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(Circulation. 2001;104:688.)
© 2001 American Heart Association, Inc.

Basic Science Reports

Heart Failure After Myocardial Infarction

Altered Excitation-Contraction Coupling

A.M. Gómez, PhD; S. Guatimosim, PhD; K.W. Dilly, PhD; G. Vassort, PhD; W.J. Lederer, MD, PhD

From INSERM-U.390, IFR-3, Montpellier, France (A.M.G., G.V.), and Medical Biotechnology Center and School of Medicine, University of Maryland Biotechnology Institute, Baltimore (A.M.G., S.G., K.W.D., W.J.L.).

Correspondence to A.M. 8Gómez, INSERM-U.390, CHU Arnaud de Villeneuve, 34295 Montpellier, France. E-mail agomez{at}montp.inserm.fr

	Abstract

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Background—— Heart failure (HF) frequently follows the occurrence of myocardial infarction (MI). Questions about how HF develops and what cellular defects contribute to this dysfunction led to this study.

Methods and Results—— MI was induced in rats by coronary artery ligation. Clinical examination of the post-MI (PMI) surviving animals indicated that they were in overt HF by all measures. Cellular examination of the cardiomyocytes by patch-clamp and confocal [Ca²⁺]_i imaging methods indicated that cellular function was significantly compromised. At the single-cell level, [Ca²⁺]_i transient amplitudes were reduced and contractions were decreased and slowed, although Ca²⁺ current (I_Ca) remained unchanged. The excitation-contraction coupling (ECC) gain function measured as [Ca²⁺]_i/I_Ca was significantly decreased. Ouabain, a cardiotonic steroid that blocks the Na⁺,K⁺-ATPase and activates Ca²⁺ entry via cardiac Na⁺ channels, largely alleviated this defect.

Conclusions—— After MI, I_Ca becomes less able to trigger release of Ca²⁺ from the sarcoplasmic reticulum. This failure of ECC is a major factor contributing to the development of contractile dysfunction and HF in PMI animals. The improved ECC gain, enhanced Ca²⁺ entry, and augmented Ca²⁺ signaling due to cardiotonic steroids contribute to the beneficial effects of these agents.

Key Words: excitation • myocardial infarction • ouabain • heart failure • calcium

	Introduction

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Myocardial infarction (MI) is one of the leading causes of cardiac mortality, morbidity, and dysfunction.¹ The time course of ventricular dysfunction is arbitrarily divided into 2 periods. MI produces cellular death and thus leads to complete loss of contractile function in the infarcted region (acute phase), whereas there is no necessary change in contractile function in other regions. In survivors, there is a remodeling of the noninfarcted area that underlies the second phase of dysfunction. Heart failure (HF) is frequently seen during and after this period of remodeling.²

Dysfunction of ventricular myocytes develops in many cardiovascular diseases. In hypertension, there are changes in contractile protein isoforms,^3,4 ionic currents,^5,6 ion transporters,⁷ and 2Ca²⁺ signaling,⁸ and cellular hypertrophy is observed.² Ca²⁺-signaling alterations appear to go through 2 phases, 1 associated with early components of hypertension^3,4 and 1 revealed as HF develops.⁸ A similar array of molecular and cellular changes is produced by other insults that lead to HF.⁹

This report presents a cellular investigation of HF in a rat model of post-MI (PMI) remodeling after coronary artery ligation.¹⁰ The work identifies specific cellular changes that are observed in cardiac myocytes after MI and shows how a controversial therapy (cardiotonic steroids) can act to improve cellular function.

	Methods

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Induction of MI
Male Wistar rats (180 to 200 g) were used to produce MI as previously described.¹⁰ Age-matched rats were used as controls.

Some of the animals were used for hemodynamic measurements (Table 1). Furthermore, before they were euthanized, animals underwent blood pressure measurements or echocardiography (Table 1). Blood pressure was measured in conscious animals as described earlier.⁸ M-mode echocardiography was performed in anesthetized animals (ketamine 50 mg/kg and xylazine 10 mg/kg).

View this table: [in this window] [in a new window]   Table 1. Animal Characteristics

Cell Isolation and Recording Techniques
Ventricular cardiac myocytes were isolated by standard enzymatic techniques.⁸ After isolation, cells were stored in DMEM (1.8 mmol/L CaCl₂); cells from the left ventricular free wall were used for the study.¹¹

Whole-cell current was monitored with an Axopatch 200A amplifier and recorded with pCLAMP-6.01 (Axon Instruments). Series resistance was electronically compensated to 40% to 60%.

Calcium current (I_Ca) was elicited by 100-ms step depolarizations according to a protocol previously described.⁸ Sarcoplasmic reticulum (SR) Ca²⁺ content was normalized by a loading protocol of 4 steps from -80 to 0 mV at 1 Hz before each test depolarization. External solution contained (in mmol/L) NaCl 135, MgCl₂ 1, CsCl 20, glucose 10, HEPES 10, 4-aminopyridine 3, and CaCl₂ 1.8; pH 7.4. Patch pipettes contained (in mmol/L) CsCl 130, fluo-3 0.05, HEPES 10, MgCl₂ 0.33, TEA-Cl 20, and Mg-ATP 4; pH 7.2.

For action potential (AP) measurements, the current-clamp mode of the patch-clamp technique was used. Cells were stimulated at 1 Hz with current pulses 1.5 times threshold. External solution contained (in mmol/L) NaCl 140, KCl 5.0, NaH₂PO₄ 0.33, MgCl₂ 1, HEPES 5, and glucose 5.5; pH 7.4. Internal solution was the same as for I_Ca recordings, but Cs⁺ was replaced with K⁺, and no TEA-Cl was added. Averaged APs were used as the voltage command with Cs⁺-containing solutions. Temperature was maintained at 35°C to 37°C.

[Ca²⁺]_i transients and Ca²⁺ sparks were imaged by confocal microscopy and analyzed as previously described.⁸

Statistics
Data are presented as mean±SEM. Two-sample comparison was made by paired or independent t test, as appropriate. A level of P<0.05 was assumed to be statistically significant.

	Results

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MI produces a dramatic change in cardiac output and may be lethal. In the animal model used here, 40% of the animals died during the first 2 days. We waited 6 months because in our hands, this is the time when consistent HF is presented in PMI rats. Visual inspection revealed large scars on the left ventricular free wall. Table 1 characterizes the cardiovascular properties of the surviving animals, indicating that PMI animals were suffering from HF. Table 2 shows that there was cellular hypertrophy.

View this table: [in this window] [in a new window]   Table 2. Animal Characteristics

Cellular Alterations
To investigate whether excitation-contraction coupling (ECC) was altered after MI, isolated cardiomyocytes were examined by electrical and optical methods. A loading protocol (see Methods) was used to normalize SR Ca²⁺ content. The similarity of the SR Ca²⁺ load was verified by a caffeine-release method.⁸ This procedure was carried out because SR Ca²⁺-ATPase (SERCA) levels are decreased in HF^7,12 and may affect our results and interpretation.

Figure 1 shows representative examples of depolarization-activated signals from control and PMI ventricular myocytes. The amplitudes of both the [Ca²⁺]_i transient and contractions were reduced in PMI cells. Cell shortening kinetics were significantly slowed in PMI myocytes (time to peak: 79.5±6.4 ms in 5 control versus 109.8±7.3 ms in 12 PMI cells, P<0.05). Whereas the slow time constant of I_Ca decay was similar in control and PMI myocytes, the fast time constant increased (at +10 mV, 6.3±0.9 ms in 9 control myocytes versus 9.0±0.7 ms in 21 PMI cells, P<0.05). This finding is consistent with the slowing of I_Ca inactivation observed in pressure overload—induced HF.⁸

View larger version (23K): [in this window] [in a new window]   Figure 1. Contractile dysfunction examined in single cardiac myocytes after MI. A, Representative signals recorded from control cell. Top to bottom: Voltage protocol, ICa trace, shortening, [Ca2+]i transient, and line-scan image. End of cell, at bottom of image, reveals contraction. Ca2+ signal is shown as fluorescence ratio (F/F0), with fluorescence signal (F) being normalized to signal before depolarization (F0). B, Data from PMI cell displayed as in A. C, Data from same PMI cell as in B, 1 minute after 100 nmol/L ouabain application.

Averaged data are plotted as a function of voltage in Figure 2. The decreases in cell shortening (Figure 2A) and [Ca²⁺]_i transient (Figure 2B) observed for PMI cells are statistically significant compared with control cells over a wide range of membrane potentials. I_Ca density was maintained (Figure 2C), however, suggesting that changes in I_Ca density cannot account for the contractile dysfunction observed in PMI cells. Additional explanations include the "myosin isoform shift hypothesis"⁴ and the "Ca²⁺-signaling hypothesis"⁸ (Figure 2D and Discussion).

View larger version (31K): [in this window] [in a new window]   Figure 2. Ca2+ signaling after MI. A, Voltage dependence of unloaded cell shortening in control (, n=11), PMI (•, n=26), and PMI after 100 nmol/L ouabain application (, n=5). Lines are drawn by eye. B, Peak [Ca2+]i transient (F/F0) plotted against voltage for control, PMI, and PMI after ouabain application. C, Current-voltage relationship for control, PMI, and PMI after ouabain application. D, ECC gain function [(F/F0)/ICa] measured at -30 mV under 3 conditions: control (open bar), PMI (solid bar), and PMI+ouabain 100 nmol/L (hatched bar). *P<0.05, **P<0.005 vs control myocytes.

The reduction of the [Ca²⁺]_i transient for PMI cells shown in Figure 2 would not have been predicted if the only significant cause of the contractile dysfunction were changes in the contractile proteins.⁴ The Ca²⁺-signaling hypothesis is consistent with the data in Figure 2 but requires further testing. To investigate the importance of Ca²⁺ signaling, an inotropic agent was applied. The cardiotonic steroid ouabain was chosen because it has no known direct actions on contractile proteins and has established actions on Ca²⁺ signaling (see below). Figure 1C shows records obtained in the same PMI myocyte as displayed in Figure 1B, 1 minute after 100 nmol/L ouabain application. Ouabain clearly increased the [Ca²⁺]_i transient and contraction. Averaged data obtained from PMI myocytes after ouabain perfusion are shown in Figure 2. Cell shortening and [Ca²⁺]_i transients were restored to normal over voltage steps negative to +20 mV. No significant changes in I_Ca density were seen.

The efficacy of I_Ca to activate SR Ca²⁺ release is measured as the ECC gain: [Ca²⁺]_i transient normalized to I_Ca [(F/F₀)/I_Ca] (Figure 2D). It is best to measure gain at fairly negative potentials because the opening of a single L-type Ca²⁺ channel at these negative potentials can trigger a single Ca²⁺ spark.¹³ The decrease in gain seen in PMI cells was restored by ouabain application.

Because the decrease in gain appears to play a role in the contractile dysfunction in PMI cells, we were interested in determining why the [Ca²⁺]_i transient was reduced. The Ca²⁺ influx (I_Ca) activates Ca²⁺ sparks that sum to produce the [Ca²⁺]_i transient.¹⁴ To investigate whether alterations in Ca²⁺-spark properties may lead to the reduction of [Ca²⁺]_i transient, Ca²⁺ sparks were analyzed. Signal-averaged Ca²⁺ sparks from control and PMI cells look alike (Figure 3A and 3B). They have similar magnitudes (F/F₀: 1.70±0.02 versus 1.72±0.02 in 141 Ca²⁺ sparks in control versus 338 Ca²⁺ sparks in PMI myocytes) and decay kinetics (, obtained by fitting the decay phase to a single exponential: 21.87±1.30 versus 24.20±0.85 ms in control versus PMI Ca²⁺ sparks). Counting the number of Ca²⁺ sparks triggered at different membrane potentials in the presence of a submaximal concentration of nifedipine¹³ revealed that fewer Ca²⁺ sparks were activated in PMI cells even though I_Ca was similar. Because Ca²⁺-spark characteristics in control and PMI cells are similar, these results suggest that the reduction in [Ca²⁺]_i transient is due to a decreased ability of Ca²⁺ current to trigger Ca²⁺ sparks.

View larger version (28K): [in this window] [in a new window]   Figure 3. Ca2+ sparks after MI. A, Average line-scan image (left) of Ca2+ sparks and its 3-dimensional projection (right) (n=141). B, Averaged Ca2+ sparks from PMI cells (n=338) as in A. C, Averaged Ca2+ sparks from PMI cells after ouabain exposure (100 nmol/L) as in A (n=111). D, Number of Ca2+ sparks/µm observed during 200-ms depolarizations plotted against voltage for control (, n=9) and PMI (•, n=6) cells. Nifedipine (1 µmol/L) was used in these experiments to allow Ca2+-spark resolution over full range of membrane potentials.13 *P<0.05, **P<0.005.

Changes in contractile protein isoforms or properties could also contribute to the observed dysfunction. To investigate this, the relationships between the [Ca²⁺]_i transient and cell shortening were examined at different voltages (Figure 4A). The shapes of these plots (phase-plane loops) reflect the kinetic response of the contractile proteins to changes in [Ca²⁺]_i.¹⁵ During the rapid [Ca²⁺]_i rise, there is little contractile response. Contraction begins in earnest after [Ca²⁺]_i is near its peak and continues even as [Ca²⁺]_i falls. Finally, both [Ca²⁺]_i and contraction decline together. [Ca²⁺]_i transient reduction in PMI cells leads to small contraction and different loop trajectory (Figure 4B) that is restored back to control by ouabain (Figure 4C). There is, however, a small residual rounding of these trajectories that may reflect alterations in the contractile proteins (see Discussion). Figure 4D shows plots of peak contraction versus peak [Ca²⁺]_i transient and is consistent with data shown in Figure 4A through 4C.

View larger version (23K): [in this window] [in a new window]   Figure 4. Ca2+-sensitive cell shortening after MI. A, Family of traces representing relationships between [Ca2+]i and shortening obtained in control myocyte. Each trace reveals relationship obtained for 100-ms step depolarization (between -40 and +40 mV). Trajectory of each loop begins at lower left corner, moves counterclockwise, and returns to point of origin. B, Traces for PMI myocyte plotted as in A. C, Traces as in B and for same cell but after 100 nmol/L ouabain. D, Peak contraction vs peak [Ca2+]i transient for control (, n=11), PMI (•, n=26), and PMI after ouabain application (, n=5) at potentials between -40 and +50 mV.

In vivo, the decreases of [Ca²⁺]_i transients in PMI cells will be influenced by changes in action potential duration (APD), which is prolonged in HF. APs were recorded in control and PMI myocytes and used to control voltage. Figure 5 shows that the PMI cells had smaller contractions and [Ca²⁺]_i transients than control cells despite their longer APD. In addition, ouabain increased both contraction and [Ca²⁺]_i transient to normal. Blockade of Na⁺ channel by tetrodotoxin (TTX) (10 µmol/L) reduced the [Ca²⁺]_i transient back to the level of PMI cells before the ouabain addition (Figure 5B). Importantly, Santana et al¹⁶ showed in normal rat cells that TTX has no immediate effect on the [Ca²⁺]_i transient in the absence of ouabain, that ouabain acutely increases the [Ca²⁺]_i transient, and that TTX can block the immediate ouabain-dependent increase in the [Ca²⁺]_i transient.

View larger version (22K): [in this window] [in a new window]   Figure 5. Ca2+ signaling and APs after MI. A, Top, AP waveform used as command of normal (left) and PMI before (middle) and after 100 nmol/L ouabain application (right). Bottom, Records of contraction, [Ca2+]i transient, and line scans of cell. B, Bar graph shows peak [Ca2+]i level (F/F0) evoked by AP-clamp protocol in control (open bar, n=19) and PMI cells under 3 conditions: untreated (black bar, n=21), 100 nmol/L ouabain (blue bar, n=21), and 100 nmol/L ouabain and 10 µmol/L TTX (green bar, n=5). *P<0.05 vs control, P<0.05 vs PMI+ouabain.

	Discussion

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Changes that contribute to contractile dysfunction in ventricular myocytes after MI were examined in this article. The reduction of SERCA^7,12 must play an important role in the altered Ca²⁺ signaling observed in this model of HF. Data presented here, however, suggest that when SR Ca²⁺ content is normalized, PMI cells still present a significant defect in Ca²⁺ signaling: the ability of Ca²⁺ influx (through L-type Ca²⁺ channels) to trigger SR Ca²⁺ release is reduced. Under our experimental conditions, changes in contractile proteins⁴ do not appear to be a major factor. The importance of defective Ca²⁺ signaling in the cellular pathophysiology of PMI myocytes shown here has many implications for medical therapy and challenges our understanding of HF.

The contractile dysfunction and altered Ca²⁺ signaling that develop after MI are similar to those observed in other models of HF.^8,9,15,17 To date, 2 molecular interventions that alleviate HF have been identified: restoration of ß-adrenergic receptor function^15,18 and augmented SERCA function.^19,20 These approaches restore or improve Ca²⁺ signaling. Three issues are raised by studies of cellular Ca²⁺-signaling defects in HF: (1) How do the molecular/drug therapies work? (2) What are the cellular defects contributing to the altered Ca²⁺ signaling? (3) What is the instigating cause of the Ca²⁺-signaling defect?

Molecular/Drug Therapies
How can 100 nmol/L ouabain improve the defective Ca²⁺ signaling in PMI cells? There are at least 4 possible explanations. (1) Inhibition of the Na⁺ pump (Na⁺,K⁺-ATPase) decreases Na⁺ extrusion and, through the Na⁺/Ca²⁺ exchanger, increases [Ca²⁺]_i. We cannot rule out a contribution by this mechanism to our findings if the changes in SR Ca²⁺ content were small (within the statistical error). These effects require time (minutes), however, and do not occur within a single heartbeat. (2) There may be sufficient elevation of subcellular [Na⁺]_i during a single depolarization for Na⁺/Ca²⁺ exchanger to trigger Ca²⁺ release (see Leblanc and Hume²¹). This possibility is examined in Figure 6. (3) Ca²⁺ flux through Na⁺ channels occurs (ie, through slip-mode conductance). This does not apply to the data in Figures 1 to 3 because I_Na is inactivated, but it probably applies in part to Figure 5, because the effect is blocked by TTX. (4) There may be a novel action of ouabain to directly activate the ryanodine receptors (RyRs).²²

View larger version (26K): [in this window] [in a new window]   Figure 6. Ca2+ signaling and cell shortening after complete Na+,K+-ATPase blockade. A, Top, Na+-pump status. Removal of extracellular activating monovalent cations leads to Na+-pump blockade. Before (left) and 5 seconds after (right) complete Na+-pump inhibition, an AP clamp is imposed. AP waveform (top) and shortening (below), [Ca2+]i transient (as F/F0), and line-scan image. B, Peak [Ca2+]i recorded in 12 cells. C, Maximum shortening for 9 cells. No statistical difference is observed.

Leblanc and Hume²¹ suggested that I_Na could provide sufficient Na⁺ influx to activate Ca²⁺ entry through the Na⁺/Ca²⁺ exchanger even during a single AP. To enable the brief Na⁺ influx to significantly elevate [Na⁺]_i, a subsarcolemmal region around Na⁺ channels with reduced diffusion, the "fuzzy space," was hypothesized.²³ To test this possibility, we examined the actions of instantaneous Na⁺-pump blockade on [Ca²⁺]_i transients and contraction on control cardiac myocytes. We produced a maximal Na⁺ influx by applying an AP clamp to activate I_Na after removal of extracellular Cs⁺ (in K⁺-free solutions) to completely block the Na⁺ pump²⁴ (Figure 6). If the mechanisms of Leblanc and Hume²¹ and of Arnon et al²⁵ were relevant to the enhanced contractions produced by ouabain (Figure 5), then an increase in [Ca²⁺]_i transients and contraction should be seen after complete Na⁺-pump inhibition in control cells. There was no statistical difference, however, in the measured [Ca²⁺]_i transients (Figure 6B and 6C). This finding is similar to that reported by Su et al²⁶ under similar conditions. From this and the fact that the effects in Figure 5 are blocked by TTX, we conclude that the positive inotropic effects of ouabain occur at least in part through the activation of slip-mode conductance of the Na⁺ channel. When [Na⁺]_i is normal to high (10 to 15 mmol/L), however, in addition to slip-mode—dependent Ca²⁺ entry, 2 mechanisms will contribute to cardiotonic sterioids-increased Ca²⁺ signaling: the mechanism of Leblanc and Hume²¹ and the increase in SR Ca²⁺ content after Na⁺-pump inhibition.²⁶

Cellular Defects That May Contribute to the Altered Ca²⁺ Signaling
The efficacy of I_Ca to activate SR Ca²⁺ release is reduced in PMI cells. In the absence of changes in other elements in the Ca²⁺-signaling cascade, a spatial change in the organization of the ECC elements is the simplest explanation. If the L-type Ca²⁺ channels, on average, were more distant from the RyRs, then the probability that the opening of a Ca²⁺ channel would activate Ca²⁺ release would decrease.⁸ There are several topologically equivalent changes in cellular structures that could lead to such changes: reorganizing the distribution of the L-type calcium channels or the RyRs with respect to each other ("mismatch"), increasing the separation of the transverse tubules from the SR ("gap"), or T-tubule remodeling ("orphan") (Figure 7). Some recent evidence favors the third possibility.^27,28 It is thus possible that the ECC defect reflects T-tubule remodeling that cuts off, or orphans, SR from the triggering Ca²⁺ signal.

View larger version (65K): [in this window] [in a new window]   Figure 7. Spatial remodeling underlies decreased ECC gain. A, Schematic of ECC elements in normal cells, including surface membrane (M), transverse tubule (TT), RyR, SR, and L-type Ca2+ channels (DHPR). B, Three topologically equivalent models to explain decreased ECC gain. (1) Mismatch: Location of DHPR relative to RyR and SR is not well aligned. (2) Gap: Separation between SR and TT membranes is increased. (3) Orphan: Reorganization of TT leaves orphaned SR along Z lines and also produces mismatched DHPR and RyRs.

During the early phase of such hypothesized cellular remodeling, the increased distance between triggering Ca²⁺ influx and RyRs makes activation of SR Ca²⁺ release less likely. By itself, however, such a change would lead to only transient changes in [Ca²⁺]_i transient amplitude, because higher than normal levels of SR Ca²⁺ would result.²⁹ Indeed, the orphaned SR phenomenon may also explain the large Ca²⁺ sparks reported in the early phases of hypertensive cardiomyopathy.³⁰ An agent that increases Ca²⁺ entry or the sensitivity of the RyRs to be triggered by Ca²⁺ would effectively reverse or reduce this effect, as has been observed with ß-adrenergic receptor activation or ouabain application.

What Is the Initiating Cause of the Ca²⁺-Signaling Defect?
It is clear from the discussion above that 2 defects are involved in the development of the Ca²⁺-signaling defect in HF: SERCA is expressed at a lower level, and the efficacy of calcium-induced calcium release is reduced. It is not clear which of these 2 events precedes the other or whether there is any causal relationship.

Conclusions
We conclude that PMI cells have a contractile defect that involves altered Ca²⁺ signaling as a major component. Changes in AP shape may serve as a means of slightly increasing Ca²⁺ entry and hence contractility, but compensation is not complete. Increased contractions with the cardiotonic steroid ouabain confirm the importance of Ca²⁺-signaling defects in the contractile dysfunction of the PMI heart. This also suggests that activation of slip-mode conductance of the cardiac Na⁺ channel by ouabain can improve the Ca²⁺ signaling in PMI cells and that Na⁺-pump inhibition produced by ouabain will provide a further beneficial effect that depends on [Na⁺]_i and increased SR Ca²⁺ content.

	Acknowledgments

 
This study was supported by the National Institutes of Health, Centre National de la Recherche Scientifique (Dr Gómez), Institut National de la Santé et la Recherche Medicale (INSERM), and Fondation pour la Recherche Medicale (Dr Gómez). We thank Cecilia Frederick for technical support, Sandra Bromble and Michèle Benoit for administrative assistance, and Dr Eric A. Sobie for comments on the manuscript. We thank Mohamed Lemallam and Patrice Bideaux for animal surgery and Dr Jean-Michel Rauzier for echocardiography.

Received January 24, 2001; revision received April 11, 2001; accepted April 17, 2001.

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