Exosomes deliver endogenous protective signals to the myocardium by a pathway involving TLR4 and classic cardioprotective HSPs.

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Due to its poor capacity for regeneration, the heart is particularly sensitive to the loss of contractile cardiomyocytes. The onslaught of damage caused by ischaemia and reperfusion, occurring during an acute myocardial infarction and the subsequent reperfusion therapy, can wipe out upwards of a billion cardiomyocytes. A similar program of cell death can cause the irreversible loss of neurons in ischaemic stroke. Similar pathways of lethal cell injury can contribute to other pathologies such as left ventricular dysfunction and heart failure caused by cancer therapy. Consequently, strategies designed to protect the heart from lethal cell injury have the potential to be applicable across all three pathologies. The investigators meeting at the 10th Hatter Cardiovascular Institute workshop examined the parallels between ST-segment elevation myocardial infarction (STEMI), ischaemic stroke, and other pathologies that cause the loss of cardiomyocytes including cancer therapeutic cardiotoxicity. They examined the prospects for protection by remote ischaemic conditioning (RIC) in each scenario, and evaluated impasses and novel opportunities for cellular protection, with the future landscape for RIC in the clinical setting to be determined by the outcome of the large ERIC-PPCI/CONDI2 study. It was agreed that the way forward must include measures to improve experimental methodologies, such that they better reflect the clinical scenario and to judiciously select combinations of therapies targeting specific pathways of cellular death and injury.

The pharmacological inhibition or genetic ablation of cyclophilin-D (CypD), a critical regulator of the mitochondrial permeability transition pore (mPTP), confers myocardial resistance to acute ischemia-reperfusion injury, but its role in post-myocardial infarction (MI) heart failure is unknown. The aim of this study was to determine whether mitochondrial CypD is also a therapeutic target for the treatment of post-MI heart failure. Wild-type (WT) and CypD–/– mice were subjected to either sham surgery or permanent ligation of the left main coronary artery to induce MI, and were assessed at either 2 or 28 days to determine the long-term effects of CypD ablation. After 2 days, myocardial infarct size was smaller and left ventricular (LV) function was better preserved in CypD–/– mice compared to WT mice. After 28 days, when compared to WT mice, in the CypD–/– mice, mortality was halved, myocardial infarct size was reduced, LV systolic function was better preserved, LV dilatation was attenuated and in the remote non-infarcted myocardium, there was less cardiomyocyte hypertrophy and interstitial fibrosis. Finally, ex vivo fibroblast proliferation was found to be reduced in CypD–/– cardiac fibroblasts, and in WT cardiac fibroblasts treated with the known CypD inhibitors, cyclosporin-A and sanglifehrin-A. Following an MI, mice lacking CypD have less mortality, smaller infarct size, better preserved LV systolic function and undergo less adverse LV remodelling. These findings suggest that the inhibition of mitochondrial CypD may be a novel therapeutic treatment strategy for post-MI heart failure.

PurposeProtecting the heart from ischaemia-reperfusion (IR) injury is a major goal in patients presenting with an acute myocardial infarction. Pyroptosis is a novel form of cell death in which caspase 1 is activated and cleaves interleukin 1β. VX-785 is a highly selective, prodrug caspase 1 inhibitor that is also clinically available. It has been shown to be protective against acute IR in vivo rat model, and therefore might be a promising possibility for future cardioprotective therapy. However, it is not known whether protection by VX-765 involves the reperfusion injury salvage kinase (RISK) pathway. We therefore investigated whether VX-765 protects the isolated, perfused rat heart via the PI3K/Akt pathway and whether protection was additive with ischaemic preconditioning (IPC).MethodsLangendorff-perfused rat hearts were subject to ischaemia and reperfusion injury in the presence of 30 μM VX-765, with precedent IPC, or the combination of VX-765 and IPC.ResultsVX-765 reduced infarct size (28 vs 48% control; P < 0.05) to a similar extent as IPC (30%; P < 0.05). The PI3 kinase inhibitor, wortmannin, abolished the protective effect of VX-765. Importantly in the model used, we were unable to show additive protection with VX-765 + IPC.ConclusionsThe caspase 1 inhibitor, VX-765, was able to reduce myocardial infarction in a model of IR injury. However, the addition of IPC did not demonstrate any further protection.

Acute myocardial infarction causes lethal cardiomyocyte injury during ischaemia and reperfusion (I/R). Histones have been described as important Danger Associated Molecular Proteins (DAMPs) in sepsis. Aims The objective of this study was to establish whether extracellular histone release contributes to myocardial infarction. Methods and results Isolated, perfused rat hearts were subject to I/R. Nucleosomes and histone H4 release was detected early during reperfusion. Sodium-β-O-Methyl cellobioside sulfate (mCBS), a newly developed histone-neutralising compound, significantly reduced infarct size whilst also reducing the detectable levels of histones. Histones were directly toxic to primary adult rat cardiomyocytes in vitro. This was prevented by mCBS, or HIPe, a recently described, histone-H4 neutralizing peptide, but not by an inhibitor of TLR4, a receptor previously reported to be involved in DAMP-mediated cytotoxicity. Furthermore, TLR4-reporter HEK293 cells revealed that cytotoxicity of histone H4 was independent of TLR4 and NF-κB. In an in vivo rat model of I/R, HIPe significantly reduced infarct size. Conclusion Histones released from the myocardium are cytotoxic to cardiomyocytes, via a TLR4-independent mechanism. The targeting of extracellular histones provides a novel opportunity to limit cardiomyocyte death during I/R injury of the myocardium. Translational perspective Acute myocardial infarction causes lethal cardiomyocyte injury during ischaemia and reperfusion (I/R). New approaches are needed to prevent cardiomyocyte injury and limit final infarct size. We show that histones released from damaged cells, and histone-H4 in particular, causes rapid cardiomyocyte death during I/R. mCBS, a compounds targeting histones non-specifically, was cardioprotective in ex vivo rat hearts, while HIPe, a targeting histone H4 specifically, was cardioprotective in an in vivo rat model. HIPe may have potential as a therapeutic agent in the setting of acute myocardial infarction.

Rationale Preconditioning is widely known to protect cardiomyocytes from reperfusion-induced cell death by activation of several pro-survival transductional pathways. The fact that preconditioning can be achieved remotely (Remote Ischaemic Preconditioning, RIPC) means that humoral factors are released from ischaemic limbs into the circulation carrying a pro-survival message. Exosomes are circulating nano-sized vesicles that mediate inter-cellular communication by carrying diverse proteins and RNA molecules. Here we studied the role of exosomes in mediating RIPC. Methods and Results We isolated exosomes from plasma of rats or humans subjected to RIPC. We characterised control or RIPC exosomes by electron microscopy, flow cytometry, western blot and nano-particle tracking analysis. Exosome concentration increased dramatically after RIPC in humans (from 3.5 ± 0.3x108 to 1.1 ± 0.3x109 exosomes/ml plasma; p < 0.01, n = 6), and administration of purified exosomes protected the heart from infarct in different settings including an in vivo rat model (vehicle: 47.4 ± 4.7; RIPC-Exosomes: 20.5 ± 3.9%Infarct/AAR; p < 0.01), ex vivo Langendorff (vehicle: 35.2 ± 3.3; RIPC-Exosomes: 21.2 ± 2.5% Infarct/AAR; p < 0.01), and in vitro hypoxia-reoxygenation of cardiomyocytes (43 ± 7% protection from death, p < 0.01). RIPC-Exosomes triggered rapid ERK phosphorylation (3.9 ± 0.1 fold over vehicle), and inhibition of upstream PI3K or MEK abolished ERK activation and inhibited cardioprotection. Conclusions We demonstrate that RIPC dramatically increases the concentration of exosomes in the circulation. Exosomes acutely activate pro-survival kinases that rapidly prepare the heart against ischemia-reperfusion injury. Exosomes represent a novel agent with the potential to be an endogenous, non-immunogenic and multi-signalling tool for cardioprotection.

Perivascular adipose tissue (PVAT) exerts an anti-contractile effect which is vital in regulating blood pressure. Evidence suggests that the sympathetic nervous stimulation of PVAT triggers the release of anti-contractile factors via activation of beta 3 -adrenoceptors. There is considerable evidence of sympathetic over-activity in obesity, which could result in the loss of PVAT function, and subsequent hypertension. Therefore it was decided to examine beta 3 -adrenoceptor function in obesity.Electrical field stimulation (EFS) profiles of healthy and obese mouse mesenteric arteries (<200 um, +/-PVAT) were characterised using wire myography (0.1-30 Hz, 20V, 0.2 ms pulse duration, 4s train duration). To demonstrate the release of an anti-contractile factor in health, the solution surrounding stimulated exogenous PVAT was transferred to a PVAT denuded vessel. Beta 3-adrenoceptor function was investigated using the agonist CL-316,243 (10uM) and antagonist SR59203A (100nM). The role of the vasodilator nitric oxide (NO) was studied using nitric oxide synthase (NOS) inhibitor L-NMMA (100uM), and NOS activator histamine (100uM).During EFS healthy PVAT elicits an anti-contractile effect (n = 8, P < 0.001); however the anti-contractile function of obese PVAT is lost (n = 8, P = 0.35). Inhibition of beta 3-adrenoceptors in healthy PVAT using SR59230A significantly reduced the anti-contractile effect (n = 8, P < 0.01), whereas activation of beta 3-adrenoceptors in obese PVAT using CL-316,243 did not restore function (n = 7, P = 0.77). Solution transfer from stimulated healthy exogenous PVAT to a -PVAT vessel significantly reduced contraction (n = 8, P < 0.01), confirming that stimulated PVAT releases a transferable anticontractile factor. The release of this factor could be inhibited using SR59230A (n = 7, P = 0.47). Solution transfer from obese PVAT had no effect on contraction (n = 6, P = 0.41), and again could not be restored using CL-316,243 (n = 6, P = 0.14). In healthy PVAT, inhibition of NOS using L-NMMA abolished the anti-contractile effect (n = 8, P < 0.01). In obese PVAT, activation of NOS using histamine was able to restore the anti-contractile function (n = 4, P < 0.05).These results demonstrate that in health PVAT releases an anti-contractile factor via activation of beta 3 -adrenoreceptors, which downstream trigger the release of NO. In obesity, the anti-contractile effect is lost and cannot be restored by beta 3 -adrenoceptor activation, but is restored by activation of NOS. This suggests that in obesity beta 3 -adrenoreceptors must be downregulated or desensitised, leading to a loss of anti-contractile function, which may contribute to the development of hypertension.