17Aging-associated diseases, including cardiac dysfunction, are increasingly common in the 18population. However, the mechanisms of physiologic aging in general, and cardiac aging in 19 particular, remain poorly understood. While effective medical interventions are available for 20 some kinds of heart failure, one age-related impairment, diastolic dysfunction in Heart Failure 21with Preserved Ejection Fraction (HFpEF) is lacking a clinically effective treatment. Using the 22 model of naturally aging mice and rats, we show direct evidence of increased proton leak in the 23 aged heart mitochondria. Moreover, we identified ANT1 as mediating the increased proton 24 permeability of old cardiomyocytes. Most importantly, the tetra-peptide drug SS-31 25(elamipretide) prevents age-related excess proton entry, decreases the mitochondrial flash 26 activity and mitochondrial permeability transition pore (mPTP) opening and rejuvenates 27 mitochondrial function by direct association with ANT1 and the mitochondrial ATP synthasome.
28Our results uncover a novel mechanism of age-related cardiac dysfunction and elucidate how 29 SS-31 is able to reverse this clinically important complication of cardiac aging. 30 31 Significance
32Aging is the greatest risk factor for cardiac dysfunction, including Heart Failure with Preserved 33Ejection Fraction (HFpEF). Unfortunately, the mechanisms of cardiac aging remain elusive, and 34there are no effective pharmacologic therapies for HFpEF. Here, we show direct evidence of 35 increased proton leak in aged cardiac mitochondria and have identified ANT1 as mediating the 36 increased proton permeability of old cardiomyocytes. Moreover, the mitochondrial-targeted 37 tetra-peptide SS-31 (elamipretide) prevents the age-related excess proton entry and 38 rejuvenates mitochondrial function by direct association with ANT1 and the mitochondrial ATP 39 synthasome, resulting in alleviation of diastolic dysfunction in old mice. Our results unmask a 40 novel mechanism of cardiac aging and elucidate how SS-31 reverses this clinically important 41 complication of aging. 42