Nintedanib Inhibits Endothelial Mesenchymal Transition in Bleomycin-Induced Pulmonary Fibrosis via Focal Adhesion Kinase Activity Reduction

Targeting endothelial cells: A novel strategy for pulmonary fibrosis treatment

Endothelial cells (ECs) are a monolayer of flat cells lining the inner surfaces of blood and lymphatic vessels. They play a key role in many physiological and pathological processes. Specifically, they maintain vascular permeability and structural stability and participate in immune responses, inflammation, coagulation, and other vital functions. ECs play a decisive role in various age-related diseases; however, their involvement in pulmonary fibrosis (PF) remains poorly understood. PF refers to a group of chronic interstitial lung diseases characterised by progressive scarring of the pulmonary parenchyma, primarily caused by aberrant tissue repair mechanisms. These changes lead to irreversible loss of lung function. Although the exact pathophysiological mechanism underlying PF has not yet been elucidated, recent studies have indicated that ECs may play a pivotal role in PF. This review outlines the involvement of pulmonary vascular ECs in PF, focusing on the regulation of vascular remodelling and endothelial barrier integrity and on the maintenance of angiogenesis through EC-specific markers, such as vascular endothelial growth factor. This review also explores processes such as endothelial-to-mesenchymal transition, immune cell interactions, anti-EC antibody reactions, metabolic dysregulation, and cellular senescence. By elucidating recent advancements in understanding the role of ECs in PF and examining drugs targeting ECs for the treatment of PF, this study provides novel insights into the pathological mechanisms of PF and the development of endothelium-based therapeutic agents.

MDA5 protein mediating persistent ER stress/unfolded protein response contributes to endothelial-mesenchymal-transition of lung microvascular endothelial cell in dermatomyositis

BACKGROUND

Dermatomyositis (DM) is an idiopathic inflammatory myopathy. Anti-MDA5 antibody positive DM (MDA5 + DM) is a distinct subtype of the disease. The model of anti-MDA5 antibody positive DM has been already reported. However, the detailed role and mechanism of MDA5 in vascular damage was still poorly understood.

METHODS

Clinical information was retrospectively collected, and a total of 127 DM patients were enrolled. Serum from DM patients and control subjects was used to treat mouse lung microvascular endothelial cells (MVECs) to investigate vascular changes. Western blotting, quantitative real-time polymerase chain reaction (qRT-PCR), immunofluorescence staining, immunoprecipitation, protein mass spectrometry, flow cytometry and bioinformatics analysis were used.

RESULTS

Firstly, clinical data analysis revealed that vascular damage and interstitial lung disease (ILD) was correlated with anti-MDA5 antibody in DM patients. Then, serum from patients was used to treat mouse lung MVECs. Serum from MDA5 + DM patients induced endothelial-mesenchymal-transition (EndMT) in MVECs, and the EndMT in MVECs was mediated by TRB3/ERK/Snai-1 pathway. Next, increased-TRB3 was confirmed induced by persistent ER stress/unfolded protein response (UPR). Notably, persistent ER stress/UPR resulted from MDA5 protein binding with PERK. At last, T cell-derived IFN-β was found to induce MDA5 expression in DM patients.

CONCLUSION

MDA5 protein mediating persistent ER stress/UPR contributed to EndMT in vascular endothelial cells, which should be involved in MDA5 + DM related ILD.

Recent advances in TGF-β signaling pathway in COVID-19 pathogenesis: A review

The coronavirus disease 2019 (COVID-19) has resulted in approximately 7.0 million fatalities between 2019 and 2022, underscoring a pressing need for comprehensive research into its underlying mechanisms and therapeutic avenues. A distinctive feature of severe COVID-19 is the dysregulated immune response characterized by excessive activation of immune cells and the consequent cytokine storms. Recent advancements in our understanding of cellular signaling pathways have illuminated the role of Transforming Growth Factor Beta (TGF-β) as a pivotal signaling molecule with significant implications for the pathogenesis of infectious diseases, including COVID-19. Emerging evidence reveals that TGF-β signaling, when activated by viral components or secondary pathways, adversely affects diverse cell types, particularly immune cells, and lung tissue, leading to complications such as pulmonary fibrosis. In our review article, we critically evaluate recent literature on the involvement of TGF-β signaling in the progression of COVID-19. We discuss a range of pharmacological interventions, including nintedanib, pirfenidone, corticosteroids, proton pump inhibitors, and histone deacetylase inhibitors, and their potential to modulate the TGF-β pathway in the context of COVID-19 treatment. Additionally, we explore ongoing clinical trials involving mesenchymal stem cells, low-dose radiation therapy, and artemisinin derivatives to assess their impact on TGF-β levels and subsequent clinical outcomes in COVID-19 patients. This review is particularly relevant at this juncture as the global health community continues to grapple with the ramifications of the COVID-19 pandemic, highlighting the urgent need for targeted therapeutic strategies aimed at TGF-β modulation to mitigate disease severity and improve patient outcomes.

The Relationship Between Differential Expression of Non-coding RNAs (TP53TG1, LINC00342, MALAT1, DNM3OS, miR-126-3p, miR-200a-3p, miR-18a-5p) and Protein-Coding Genes (PTEN, FOXO3) and Risk of Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a rapidly progressive interstitial lung disease of unknown pathogenesis with no effective treatment currently available. Given the regulatory roles of lncRNAs (TP53TG1, LINC00342, H19, MALAT1, DNM3OS, MEG3), miRNAs (miR-218-5p, miR-126-3p, miR-200a-3p, miR-18a-5p, miR-29a-3p), and their target protein-coding genes (PTEN, TGFB2, FOXO3, KEAP1) in the TGF-β/SMAD3, Wnt/β-catenin, focal adhesion, and PI3K/AKT signaling pathways, we investigated the expression levels of selected genes in peripheral blood mononuclear cells (PBMCs) and lung tissue from patients with IPF. Lung tissue and blood samples were collected from 33 newly diagnosed, treatment-naive patients and 70 healthy controls. Gene expression levels were analyzed by RT-qPCR. TaqMan assays and TaqMan MicroRNA assay were employed to quantify the expression of target lncRNAs, mRNAs, and miRNAs. Our study identified significant differential expression in PBMCs from IPF patients compared to healthy controls, including lncRNAs MALAT1 (Fold Change = 3.809, P = 0.0001), TP53TG1 (Fold Change = 0.4261, P = 0.0021), and LINC00342 (Fold Change = 1.837, P = 0.0448); miRNAs miR-126-3p (Fold Change = 0.102, P = 0.0028), miR-200a-3p (Fold Change = 0.442, P = 0.0055), and miR-18a-5p (Fold Change = 0.154, P = 0.0034); and mRNAs FOXO3 (Fold Change = 4.604, P = 0.0032) and PTEN (Fold Change = 2.22, P = 0.0011). In lung tissue from IPF patients, significant expression changes were observed in TP53TG1 (Fold Change = 0.2091, P = 0.0305) and DNM3OS (Fold Change = 4.759, P = 0.05). Combined analysis of PBMCs expression levels for TP53TG1, MALAT1, miRNA miR-126-3p, and PTEN distinguished IPF patients from healthy controls with an AUC = 0.971, sensitivity = 0.80, and specificity = 0.955 (P = 6 × 10-8). These findings suggest a potential involvement of the identified ncRNAs and mRNAs in IPF pathogenesis. However, additional functional validation studies are needed to elucidate the precise molecular mechanisms by which these lncRNAs, miRNAs, and their targets contribute to PF.

Broadening horizons: molecular mechanisms and disease implications of endothelial-to-mesenchymal transition

Endothelial-mesenchymal transition (EndMT) is defined as an important process of cellular differentiation by which endothelial cells (ECs) are prone to lose their characteristics and transform into mesenchymal cells. During EndMT, reduced expression of endothelial adhesion molecules disrupts intercellular adhesion, triggering cytoskeletal reorganization and mesenchymal transition. Numerous studies have proved that EndMT is a multifaceted biological event driven primarily by cytokines such as TGF-β, TNF-α, and IL-1β, alongside signaling pathways like WNT, Smad, MEK-ERK, and Notch. Nevertheless, the exact roles of EndMT in complicated diseases have not been comprehensively reviewed. In this review, we summarize the predominant molecular regulatory mechanisms and signaling pathways that contribute to the development of EndMT, as well as highlight the contributions of a series of imperative non-coding RNAs in curbing the initiation of EndMT. Furthermore, we discuss the significant impact of EndMT on worsening vasculature-related diseases, including cancer, cardiovascular diseases, atherosclerosis, pulmonary vascular diseases, diabetes-associated fibrotic conditions, and cerebral cavernous malformation, providing the implications that targeting EndMT holds promise as a therapeutic strategy to mitigate disease progression.

Vascular involvement in idiopathic pulmonary fibrosis

Background

Idiopathic pulmonary fibrosis (IPF) is a chronic, fibrosing and progressive interstitial lung disease of unknown aetiology with a pathogenesis still partly unknown. Several microvascular and macrovascular abnormalities have been demonstrated in the pathogenesis of IPF and related pulmonary hypertension (PH), a complication of the disease.

Methods

We carried out a non-systematic, narrative literature review aimed at describing the role of the vasculature in the natural history of IPF.

Results

The main molecular pathogenetic mechanisms involving vasculature (i.e. endothelial-to-mesenchymal transition, vascular remodelling, endothelial permeability, occult alveolar haemorrhage, vasoconstriction and hypoxia) and the genetic basis of vascular remodelling are described. The prevalence and clinical relevance of associated PH are highlighted with focus on the vasculature as a prognostic marker. The vascular effects of current antifibrotic therapies, the role of pulmonary vasodilators in the treatment of disease, and new pharmacological options with vascular-targeted activity are described.

Conclusions

The vasculature plays a key role in the natural history of IPF from the early phases of disease until development of PH in a subgroup of patients, a complication related to a worse prognosis. Pulmonary vascular volume has emerged as a novel computed tomography finding and a predictor of mortality, independent of PH. New pharmacological options with concomitant vascular-directed activity might be promising in the treatment of IPF.

Multicenter, prospective, observational study for urinary exosomal biomarkers of kidney allograft fibrosis

Severity of deceased donor kidney fibrosis impacts graft survival in deceased-donor kidney transplantation. Our aim was to identify potential miRNA biomarkers in urinary exosomes that mirror interstitial fibrosis and tubular atrophy (IFTA) severity. Among 109 urine samples from deceased donors, 34 displayed no IFTA in the zero-day biopsy (No IFTA group), while the remaining 75 deceased donor kidneys exhibited an IFTA score ≥ 1 (IFTA group). After analyzing previous reports and electronic databases, six miRNAs (miR-19, miR-21, miR-29c, miR-150, miR-200b, and miR-205) were selected as potential IFTA biomarker candidates. MiR-21, miR-29c, miR-150, and miR-205 levels were significantly higher, while miR-19 expression was significantly lower in the IFTA group. MiR-21 (AUC = 0.762; P < 0.001) and miR-29c (AUC = 0.795; P < 0.001) showed good predictive accuracy for IFTA. In the No IFTA group, the eGFR level at 1 week after transplantation was significantly higher compared to the IFTA group (41.34 mL/min/1.73m2 vs. 28.65 mL/min/1.73m2, P = 0.012). These findings signify the potential of urinary exosomal miRNAs as valuable biomarker candidates for evaluating the severity of IFTA in deceased donor kidneys before they undergo recovery.

The potential ameliorating effect of vitamin E on bleomycin - induced lung fibrosis in adult albino rats

Lung fibrosis is a critical interstitial lung disease with poor prognosis. There is an urgent need to develop a proper and cost-effective therapeutic modality that can reverse and/or ameliorate lung fibrosis. Vitamin E is one of the widely investigated dietary antioxidants which has been linked to improvement of many health problems. The current study was conducted to evaluate the possible roles of vitamin E in prevention and treatment of bleomycin (BLM) induced lung fibrosis. Physiological, anatomical, histopathological and immunohistochemical studies were done to assess and compare between the structure and function of the lung tissue in lung fibrosis model, early and late treated groups with vitamin E. Furthermore, measurement of transforming growth factor-β(TGF-β), E-cadherin, Smad-3, BAX, BCL2, malondialdehyde (MDA), and superoxide dismutase (SOD) were done. The study revealed that administration of vitamin E helped to improve signs of lung fibrosis, as reflected by amelioration of structure and functions of lungs as well as the decrease in TGF-β levels and inhibition of α-SMA/collagen I profibrotic pathway. These findings highlight the importance of administration of vitamin E as a prophylactic agent prior to BLM therapy and as an adjuvant treatment in cases of lung fibrosis.

Research Progress in pathogenesis of connective tissue disease-associated interstitial lung disease from the perspective of pulmonary cells

The lungs are a principal factor in the increased morbidity and mortality observed in patients with Connective Tissue Disease (CTD), frequently presenting as CTD-associated Interstitial Lung Disease (ILD). Currently, there is a lack of comprehensive descriptions of the pulmonary cells implicated in the development of CTD-ILD. This review leverages the Human Lung Cell Atlas (HLCA) and spatial multi-omics atlases to discuss the advancements in research on the pathogenesis of CTD-ILD from a pulmonary cell perspective. This facilitates a more precise localization of disease sites and a more systematic consideration of disease progression, supporting further mechanistic studies and targeted therapies.

Current state of signaling pathways associated with the pathogenesis of idiopathic pulmonary fibrosis

Idiopathic Pulmonary Fibrosis (IPF) represents a chronic and progressive pulmonary disorder distinguished by a notable mortality rate. Despite the elusive nature of the pathogenic mechanisms, several signaling pathways have been elucidated for their pivotal roles in the progression of this ailment. This manuscript aims to comprehensively review the existing literature on the signaling pathways linked to the pathogenesis of IPF, both within national and international contexts. The objective is to enhance the comprehension of the pathogenic mechanisms underlying IPF and offer a scholarly foundation for the advancement of more efficacious therapeutic strategies, thereby fostering research and clinical practices within this domain.

Pirfenidone and nintedanib attenuates pulmonary artery endothelial and smooth muscle cells transformations induced by IL-11

Idiopathic pulmonary fibrosis (IPF) associated to pulmonary hypertension (PH) portends a poor prognosis, characterized by lung parenchyma fibrosis and pulmonary artery remodeling. Serum and parenchyma levels of Interleukin 11 (IL-11) are elevated in IPF-PH patients and contributes to pulmonary artery remodeling and PH. However, the effect of current approved therapies against IPF in pulmonary artery remodeling induced by IL-11 is unknown. The aim of this study is to analyze the effects of nintedanib and pirfenidone on pulmonary artery endothelial and smooth muscle cell remodeling induced by IL-11 in vitro. Our results show that nintedanib (NTD) and pirfenidone (PFD) ameliorates endothelial to mesenchymal transition (EnMT), pulmonary artery smooth muscle cell to myofibroblast-like transformation and pulmonary remodeling in precision lung cut slices. This study provided also evidence of the inhibitory effect of PFD and NTD on IL-11-induced endothelial and muscle cells proliferation and senescence. The inhibitory effect of these drugs on monocyte arrest and angiogenesis was also studied. Finally, we observed that IL-11 induced canonical signal transducer and activator of transcription 3 (STAT3) and non-canonical mitogen-activated protein kinase 1/2 (ERK1/2) phosphorylation, but, PFD and NTD only inhibited ERK1/2 phosphorylation. Therefore, this study provided evidence of the inhibitory effect of NTD and PFD on markers of pulmonary artery remodeling induced by IL-11.

Exosomes derived from adipose tissue-derived stem cells alleviated H2O2-induced oxidative stress and endothelial-to-mesenchymal transition in human umbilical vein endothelial cells by inhibition of the mir-486-3p/Sirt6/Smad signaling pathway

Hypertrophic scar (HS) is characterized by excessive collagen deposition and myofibroblasts activation. Endothelial-to-mesenchymal transition (EndoMT) and oxidative stress were pivotal in skin fibrosis process. Exosomes derived from adipose tissue-derived stem cells (ADSC-Exo) have the potential to attenuate EndoMT and inhibit fibrosis. The study revealed reactive oxygen species (ROS) levels were increased during EndoMT occurrence of dermal vasculature of HS. The morphology of endothelial cells exposure to H2O2, serving as an in vitro model of oxidative stress damage, transitioned from a cobblestone-like appearance to a spindle-like shape. Additionally, the levels of endothelial markers decreased in H2O2-treated endothelial cell, while the expression of fibrotic markers increased. Furthermore, H2O2 facilitated the accumulation of ROS, inhibited cell proliferation, retarded its migration and suppressed tube formation in endothelial cell. However, ADSC-Exo counteracted the biological effects induced by H2O2. Subsequently, miRNAs sequencing analysis revealed the significance of mir-486-3p in endothelial cell exposed to H2O2 and ADSC-Exo. Mir-486-3p overexpression enhanced the acceleration of EndoMT, its inhibitors represented the attenuation of EndoMT. Meanwhile, the target regulatory relationship was observed between mir-486-3p and Sirt6, whereby Sirt6 exerted its anti-EndoMT effect through Smad2/3 signaling pathway. Besides, our research had successfully demonstrated the impact of ADSC-Exo and mir-486-3p on animal models. These findings of our study collectively elucidated that ADSC-Exo effectively alleviated H2O2-induced ROS and EndoMT by inhibiting the mir-486-3p/Sirt6/Smad axis.

Nintedanib-loaded exosomes from adipose-derived stem cells inhibit pulmonary fibrosis induced by bleomycin

BACKGROUND

Pulmonary fibrosis (PF) is a progressive lung disorder with a high mortality rate; its therapy remains limited due to the inefficiency of drug delivery. In this study, the system of drug delivery of nintedanib (Nin) by exosomes derived from adipose-derived stem cells (ADSCs-Exo, Exo) was developed to effectively deliver Nin to lung lesion tissue to ensure enhanced anti-fibrosis therapy.

METHODS

The bleomycin (BLM)-induced PF model was constructed in vivo and in vitro. The effects of Exo-Nin on BLM-induced PF and its regulatory mechanism were examined using RT-qPCR, Western blotting, immunofluorescence, and H&E staining.

RESULTS

We found Exo-Nin significantly improved BLM-induced PF in vivo and in vitro compared to Nin and Exo groups alone. Mechanistically, Exo-Nin alleviated fibrogenesis by suppressing endothelial-mesenchymal transition through the down-regulation of the TGF-β/Smad pathway and the attenuation of oxidative stress in vivo and in vitro.

CONCLUSIONS

Utilizing adipose stem cell-derived exosomes as carriers for Nin exhibited a notable enhancement in therapeutic efficacy. This improvement can be attributed to the regenerative properties of exosomes, indicating promising prospects for adipose-derived exosomes in cell-free therapies for PF.

IMPACT

The system of drug delivery of nintedanib (Nin) by exosomes derived from adipose-derived stem cells was developed to effectively deliver Nin to lung lesion tissue to ensure enhanced anti-fibrosis therapy. The use of adipose stem cell-derived exosomes as the carrier of Nin may increase the therapeutic effect of Nin, which can be due to the regenerative properties of the exosomes and indicate promising prospects for adipose-derived exosomes in cell-free therapies for PF.

PTK2-associated gene signature could predict the prognosis of IPF

Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease with a poor prognosis. Current/available clinical prediction tools have limited sensitivity and accuracy when evaluating clinical outcomes of IPF. Research has shown that focal adhesion kinase (FAK), produced by the protein tyrosine kinase 2 (PTK2) gene, is crucial in IPF development. FAK activation is a characteristic of lesional fibroblasts; Thus, FAK may be a valuable therapeutic target or prognostic biomarker for IPF. This study aimed to create a gene signature based on PTK2-associated genes and microarray data from blood cells to predict disease prognosis in patients with IPF. PTK2 levels were found to be higher in lung tissues of IPF patients compared to healthy controls, and PTK2 inhibitor Defactinib was found to reduce TGFβ-induced FAK activation and increase α-smooth muscle actin. Although the blood PTK2 levels were higher in IPF patients, blood PTK level alone could not predict IPF prognosis. From 196 PTK2-associated genes, 11 genes were prioritized to create a gene signature (PTK2 molecular signature) and a risk score system using univariate and multivariate Cox regression analysis. Patients were divided into high-risk and low-risk groups using PTK2 molecular signature. Patients in the high-risk group experienced decreased survival rates compared to patients in the low-risk group across all discovery and validation cohorts. Further functional enrichment and immune cell proportion analyses revealed that the PTK2 molecular signature strongly reflected the activation levels of immune pathways and immune cells. These findings suggested that PTK2 is a molecular target of IPF and the PTK2 molecular signature is an effective IPF prognostic biomarker.

Post-COVID-19 pulmonary fibrosis: An ongoing concern

Coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 rapidly spread across the globe causing over 6 million deaths and major compromization of health facilities. The vast majority of survivors post-COVID-19 are left with variable degrees of health sequelae including pulmonary, neurological, psychological, and cardiovascular complications. Post-COVID-19 pulmonary fibrosis is one of the major concerns arising after the recovery from this pandemic. Risk factors for post-COVID-19 pulmonary fibrosis include age, male sex, and the severity of COVID-19 disease. High-resolution computed tomography provides diagnostic utility to diagnose pulmonary fibrosis as it provides more details regarding the pattern and the extent of pulmonary fibrosis. Emerging data showing similarities between post-COVID-19 pulmonary fibrosis and idiopathic pulmonary fibrosis, finding that needs further exploration. The management of post-COVID-19 pulmonary fibrosis depends on many factors but largely relies on excluding other causes of pulmonary fibrosis, the extent of fibrosis, and physiological impairment. Treatment includes immunosuppressants versus antifibrotics or both.

Overview on the Link Between the Complement System and Auto-Immune Articular and Pulmonary Disease

Complement system (CS) dysregulation is a key factor in the pathogenesis of different autoimmune diseases playing a central role in many immune innate and adaptive processes. Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by ta breach of self-tolerance leading to a synovitis and extra-articular manifestations. The CS is activated in RA and seems not only to mediate direct tissue damage but also play a role in the initiation of RA pathogenetic mechanisms through interactions with citrullinated proteins. Interstitial lung disease (ILD) represents the most common extra-articular manifestation that can lead to progressive fibrosis. In this review, we focused on the evidence of CS dysregulation in RA and in ILD, and highlighted the role of the CS in both the innate and adaptive immune responses in the development of diseases, by using idiopathic pulmonary fibrosis as a model of lung disease. As a proof of concept, we dissected the evidence that several treatments used to treat RA and ILD such as glucocorticoids, pirfenidone, disease modifying antirheumatic drugs, targeted biologics such as tumor necrosis factor (TNF)-inhibitors, rituximab, tocilizumab, and nintedanib may act indirectly on the CS, suggesting that the CS might represent a potential therapeutic target in these complex diseases.

Injured Endothelial Cell: A Risk Factor for Pulmonary Fibrosis

The pathological features of pulmonary fibrosis (PF) are the abnormal activation and proliferation of myofibroblasts and the extraordinary deposition of the extracellular matrix (ECM). However, the pathogenesis of PF is still indistinct. In recent years, many researchers have realized that endothelial cells had a crucial role in the development of PF. Studies have demonstrated that about 16% of the fibroblasts in the lung tissue of fibrotic mice were derived from endothelial cells. Endothelial cells transdifferentiated into mesenchymal cells via the endothelial-mesenchymal transition (E(nd)MT), leading to the excessive proliferation of endothelial-derived mesenchymal cells and the accumulation of fibroblasts and ECM. This suggested that endothelial cells, a significant component of the vascular barrier, played an essential role in PF. Herein, this review discusses E(nd)MT and its contribution to the activation of other cells in PF, which could provide new ideas for further understanding the source and activation mechanism of fibroblasts and the pathogenesis of PF.

Mechanical homeostasis imbalance in hepatic stellate cells activation and hepatic fibrosis

Chronic liver disease or repeated damage to hepatocytes can give rise to hepatic fibrosis. Hepatic fibrosis (HF) is a pathological process of excessive sedimentation of extracellular matrix (ECM) proteins such as collagens, glycoproteins, and proteoglycans (PGs) in the hepatic parenchyma. Changes in the composition of the ECM lead to the stiffness of the matrix that destroys its inherent mechanical homeostasis, and a mechanical homeostasis imbalance activates hepatic stellate cells (HSCs) into myofibroblasts, which can overproliferate and secrete large amounts of ECM proteins. Excessive ECM proteins are gradually deposited in the Disse gap, and matrix regeneration fails, which further leads to changes in ECM components and an increase in stiffness, forming a vicious cycle. These processes promote the occurrence and development of hepatic fibrosis. In this review, the dynamic process of ECM remodeling of HF and the activation of HSCs into mechanotransduction signaling pathways for myofibroblasts to participate in HF are discussed. These mechanotransduction signaling pathways may have potential therapeutic targets for repairing or reversing fibrosis.