Echocardiographic and hemodynamic assessment for predicting early clinical events in severe acute mitral regurgitation

The diagnostic role of echocardiographic and hemodynamic assessment in acute mitral regurgitation (AMR) remains unclear. The central question of this study was to determine if echocardiographic and hemodynamic parameters can predict early clinical events in AMR. AMR was induced by percutaneously severing the mitral valve chordae tendineae in 39 Yorkshire pigs. Immediately after AMR induction, echocardiographic and hemodynamic exams were performed, and compared between those who died and those who survived within 30-days of the procedure. Echocardiographic indices of MR severity as well as the left atrial pressure showed significant differences between survivors and non-survivors in univariate analysis. Multi-variate logistic regression analysis revealed that echocardiography-derived regurgitant fraction and vena contracta as well as mean left atrial pressure could be used to segment the cohort into survivors and non-survivors. Our study demonstrated, for the first time, that echocardiographic and hemodynamic assessment of AMR provides predictive information on early clinical events in a clinically relevant animal model of AMR.

Abstract 12: M6A Modification in RNA Regulates Cardiomyocyte and Cardiac Function in Heart Failure

Background: Adenosine in RNA is a substrate for addition or removal of methyl group. Reported five decades ago, methylated adenosine (m6A), the most abundant and functionally relevant chemical modification in RNA, whose transcriptome-wide mapping became possible only recently due to next generation sequencing (NGS). Coupled with NGS, m6A-methylated RNA capture (MeRIP-seq) identified widespread m6A distribution in ~8000 mRNA and ~1000 lncRNA transcripts in human and mouse transcriptome.

Methods and Results: In a first of its kind approach, we examined m6A RNA methylation in both failing and non-failing hearts. We discovered that global m6A RNA methylation is significantly higher in left ventricles (LV) of failing human, swine and mouse hearts as compared to non-failing controls. Increase in m6A was associated with significantly lower expression of one of the key m6A demethylases, FTO, in the ischemic heart. siRNA-mediated silencing of FTO resulted in significant arrhythmias, loss of Ca 2+ dynamics such as Ca 2+ transient decay (Tau) and cardiomyocyte relaxation time in isolated adult rat cardiomyocytes. Conversely, FTO gene transfer reduced m6A and improved Ca 2+ transients and contractile function in primary cardiomyocytes under hypoxia. In a mouse model of MI, AAV-mediated gene transfer of FTO significantly improved cardiac function post-MI. We identified transcriptome-wide m6A distribution signatures and conserved methylated sites of several mRNAs and lncRNAs using MeRIP-seq in both human and mouse failing and non-failing LV. Detailed MeRIP map of individual transcripts identified differentially methylated 3’-UTR, 5’-UTR and exon sites within several cardiac mRNAs that are important for cardiac function.

Conclusion: Our data provide first evidence that m6A modification in RNA is a regulator of cardiomyocyte Ca 2+ dynamics and cardiac function. Our findings on the dynamic nature of the cardiac m6A-epitranscriptome will add another portfolio to mRNA and lncRNA regulation of cardiac remodeling.

Abstract 271: Deletion of Delta-like 1 Homolog Accelerates Fibroblast-myofibroblast Differentiation and Induces Myocardial Fibrosis

Myocardial fibrosis is associated with profound changes in ventricular architecture and geometry, resulting in diminished cardiac function. Here we uncover that Delta-like homologue 1 (Dlk1), a paternally imprinted gene encoding a transmembrane protein belonging to the Epidermal Growth Factor (EGF)-like family, orchestrates the process of cardiac fibroblast to myofibroblast differentiation and controls myocardial fibrosis. We first show that cardiomyocytes and cardiac fibroblasts express different Dlk1 mRNA spliced variants and its absence accelerates fibroblast differentiation into myofibroblasts in vitro. Overexpression of Dlk1 in cardiac fibroblasts resulted in inhibition of fibroblast proliferation and differentiation into myofibroblasts. This process appears to be regulated by TGFβ-1 signaling, since fibroblasts lacking Dlk1 exhibited a higher activation of the TGFβ-1/Smad-3 pathway at baseline, leading to an earlier acquisition of the myofibroblast phenotype. Dlk1-null mice myocardium displayed increased TGFβ-1/Smad3 profibrotic activity, resulting in infiltration/accumulation of myofibroblasts, and induction and deposition of the extracellular matrix fibronectin extra domain A isoform and collagen, supporting a role for Dlk1 in cardiac fibrosis. Furthermore, these profibrotic events were associated with reduced myofibril integrity, myocyte hypertrophy and cardiac dysfunction. Interestingly, Dlk1 expression was downregulated in ischemic heart tissue from human patients and in the border and scar-zones of infarcted pigs’ hearts. This phenotype was paralleled by increased expression of the profibrotic markers, collagen I, lysyl oxidase and α-smooth muscle actin. Mechanistically, the inhibitory action of Dlk1 on cardiac fibroblast-myofibroblast differentiation is mediated by miR-370 direct targeting of TGFβ-R2/Smad-3 signaling in the myocardium. Given the deleterious effects of continuous activation of this pathway, we propose Dlk1 as a new potential candidate for therapy in cases where aberrant TGFβ signaling leads to chronic fibrosis.

Intratracheal Gene Delivery of SERCA2a Ameliorates Chronic Post-Capillary Pulmonary Hypertension: A Large Animal Model

BACKGROUND

Pulmonary hypertension (PH) is characterized by pulmonary arterial remodeling that results in increased pulmonary vascular resistance, right ventricular (RV) failure, and premature death. Down-regulation of sarcoplasmic reticulum Ca(2+)-ATPase 2a (SERCA2a) in the pulmonary vasculature leads to perturbations in calcium ion (Ca(2+)) homeostasis and transition of pulmonary artery smooth muscle cells to a proliferative phenotype.

OBJECTIVES

We assessed the feasibility of sustained pulmonary vascular SERCA2a gene expression using aerosolized delivery of adeno-associated virus type 1 (AAV1) in a large animal model of chronic PH and evaluated the efficacy of gene transfer regarding progression of pulmonary vascular and RV remodeling.

METHODS

A model of chronic post-capillary PH was created in Yorkshire swine by partial pulmonary vein banding. Development of chronic PH was confirmed hemodynamically, and animals were randomized to intratracheal administration of aerosolized AAV1 carrying the human SERCA2a gene (n = 10, AAV1.SERCA2a group) or saline (n = 10). Therapeutic efficacy was evaluated 2 months after gene delivery.

RESULTS

Transduction efficacy after intratracheal delivery of AAV1 was confirmed by β-galactosidase detection in the distal pulmonary vasculature. Treatment with aerosolized AAV1.SERCA2a prevented disease progression as evaluated by mean pulmonary artery pressure, vascular resistance, and limited vascular remodeling quantified by histology. Therapeutic efficacy was supported further by the preservation of RV ejection fraction (p = 0.014) and improvement of the RV end-diastolic pressure-volume relationship in PH pigs treated with aerosolized AAV1.SERCA2a.

CONCLUSIONS

Airway-based delivery of AAV vectors to the pulmonary arteries was feasible, efficient, and safe in a clinically relevant chronic PH model. Vascular SERCA2a overexpression resulted in beneficial effects on pulmonary arterial remodeling, with attendant improvements in pulmonary hemodynamics and RV performance, and might offer therapeutic benefit by modifying fundamental pathophysiology in pulmonary vascular diseases.

Gene therapy for heart failure: status quo and quo vadis

Gene therapy is recently attracting increased attention and cardiac gene therapy is not an exception. Advances in gene transfer vectors, development of new vector delivery methods, and discovery of new gene targets continue to fuel our motivation to use this approach in routine bedside care. In the past two years, we have witnessed important advances in the field, as the results of three recently completed cardiac gene therapy programs have been published. Unfortunately, none of the trials have met their primary efficacy endpoints, but sub-analysis demonstrated potential efficacy. Careful review and interpretation of these trial results will provide important insights and direct us to improve the future trial design. In this review, we update our previous overview with a specific focus on recent clinical trial results. We then contemplate future strategies towards successful application of gene therapy for treating clinical heart failure.

Direct Myocardial Injection of Vectors

Gene therapy holds great promise as a targeted treatment of cardiovascular diseases, which remain a major cause of morbidity and mortality in contemporary societies. Selection of the appropriate vector delivery method is critical for efficient transduction in the myocardium. Direct myocardial delivery is a feasible and effective method that has been shown to exhibit enhanced gene expression compared to coronary infusion and pericardial delivery. It is one of the most widely used gene transfer methods in both animal studies and clinical trials. The advantages, which result from a delivery that avoids exposure to the blood and bypasses the endothelial barrier, are a high local concentration at the injection site and a decreased leakage to off-target organs. The vectors are injected either with an endomyocardial or an epicardial approach, either surgically or percutaneously. In this chapter, we present the different approaches of direct myocardial injection, their advantages and their realization method in preclinical large animal models of cardiovascular diseases.

Current Methods in Cardiac Gene Therapy: Overview

During the last decade, there has been a significant progress toward clinical translation in the field of cardiac gene therapy based on extensive preclinical data. However, despite encouraging positive results in early phase clinical trials, more recent larger trials reported only neutral results. Nevertheless, the field has gained important knowledge from these trials and is leading to the development of more cardiotropic vectors and improved delivery systems. It has become more evident that humans are more resistant to therapeutic transgene expression compared to experimental animals and thus refinement in gene delivery tools and methods are essential for future success. We provide an overview of the current status of cardiac gene therapy focusing on gene delivery tools and methods. Newer technologies, devices, and approaches will undoubtedly lead to more promising clinical results in the near future.

Cardiac Gene Delivery in Large Animal Models: Antegrade Techniques

Percutaneous antegrade coronary injection is among the least invasive cardiac selective gene delivery methods. However, transduction efficiency is quite low with a simple bolus antegrade injection. In order to improve the transduction efficiency using antegrade delivery, several additional approaches have been proposed.In this chapter, we briefly discuss important elements associated with intracoronary delivery methods and present protocols for three different catheter-based antegrade delivery techniques in a preclinical large animal model. Despite the lower transduction efficacy relative to more invasive delivery techniques, antegrade techniques have the advantage of being clinically well established and having safer profiles which is important when treating patients with cardiac disease.

An in vivo screening system to identify tumorigenic genes

Screening for oncogenes has mostly been performed by in vitro transformation assays. However, some oncogenes might not exhibit their transforming activities in vitro unless putative essential factors from in vivo microenvironments are adequately supplied. Here, we have developed an in vivo screening system that evaluates the tumorigenicity of target genes. This system uses a retroviral high-efficiency gene transfer technique, a large collection of human cDNA clones corresponding to ~70% of human genes and a luciferase-expressing immortalized mouse mammary epithelial cell line (NMuMG-luc). From 845 genes that were highly expressed in human breast cancer cell lines, we focused on 205 genes encoding membrane proteins and/or kinases as that had the greater possibility of being oncogenes or drug targets. The 205 genes were divided into five subgroups, each containing 34-43 genes, and then introduced them into NMuMG-luc cells. These cells were subcutaneously injected into nude mice and monitored for tumor development by in vivo imaging. Tumors were observed in three subgroups. Using DNA microarray analyses and individual tumorigenic assays, we found that three genes, ADORA2B, PRKACB and LPAR3, were tumorigenic. ADORA2B and LPAR3 encode G-protein-coupled receptors and PRKACB encodes a protein kinase A catalytic subunit. Cells overexpressing ADORA2B, LPAR3 or PRKACB did not show transforming phenotypes in vitro, suggesting that transformation by these genes requires in vivo microenvironments. In addition, several clinical data sets, including one for breast cancer, showed that the expression of these genes correlated with lower overall survival rate.