydrogen bonding, ion solvation, and ion permeation, we replaced the peptide bond between Val(1) and Gly(2) in gramicidin A by an ester bond. The substitution is at the junction between the two channel subunits, where it removes an intramolecular hydrogen bond between the NH of Gly(2) and the C==O of Val(7) and perturbs an intermolecular hydrogen bond between the C==O of Val(1) in one subunit and the NH of Ala(5) in the other subunit. The substitution thus perturbs not only subunit folding but also dimer assembly, in addition to any effects on ion permeation. This backbone modification has large effects on channel function: It alters channel stability, as monitored by the channel forming ability and channel lifetime, and ion permeability, as monitored by changes in single-channel conductance and cation permeability ratios. In fact, the homodimeric channels, with two ester-containing subunits, have lifetimes so short that it becomes impossible to characterize them in any detail. The peptide --> ester substitution, however, does not affect the basic subunit fold because heterodimeric channels can form between a subunit with an ester bond and a native subunit. These heterodimeric channels, with only a single ester bond, are more easily characterized; the lone ester reduces the single-channel conductance about 4-fold and the lifetime about 200-fold as compared to the native homodimeric channels. The altered channel function results from a perturbation/disruption of the hydrogen bond network that stabilizes the backbone, as well as the membrane-spanning dimer, and that forms the lining of the ion-conducting pore. Molecular dynamics simulations show the expected destabilization of the modified heterodimeric or homodimeric channels, but the changes in backbone structure and dynamics are remarkably small. The ester bond is somewhat unstable, which precluded further structural characterization. The lability also led to a hydrolysis product that terminates with an alcohol and lacks formyl-Val. Symmetric channels formed by the hydrolyzed product again have short lifetimes, but the channels are distinctly different from those formed by the ester gramicidin A. Furthermore, well-behaved asymmetric channels form between the hydrolysis product and reference subunits that have either an L- or a D-residue at the formyl-NH-terminus.

IFCC recommended reference method for the determination of the substance concentration of ionized calcium in undiluted serum, plasma or whole blood

A reference method is described for the determination of the substance concentration of ionized calcium in plasma by which ionized calcium (free or unbound) may be reliably determined on the basis of calibration with aqueous solutions with known concentration of ionized calcium. The composition of the calibration solutions is chosen such that the activity coefficient of the calcium ion is assumed to be identical both in the calibration solutions and in "normal" plasma, i.e. by convention, the ionic strength (Im) is 0.160 mol/kg. The convention is adopted of reporting ionized calcium measurements as concentration expressed as mmol/l. The proposed reference method for ionized calcium measurement in plasma is based on the use of a cell consisting of an external reference electrode with a saturated potassium chloride liquid/liquid junction in combination with a calcium ion-selective membrane electrode of defined construction and performance. Procedures for using the reference cell and a protocol for sample measurement are described. The preparation of the calibration solutions to be used are described in detail in Appendix A, secondary calibration solutions and check standards in Appendix B, and reference cell vessel design in Appendix C.

Inclusion-induced bilayer deformations: effects of monolayer equilibrium curvature

The energetics of protein-induced bilayer deformation in systems with finite monolayer equilibrium curvature were investigated using an elastic membrane model. In this model the bilayer deformation energy delta G(def) has two major components: a compression-expansion component and a splay-distortion component, which includes the consequences of a bilayer curvature frustration due to a monolayer equilibrium curvature, c(0), that is different from zero. For any choice of bilayer material constants, the value of delta G(def) depends on global bilayer properties, as described by the bilayer material constants, as well as the energetics of local lipid packing adjacent to the protein. We introduce this dependence on lipid packing through the contact slope, s, at the protein-bilayer boundary. When c(0) = 0, delta G(def) can be approximated as a biquadratic function of s and the monolayer deformation at the protein/bilayer boundary, u(0): delta G(def) = a(1)u(0)(2) + a(2)u(0)s + a(3)s(2), where a(1), a(2), and a(3) are functions of the bilayer thickness, the bilayer compression-expansion and splay-distortion moduli, and the inclusion radius (this expression becomes exact when the Gaussian curvature component of delta G(def) is negligible). When c(0) not equal 0, the curvature frustration contribution is determined by the choice of boundary conditions at the protein-lipid boundary (by the value of s), and delta G(def) is the sum of the energy for c(0) = 0 plus the curvature frustration-dependent contribution. When the energetic penalty for the local lipid packing can be ignored, delta G(def) will be determined only by the global bilayer properties, and a c(0) > 0 will tend to promote a local inclusion-induced bilayer thinning. When the energetic penalty for local lipid packing is large, s will be constrained by the value of c(0). In a limiting case, where s is determined only by geometric constraints imposed by c(0), a c(0) > 0 will impede such local bilayer thinning. One cannot predict curvature effects without addressing the proper choice of boundary conditions at the protein-bilayer contact surface.

Neighboring aliphatic/aromatic side chain interactions between residues 9 and 10 in gramicidin channels

The interactions between an aliphatic or phenyl side chain and an indole ring in a phospholipid environment were investigated by synthesizing and characterizing gramicidins in which Trp(9) was ring-labeled and D-Leu(10) was replaced by D-Val, D-Ala, or D-Phe. All three analogues form conducting channels, with conductances that are lower than that of gramicidin A (gA) channels. The channel lifetimes vary by less than 50% from that of gA channels. Circular dichroism spectra and size-exclusion chromatography show that the conformation of each analogue in dimyristoylphosphatidylcholine (DMPC) vesicles is similar to the right-handed beta(6.3)-helical conformation that is observed for gA. (2)H NMR spectra of oriented samples in DMPC show large changes for the Trp(9) ring when residue 10 is modified, suggesting a steric interaction between D-Leu(10) and Trp(9), in agreement with previous acylation studies (R. E. Koeppe II et al. (1995) Biochemistry 34, 9299-9307). The outer quadrupolar splitting for Trp(9) is unchanged with D-Phe(10), at approximately 153 kHz, but increases by approximately 25 kHz with D-Val(10) and decreases by approximately 10 kHz with D-Ala(10). With D-Ala(10) or D-Val(10), the outer resonance splits into two in a temperature-dependent manner. The NMR spectra indicate that the side chain torsion angles chi1 and chi2 for Trp(9) change when residue 10 is substituted. The changes in chi1 are small, in all cases less than 10 degrees, as is Deltachi2 when D-Ala(10) is introduced, but with D-Val(10) and D-Phe(10) Deltachi2 is at least 25 degrees. We conclude that D-Leu(10) helps to stabilize an optimal orientation of Trp(9) in gA channels in lipid bilayers and that changes in Trp orientation alter channel conductance and lifetime without affecting the basic channel fold.

Spring constants for channel-induced lipid bilayer deformations. Estimates using gramicidin channels

Hydrophobic interactions between a bilayer and its embedded membrane proteins couple protein conformational changes to changes in the packing of the surrounding lipids. The energetic cost of a protein conformational change therefore includes a contribution from the associated bilayer deformation energy (DeltaGdef0), which provides a mechanism for how membrane protein function depends on the bilayer material properties. Theoretical studies based on an elastic liquid-crystal model of the bilayer deformation show that DeltaGdef0 should be quantifiable by a phenomenological linear spring model, in which the bilayer mechanical characteristics are lumped into a single spring constant. The spring constant scales with the protein radius, meaning that one can use suitable reporter proteins for in situ measurements of the spring constant and thereby evaluate quantitatively the DeltaGdef0 associated with protein conformational changes. Gramicidin channels can be used as such reporter proteins because the channels form by the transmembrane assembly of two nonconducting monomers. The monomerleft arrow over right arrow dimer reaction thus constitutes a well characterized conformational transition, and it should be possible to determine the phenomenological spring constant describing the channel-induced bilayer deformation by examining how DeltaGdef0 varies as a function of a mismatch between the hydrophobic channel length and the unperturbed bilayer thickness. We show this is possible by analyzing experimental studies on the relation between bilayer thickness and gramicidin channel duration. The spring constant in nominally hydrocarbon-free bilayers agrees well with estimates based on a continuum analysis of inclusion-induced bilayer deformations using independently measured material constants.

Modulation of gramicidin channel structure and function by the aliphatic "spacer" residues 10, 12, and 14 between the tryptophans

In the linear gramicidins, the four aromatic residues at positions 9, 11, 13, and 15 are well-known to be important for the structure and function of membrane-spanning gramicidin channels. To investigate whether the "spacer" residues between the tryptophans in gramicidin A (gA) are important for channel structure and function, D-Leu-10, -12. and -14 of gA were replaced by Ala, Val, or Ile. (For practical reasons, the Ile substitutions were introduced into the enantiomeric gramicidin A-, gA-.) Circular dichroism spectra of [D-Ala10,12,14]gA, [D-Val10,12,14]gA, or [Ile10,12,14]gA- incorporated into sodium dodecyl sulfate micelles or 1, 2-dimyristoyl-sn-glycero-3-phosphocholine vesicles differ from the spectrum of the native [D-Leu10,12,14]gA. All the analogue spectra display reduced ellipticity at both 218 and 235 nm, indicating the presence of double-stranded conformers with the Ala analogue spectra showing the largest departure from the native gA spectra. Size-exclusion chromatograms of the Val and Ile analogues show both monomer and dimer peaks, accompanied by peak broadening; the chromatograms for the Ala analogue show broad, overlapping peaks and suggest the presence of higher oligomers and/or (rapidly) interconverting conformations. All three analogues form membrane-spanning channels, with the channel-forming potency of the Ala analogue being much less than that of gA or the other analogues. In 1.0 M CsCl, the conductance of each analogue channel is approximately 25% less than that of [D-Leu10,12,14]gA channels. The lifetimes of the analogue channels also are less than of [D-Leu10,12, 14]gA channels, with the largest (8-fold) reduction being for [D-Ala10,12,14]gA channels. Hybrid channel experiments show that the beta6.3-helical backbone folding pattern is retained in the channel-forming subunits and that the substitutions primarily influence ion entry. Both the bulk and the stereochemistry of the aliphatic residues between the tryptophans of gA are important for channel structure and function.

Energetics of inclusion-induced bilayer deformations

The material properties of lipid bilayers can affect membrane protein function whenever conformational changes in the membrane-spanning proteins perturb the structure of the surrounding bilayer. This coupling between the protein and the bilayer arises from hydrophobic interactions between the protein and the bilayer. We analyze the free energy cost associated with a hydrophobic mismatch, i.e., a difference between the length of the protein's hydrophobic exterior surface and the average thickness of the bilayer's hydrophobic core, using a (liquid-crystal) elastic model of bilayer deformations. The free energy of the deformation is described as the sum of three contributions: compression-expansion, splay-distortion, and surface tension. When evaluating the interdependence among the energy components, one modulus renormalizes the other: e.g., a change in the compression-expansion modulus affects not only the compression-expansion energy but also the splay-distortion energy. The surface tension contribution always is negligible in thin solvent-free bilayers. When evaluating the energy per unit distance (away from the inclusion), the splay-distortion component dominates close to the bilayer/inclusion boundary, whereas the compression-expansion component is more prominent further away from the boundary. Despite this complexity, the bilayer deformation energy in many cases can be described by a linear spring formalism. The results show that, for a protein embedded in a membrane with an initial hydrophobic mismatch of only 1 A, an increase in hydrophobic mismatch to 1.3 A can increase the Boltzmann factor (the equilibrium distribution for protein conformation) 10-fold due to the elastic properties of the bilayer.

Gramicidin channel kinetics under tension

We have measured the effect of tension on dimerization kinetics of the channel-forming peptide gramicidin A. By aspirating large unilamellar vesicles into a micropipette electrode, we are able to simultaneously monitor membrane tension and electrical activity. We find that the dimer formation rate increases by a factor of 5 as tension ranges from 0 to 4 dyn/cm. The dimer lifetime also increases with tension. This behavior is well described by a phenomenological model of membrane elasticity in which tension modulates the mismatch in thickness between the gramicidin dimer and membrane.

Gramicidin channels in phospholipid bilayers with unsaturated acyl chains

In organic solvents gramicidin A (gA) occurs as a mixture of slowly interconverting double-stranded dimers. Membrane-spanning gA channels, in contrast, are almost exclusively single-stranded beta(6,3)-helical dimers. Based on spectroscopic evidence, it has previously been concluded that the conformational preference of gA in phospholipid bilayers varies as a function of the degree of unsaturation of the acyl chains. Double-stranded pi pi(5,6)-helical dimers predominate (over single-stranded beta(6,3)-helical dimers) in lipid bilayer membranes with polyunsaturated acyl chains. We therefore examined the characteristics of channels formed by gA in 1-palmitoyl-2-oleoylphosphatidylcholine/n-decane, 1,2-dioleoylphosphatidylcholine/n-decane, and 1,2-dilinoleoylphosphatidylcholine/n-decane bilayers. We did not observe long-lived channels that could be conducting double-stranded pi pi(5,6)-helical dimers in any of these different membrane environments. We conclude that the single-stranded beta(6,3)-helical dimer is the only conducting species in these bilayers. Somewhat surprisingly, the average channel duration and channel-forming potency of gA are increased in dilinoleoylphosphatidylcholine/n-decane bilayers compared to 1-palmitoyl-2-oleoylphosphatidylcholine/n-decane and dioleoylphosphatidylcholine/n-decane bilayers. To test for specific interactions between the aromatic side chains of gA and the acyl chains of the bilayer, we examined the properties of channels formed by gramicidin analogues in which the four tryptophan residues were replaced with naphthylalanine (gN), tyrosine (gT), and phenylalanine (gM). The results show that all of these analogue channels experience the same relative stabilization when going from dioleoylphosphatidylcholine to dilinoleoylphosphatidylcholine bilayers.

The conformational preference of gramicidin channels is a function of lipid bilayer thickness

In order to understand how the material properties of lipid bilayers could affect integral membrane protein function, we examined the effect of a hydrophobic mismatch on the structure and function of membrane-spanning gramicidin channels. Changes in lipid bilayer thickness affect the conformational preference of membrane-spanning gramicidin A (gA) channels (single-stranded [SS] dimers <--> double-stranded [DS] dimers) and induces an additional conductance state in the standard (SS) beta6.3-helical channel. These results provide experimental evidence for the importance of energetic coupling between the bilayer and imbedded inclusions.

Lipid bilayer electrostatic energy, curvature stress, and assembly of gramicidin channels

Hydrophobic interactions between lipid bilayers and imbedded membrane proteins couple protein conformation to the mechanical properties of the bilayer. This coupling is widely assumed to account for the regulation of membrane protein function by the membrane lipids' propensity to form nonbilayer phases, which will produce a curvature stress in the bilayer. Nevertheless, there is only limited experimental evidence for an effect of bilayer curvature stress on membrane protein structure. We show that alterations in curvature stress, due to alterations in the electrostatic energy of dioleoylphosphatidylserine bilayers, modulate the structurally well-defined gramicidin A monomer <--> dimer reaction. Maneuvers that decrease the electrostatic energy of the unperturbed bilayer promote channel dissociation; we measure the change in interaction energy. The bilayer electrostatic energy thus can affect membrane protein structure by a mechanism that does not involve the electrostatic field across the bilayer, but rather electrostatic interactions among the phospholipid head groups in each monolayer which affect the bilayer curvature stress. These results provide further evidence for the importance of mechanical interactions between a bilayer and its imbedded proteins for protein structure and function.

Gramicidin channels--a solvable membrane "protein" folding problem

The linear gramicidins are peptide antibiotics that form cation-selective channels in lipid bilayers. Gramicidin channels have very well-defined functional characteristics, and the structure of membrane-spanning gramicidin A channels is known at atomic resolution. These features make the gramicidins well suited to study how the amino acid sequence encodes the structure and function of a membrane-spanning channel. We show how one can use electrophysiological measurements to obtain structural information about conducting channels and to quantify the conformational preferences of sequence-substituted gramicidin mutants.

Membrane stiffness and channel function

Alterations in the stiffness of lipid bilayers are likely to constitute a general mechanism for modulation of membrane protein function. Gramicidin channels can be used as molecular force transducers to measure such changes in bilayer stiffness. As an application, we show that N-type calcium channel inactivation is shifted reversibly toward negative potentials by synthetic detergents that decrease bilayer stiffness. Cholesterol, which increases bilayer stiffness, shifts channel inactivation toward positive potentials. The voltage activation of the calcium channels is unaffected by the changes in stiffness. Changes in bilayer stiffness can be predicted from the molecular shapes of membrane-active compounds, which suggests a basis for the pharmacological effects of such compounds.

Gramicidin channel function does not depend on phospholipid chirality

Chiral interactions are often important determinants for molecular recognition in chemistry and biochemistry. In order to determine whether the phospholipid backbone could be important for the conformational preference of membrane-spanning channels, we made use of the linear pentadecapeptide antibiotic gramicidin A (gA+) and a Trp-->Phe-substituted gA+ analogue, gramicidin M+ (gM+), as well as their enantiomers [gramicidin A- (gA-) and gramicidin M- (gM-), respectively]. All four analogues form conducting channels in planar bilayers formed from the dialkylphospholipids (R)- or (S)- dioleylphosphatidylcholine or from the diacylphospholipid (R)-dioleoylphosphatidylcholine. The characteristics of channels formed by the two gramicidin A enantiomers, or the two gramicidin M enantiomers, in membranes formed by either of the dioleylphosphatidylcholine enantiomers are indistinguishable. Similarly, channels formed by either pair of gramicidin enantiomers in dioleoylphosphatidylcholine bilayers are indistinguishable. We conclude that chiral interactions between gramicidin channels and the lipids in the host bilayer cannot be important determinants of gramicidin channel structure or function. The membrane/solution interface, therefore, seems to organize the channel structure because of the general characteristics of the nonpolar/polar transition at the interface rather than because of specific chemical interactions.

Stabilizing effect of D-alanine2 in gramicidin channels

We have investigated the effects of replacing Gly2 by D-Ala2 in gramicidin A (gA) analogues that have either L-Val, L-Ala, or Gly as the formyl-N-terminal residue. Circular dichroism, two-dimensional nuclear magnetic resonance, and hybrid channel experiments all show that [Ala1,D-Ala2]gA channels are structurally equivalent to the native [Val1,Gly2]gA channels, being formyl-NH-to-formyl-NH dimers of single-stranded, right-handed beta 6.3 helices. Replacing the Val1 of gA by Ala or Gly decreases the average channel duration. Replacing Gly2 by D-Ala in [Val1,Gly2]gA increases the average channel duration 4-fold and the single-channel conductance by approximately 15%; replacing Gly2 with D-Ala in [Ala1,Gly2]gA or [Gly1,Gly2]-gA leads in each case to a 10-fold increase in the average channel duration with only modest changes in the single-channel conductance, which depends on the identity of the position-one residue and the permeant ion. These results illustrate the importance of neighboring-residue side chain and backbone interactions for the modulation of channel properties.

Voltage-dependent gating of an asymmetric gramicidin channel

In an effort to understand the molecular mechanisms of voltage activation of ion channels, we have chosen a system of known structure and examined the properties of heterodimeric channels formed between [Val1]gramicidin A ([Val1]gA) and [F6Val1]gramicidin A ([F6Val1]gA). Gramicidin channels are usually not voltage-dependent; but the introduction of a single symmetry-breaking dipolar F6Val1 residue into a ([Val1]gA)2 dimer to form the [F6Val1]gA/[Val1]gA heterodimer induces voltage-dependent transitions between two conducting states: a high-conductance state and a zero conductance (closed) state. The distribution between these states varies as a function of the applied potential but is not dependent on the nature of the permeant ion (H+ or Cs+). The permeating ions do not seem to contribute to the apparent gating charge.

Lysophospholipids modulate channel function by altering the mechanical properties of lipid bilayers

Lipid metabolites, free fatty acids and lysophospholipids, modify the function of membrane proteins including ion channels. Such alterations can occur through signal transduction pathways, but may also result from "direct" effects of the metabolite on the protein. To investigate possible mechanisms for such direct effects, we examined the alterations of gramicidin channel function by lysophospholipids (LPLs): lysophosphatidylcholine (LPC), lysophosphatidylethanolamine (LPE), lysophosphatidylserine (LPS), and lysophosphatidylinositol (LPI). The experiments were done on planar bilayers formed by diphytanoylphosphatidylcholine in n-decane a system where receptor-mediated effects can be excluded. At aqueous concentrations below the critical micelle concentration (CMC), LPLs can increase the dimerization constant for membrane-bound gramicidin up to 500-fold (at 2 microM). The relative potency increases as a function of the size of the polar head group, but does not seem to vary as a function of head group charge. The increased dimerization constant results primarily from an increase in the rate constant for channel formation, which can increase more than 100-fold (in the presence of LPC and LPI), whereas the channel dissociation rate constant decreases only about fivefold. The LPL effect cannot be ascribed to an increased membrane fluidity, which would give rise to an increased channel dissociation rate constant. The ability of LPC to decrease the channel dissociation rate constant varies as a function of channel length (which is always less than the membrane's equilibrium thickness): as the channel length is decreased, the potency of LPC is increased. LPC has no effect on membrane thickness or the surface tension of monolayers at the air/electrolyte interface. The bilayer-forming glycerolmonooleate does not decrease the channel dissociation rate constant. These results show that LPLs alter gramicidin channel function by altering the membrane deformation energy, and that the changes in deformation energy can be related to the molecular "shape" of the membrane-modifying compounds. Similar alterations in the mechanical properties of biological membranes may form a general mechanism by which one can alter membrane protein function.

Asymmetric gramicidin channels: heterodimeric channels with a single F6Val1 residue

Substitution of Val1 by 4,4,4,4',4',4'-F6Val in [Val1]gramicidin A ([Val1]gA) produces channels in which the effects of amino acid replacements on dimer stability and ion permeation are nonadditive. If only one Val1 (in a symmetric [Val1]gA channel) is substituted by F6Val, the resulting heterodimeric channels are destabilized relative to both homodimeric parent channels and the single-channel conductance of the heterodimeric channels is reduced relative to the parent channels (Russell, E. W. B., L. B. Weiss, F. I. Navetta, R. E. Koeppe II, and O. S. Andersen. 1986. Single-channel studies on linear gramicidins with altered amino acid side chains. Effects of altering the polarity of the side chain at position #1 in gramicidin A. Biophys. J. 49:673; Durkin, J. T., R. E. Koeppe II, and O. S. Andersen. 1990. Energetics of gramicidin hybrid channel formation as a test for structural equivalence. Side-chain substitutions in the native sequence. J. Mol. Biol. 211:221-234). To understand the basis for this destabilization, we have examined further the characteristics of [F6Val1]/[Xxx1]gA heterodimers, where Xxx = Gly, Val, and Ala. These heterodimeric channels show rapid current transitions between (at least) two current levels and display asymmetric i-V characteristics. The orientation of the heterodimers relative to the applied potential was determined by asymmetric addition of the gramicidin analogs, one to each side of a preformed bilayer. The current transitions are most clearly illustrated for [F6Val1]/[Gly1]gA heterodimers, which possess two finite and well defined current levels. Based on the existence of these two conductance states and the analysis of duration and interval distributions, we conclude that the transitions between the two current levels correspond to conformational transitions in "stable" heterodimers. In the case of [F6Val1]/[Val1]gA and [F6Val1]/[Ala1]gA heterodimers, the low-conductance state is indistinguishable from zero. The two (or more) conductance states presumably correspond to different orientations of the dipolar F6Val1 side chain. The distribution between the high- and the low-conductance states varies as a function of potential in [F6Val1]/[Gly1]gA channels. These characteristics cause the [F6Val1]/nonpolar (Val, Ala, Gly)gA hybrid channels to serve as a "simple" model for understanding gating transitions in membrane-spanning channels.

Helix sense of gramicidin channels as a "nonlocal" function of the primary sequence

Gramicidin A (gA) channels are dimers formed by right-handed beta 6.3-helical monomers. The stereochemical basis for the preference of a right-handed conformation remains obscure, but it has earlier been demonstrated that the handedness can be shifted by changing the chirality of each residue in the LD-sequence and therefore is determined by the peptide itself and not by channel-membrane interactions. We now examine the contributions of Trp15, the central Val residues 6-8, and residues 1-5. None of these alone are sufficient to specify the helix sense. To examine the D-Val6-L-Val7-D-Val8 sequence, the register of the 3 valines was shifted by one to L-Val5-D-Val6-L-Val7. The resulting analogue, [Val5,D-Ala8]gA, forms channels with a conductance and duration that are both somewhat less than those of gA channels. The reduced channel duration can be attributed to a steric conflict between the side chains of Val1 in one monomer and Val5 in the other monomer. The helix handedness is not altered by this modification, as shown by circular dichroism and two-dimensional nuclear magnetic resonance spectroscopy and by hybrid channel experiments. [Val5,D-Ala8]gA forms hybrid channels with gA (which forms right-handed channels), but not with des-Val1-gA- (which forms left-handed channels). Similar hybrid channel analysis shows that des-Trp15-gA and [L-Ala1,D-Ala2,L-Ala3,D-Ala4]gA also form right-handed channels. We conclude that the helix handedness most probably is a complex function of the arrangement of both the D-Val-L-Val-D-Val and the L-Trp-(D-Leu-L-Trp)3 segments.