(Circulation. 1999;99:3009-3016.)
© 1999 American Heart Association, Inc.
Clinical Investigation and Reports |
Endomyocardial Nitric Oxide Synthase and Left Ventricular Preload Reserve in Dilated Cardiomyopathy
From the Cardiovascular Center, O.L.V. Ziekenhuis, Aalst, Belgium (C.H., M.V., W.J.P.); Inserm U127, IFR Circulation, Université D. Diderot, Paris, France (C.H.); Department of Cardiology, Free University Hospital, Amsterdam, the Netherlands (J.G.F.B.); and Department of Cardiology, University of Wales College of Medicine, Cardiff, UK (A.M.S.).
Correspondence to Dr Walter J. Paulus, MD, PhD, Cardiovascular Center, O.L.V. Ziekenhuis, Moorselbaan 164, B 9300 Aalst, Belgium. E-mail Walter.Paulus{at}ping.be
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Abstract |
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Background—Patients with heart failure have modified myocardial expression of nitric oxide synthase (NOS), as is evident from induction of calcium-insensitive NOS isoforms. The functional significance of this modified NOS gene expression for left ventricular (LV) contractile performance was investigated in patients with dilated nonischemic cardiomyopathy.
Methods and Results—In patients with dilated, nonischemic cardiomyopathy, invasive measures of LV contractile performance were derived from LV microtip pressure recordings and angiograms and correlated with intensity of gene expression of inducible (NOS2) and constitutive (NOS3) NOS isoforms in simultaneously procured LV endomyocardial biopsies (n=20). LV endomyocardial expression of NOS2 was linearly correlated with LV stroke volume (P=0.001; r=0.66), LV ejection fraction (P=0.007; r=0.58), and LV stroke work (P=0.003; r=0.62). In patients with elevated LV end-diastolic pressure (>16 mm Hg), a closer correlation was observed between endomyocardial expression of NOS2 and LV stroke volume (P=0.001; r=0.74), LV ejection fraction (P=0.0007; r=0.77), and LV stroke work (r=0.82; P=0.0002). LV endomyocardial expression of NOS3 was linearly correlated with LV stroke volume (P=0.01; r=0.53) and LV stroke work (P=0.01; r=0.52). To establish the role of nitric oxide (NO) as a mediator of the observed correlations, substance P (which causes endothelial release of NO) was infused intracoronarily (n=12). In patients with elevated LV end-diastolic pressure, an intracoronary infusion of substance P increased LV stroke volume from 72±13 to 91±16 mL (P=0.06) and LV stroke work from 67±11 to 90±15 g · m (P=0.03) and shifted the LV end-diastolic pressure–volume relation to the right.
Conclusions—In patients with dilated cardiomyopathy, an increase in endomyocardial NOS2 or NOS3 gene expression augments LV stroke volume and LV stroke work because of a NO-mediated rightward shift of the diastolic LV pressure-volume relation and a concomitant increase in LV preload reserve.
Key Words: nitric oxide • cardiomyopathy • ventricles • diastole
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Introduction |
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In patients with heart failure, the functional significance for left ventricular (LV) performance of modified myocardial expression of nitric oxide synthase (NOS) remains unclear.1 Expression of cytokine-inducible, calcium-insensitive NOS isoform (NOS2) was first reported in the ventricular myocardium of patients with dilated cardiomyopathy after myocarditis2 and, subsequently, in the myocardium of failing hearts, regardless of the underlying cause.3 In the latter study, NOS2 gene expression was more frequent in NYHA class II patients than in class IV patients, but in a subsequent study,4 high NOS2 gene expression was associated not with functional class but with low LV ejection fraction. In allograft recipients, a Doppler echocardiographic study5 showed that NOS2 gene expression correlated with LV dysfunction, but an invasive assessment of LV performance6 failed to demonstrate any effects of high myocardial NOS2 expression on LV ejection fraction or on the peak rate of rise of LV pressure (LV dP/dtmax). In the normal human heart and in allograft recipients, intracoronary infusions of NO donors or of substance P, which releases nitric oxide (NO) from the coronary endothelium, also failed to alter LV ejection fraction or LV dP/dtmax; instead, they hastened LV relaxation and increased LV diastolic distensibility.7 8 These effects of NO on diastolic LV function were recently corroborated by experimental observations. In isolated guinea pig hearts, administration of a NOS inhibitor reduced LV diastolic distensibility,9 and in the beating rabbit heart, a porphyrinic microsensor in the LV wall revealed a prominent diastolic peak of myocardial NO concentration.10
In end-stage explanted human cardiomyopathic hearts, expression and activity of endothelial constitutive NOS isoform (NOS3) was reduced, but expression and activity of NOS2 were enhanced.11 In trabeculae isolated from these hearts, NOS2 activity hastened isometric tension decline and blunted the ß-agonist–induced increase in twitch tension. A blunted myocardial contractile response to ß-agonists because of NOS activity was also observed in adult rat cardiomyocytes,1 in dogs with pacing-induced heart failure,12 in patients with LV dysfunction,13 14 and in the human allograft.6 13
To investigate the in vivo functional significance of modified myocardial NOS expression for LV contractile performance in patients with nonischemic, dilated cardiomyopathy, invasive measures of LV function were derived from LV angiograms and high-fidelity tip-micromanometer LV pressure recordings; they were then correlated with the intensity of myocardial NOS2 and NOS3 gene expression in simultaneously procured LV endomyocardial biopsies. To confirm the role of NO as a mediator of the observed correlation between LV stroke volume or LV stroke work and myocardial NOS2 or NOS3 activity, repeat LV angiograms and LV pressure recordings were obtained during intracoronary substance P infusion, which causes receptor-mediated release of NO from the coronary endothelium.8 15
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Methods |
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Patients
A total of 32 patients with nonischemic, dilated cardiomyopathy underwent diagnostic cardiac catheterization and coronary angiography. The group consisted of 9 women and 23 men (mean age, 51 years; range, 23 to 75 years). For ethical reasons, heart failure therapy was maintained; it consisted of angiotensin-converting enzyme (ACE) inhibitors (n=31), diuretics (n=31), digitalis (n=14), and ß-blockers (n=2; Table
; patients 11 and 31). LV
angiography revealed a LV end-diastolic volume index of
148±37 mL/m2 and a LV ejection fraction of
29±10%. A LV end-diastolic volume index >102
mL/m2 (normal average value +2SD) and an LV
ejection fraction 
45% were used as cutoff values for dilated
cardiomyopathy. Informed consent was obtained from
all patients, and the study was approved by the local review boards.
There were no complications.
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Study Protocol
LV pressure was measured by using a high-fidelity
tip-micromanometer catheter, and right heart
pressures were measured by using a Swan-Ganz catheter. Left
ventricular endomyocardial biopsies
were obtained in 20 patients (Table
; patients 1 through 15 and
28 through 32) using a long bioptome-guiding sheath and a disposable
transfemoral bioptome (Cordis Corp). Baseline LV function
(Table) of the 20 patients in whom LV
endomyocardial biopsies were obtained was
comparable to the baseline LV function of the entire patient
cohort.
After diagnostic cardiac catheterization,
an intracoronary infusion of substance P (20 pmol/min for a
5-minute period)8 13 was performed in 12 patients
(Table; patients 16 through 27). At the end of the infusion
period, hemodynamic measures were repeated. In 11
patients (Table; patients 1, 2, 4 through 9, 12, 13, and 15), an
intravenous infusion of
dobutamine6 13 was administered; it was
progressively titrated upward to a dose of 11±2 µg ·
kg-1 · min-1 to
increase resting heart rate by 20 bpm. The infusion protocols for
substance P and for dobutamine were extensively described
in a previous study.13 Data from 3 patients who were part
of this previous study were included in the present study.
Reverse Transcription–Polymerase Chain Reaction for NOS2 and
NOS3 mRNA
Biopsy Procurement
Biopsy samples used for the subsequent quantification of NOS2
and NOS3 mRNA by reverse transcription–polymerase chain reaction
(RT-PCR) were immediately frozen in liquid nitrogen and stored at
-80°C. In 15 patients (Table; patients 1 through 15), 1
biopsy sample was used, and in 5 patients (Table; patients 28
through 32), 2 biopsy samples from different sites of the LV cavity
were used. In these 5 patients, the variability of the NOS2 and NOS3
mRNA concentrations was 7±2% and 15±3%, respectively.
RNA Extraction
Total RNA from 25 LV endomyocardial biopsies
was extracted according to Trizol reagent protocol (Life Technologies).
Purified RNA was dissolved in water, and the concentration was measured
by absorbance at 260 nm. Quantitative RT-PCR for NOS2 and NOS3 was then
performed in the presence of a defined amount of specific RNA mutant as
an internal standard.
Internal Standard Preparation
The NOS2 and NOS3 internal standards were subcloned into a
pSP(64)poly(A) vector (Promega). cRNA was then synthesized in vitro as
a sense probe from 10 µg of the PvuI-linearized plasmid using SP6 RNA
polymerase in the presence of 10 µCi of
-32P-UTP. The concentration of the transcript
was determined after measuring the radioactivity incorporated into the
RNA product.
Oligonucleotides Used for RT-PCR
For NOS2, the primers chosen were 5'-AAGACCCAGTGCCCTGCTTT-3'
for sense and 5'-CGCAAACATAGAGGTGGCC-3' for antisense; they allowed the
distinct amplification of NOS2 mRNA (388 bp) and of the internal
standard (452 bp). For NOS3, the primers chosen were
5'-TGCCTGCCCCACTGCTCCTC-3' for sense and 5'-TGCACGGTCTGCAGGACGTTGGT-3'
for antisense, thus amplifying a DNA fragment of 616 bp for NOS3 and of
680 bp for the internal standard. These primers were chosen to
encompass several introns to avoid amplification of contaminating
genomic DNA.
Quantitative RT-PCR Protocol
Total RNA was reverse-transcribed with a fixed amount of the
specific synthetic RNA and 200 U of Moloney murine leukemia virus
reverse transcriptase (Life Technologies). Single-strand cDNA synthesis
was performed in 20 µL of reaction buffer (in mmol/L): Tris-HCl
20 (pH 8.3), KCl 50, MgCl2 4, dNTP 1, and DTT 10
and 0.2 µmol/L oligo-p(dT). The reaction mixture was incubated
for 10 minutes at 25°C and then for 60 minutes at 37°C. The
resultant cDNA was amplified using 2.5 U of Taq DNA polymerase
(Boehringer) and 0.5 µmol/L sense and antisense primers
in 50 µL of (in mmol/L) KCl 50, Tris-HCl 10 (pH 8.3),
MgCl2 4, and dNTP 1 and 0.01% gelatin. A total
of 28 amplification cycles were undertaken as follows: denaturation at
94°C for 1 minute, annealing at 62°C for NOS2 and at 63°C for
NOS3 for 1 minute, and extension at 72°C for 1 minute. The final
extension was performed for 10 minutes. To quantify NOS isoform mRNA
levels, a trace amount of [32P]-dCTP was
included in the PCR reaction. After PCR amplification, the PCR
products were separated on a 5% polyacrylamide gel, and
radioactive signals were analyzed using a computer-based
imaging system (Fuji Bas 1000, Fuji Medical Systems).
Data Analysis
LV volumes were derived from single-plane LV angiograms by using
the area-length method and a regression equation. The duration of LV
electromechanical systole (LVEST), which indicates the time to onset of
LV relaxation, was measured as the interval from the Q wave on the ECG
to the moment of the peak rate of fall of LV pressure (LV
dP/dtmin). LV stroke work was derived from
the area within the LV pressure-volume diagram. Single comparison data
were analyzed with a Student t test for paired
data.
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Results |
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NOS Gene Expression and LV Function at Rest
The Table
summarizes indices of baseline LV function in the
dilated, nonischemic cardiomyopathy study
population. Figure 1 shows
representative RT-PCR amplification products of
NOS2 and NOS3 mRNA derived from LV endomyocardial
biopsies obtained from 4 patients (Table; patients 1, 2, 6, 8).
In the subgroup of patients (n=20) in whom LV
endomyocardial biopsies were obtained, a
significant linear correlation was observed between intensity of NOS2
mRNA expression and LV stroke volume (P=0.001;
r=0.66), LV ejection fraction (P=0.007;
r=0.58), or LV stroke work (P<0.003;
r=0.62) (Figure 2). In the
same group of patients, a significant linear correlation was also
observed between intensity of NOS3 mRNA expression and LV stroke volume
(P=0.01; r=0.53) or LV stroke work
(P=0.01; r=0.52) (Figure 3). There were no significant
correlations between intensity of NOS2 or NOS3 mRNA expression and
other hemodynamic indices, such as LV
end-diastolic volume index, LV end-systolic volume
index, or LV dP/dtmax.
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A closer correlation was observed between intensity of NOS2 mRNA
expression and LV stroke volume (P=0.001;
r=0.74), LV ejection fraction (P=0.0007;
r=0.77), or LV stroke work (P=0.0002;
r=0.82) when the analysis was limited to those
patients who, at the time of the study, were using LV preload reserve,
as evident from elevated LV end-diastolic pressure
(LVEDP>16 mm Hg) (Figure 4).
Limiting the analysis to patients who were using LV preload
reserve did not improve the correlation between intensity of NOS3 mRNA
expression and LV stroke volume or LV stroke work.
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LV Preload Reserve and Coronary Endothelial NO
To investigate the myocardial effects of NO on LV preload
reserve, an intracoronary infusion of substance P was performed
in 12 patients. This resulted in a significant fall in LV peak
systolic pressure from 121±8 to 111±7 mm Hg
(P=0.0009), in LV end-systolic pressure from 64±6
to 58±6 mm Hg (P=0.01) and in LVEDP from 25±3 to
18±2 mm Hg (P<0.0001) and in LVEST from 410±17 to
393±17 ms (P=0.04). There were no significant changes in LV
dP/dtmax, heart rate, LV
end-diastolic volume, LV ejection fraction, LV stroke
volume, or LV stroke work, except in those patients who, at the time of
the study, had elevated LV filling pressures (LVEDP >16 mm Hg).
In these patients, intracoronary substance P significantly
increased LV end-diastolic volume from 220±26 to 240±29
mL (P=0.04), LV stroke volume from 72±13 to 91±16 mL
(P=0.06), and LV stroke work from 67±11 to 90±15 g
· m (P=0.03) (Figure 5).
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P=0.06.
NOS Gene Expression and LV Response to ß-Adrenoreceptor
Stimulation
Intravenous infusion of dobutamine caused
a significant increase in heart rate from 82±1 to 100±3 bpm
(P=0.0001) and in LV dP/dtmax from
924±120 to 1356±175 mm Hg/s (P<0.0001), a
significant decrease in LVEST from 430±19 to 328±16 ms
(P=0.0002), and no change in LV peak or end-systolic
pressures. LV endomyocardial NOS2 mRNA expression
was inversely correlated with the dobutamine-induced
decrease in LVEST (P=0.04; r=0.63) and the ratio
of the dobutamine-induced decrease in LVEST divided by the
dobutamine-induced increase in LV
dP/dtmax (expressed as a fraction of baseline LV
dP/dtmax value) (P=0.004;
r=0.78) (Figure 6). The
dobutamine-induced changes in heart rate and in LV
dP/dtmax were unrelated to LV
endomyocardial NOS2 mRNA. The
dobutamine-induced changes in heart rate, LV
dP/dtmax, LVEST, and the ratio of 
LVEST/LV
dP/dtmax were also unrelated to LV
endomyocardial NOS3 mRNA expression.
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Discussion |
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The present study provides the first evidence that LV endomyocardial NOS2 and NOS3 gene expression varies with the severity of LV dysfunction in patients with dilated, nonischemic cardiomyopathy. In these patients, higher LV endomyocardial NOS2 and NOS3 gene expression was accompanied by higher LV stroke volume and higher LV stroke work.
Myocardial NOS Gene Expression in Heart Failure
Experimental evidence on endomyocardial NOS3
expression and activity in heart failure provides support for the idea
that intensity of NOS3 gene expression varies with the severity of LV
dysfunction. In a pacing-induced heart failure dog model, NOS3 activity
increased after 2 weeks of pacing, as evident from enhanced
endothelium-dependent relaxation of isolated
coronary artery rings.16 This increase in NOS3
activity could have resulted from higher coronary blood flow
because of increased myocardial metabolic
demand17 or from higher mechanical stress because of LV
cavity dilatation.10 In the same pacing-induced heart
failure dog model, cardiac NO production was reduced after 4
weeks of pacing, and this reduction was accompanied by a switch in
myocardial substrate use, a rise in LV end-diastolic
pressure, and a fall in LV stroke work.18
Clinical studies reporting on myocardial NOS3 gene expression and activity in patients with dilated cardiomyopathy used right ventricular tissue obtained by transvascular biopsy,2 3 4 right ventricular tissue excised during cardiopulmonary bypass,3 or LV tissue from explanted hearts at the time of cardiac transplantation.11 19 20 Detection of upregulation of myocardial NOS3 as a result of mechanical stress applied to the left ventricle requires LV and not right ventricular tissue, as illustrated in spontaneously hypertensive rats in which NOS3 activity was upregulated in LV but not right ventricular tissue.21 Both low11 and high19 20 intensities of NOS3 gene expression have been observed in the LV tissue of end-stage explanted cardiomyopathic human hearts. These conflicting results are explained by the present study, which observed that the intensity of NOS3 gene expression varied with the severity of LV dysfunction. The present study determined NOS2 and NOS3 gene expression in LV tissue samples procured by LV transvascular biopsy. The use of LV transvascular biopsies allowed LV endomyocardial NOS gene expression to be assessed not only in patients with end-stage heart failure but also in patients with compensated heart failure. In the present study, most patients were on ACE inhibitor therapy. ACE inhibitor therapy could have augmented NOS3 expression, as evident from the Trial on Reversing Endothelial Dysfunction (TREND), which showed improved coronary endothelial-dependent vasodilator responses during chronic quinapril therapy.22 The 2 patients in the present study who were on ß-blocker therapy had high-intensity NOS3 gene expression. In failing human myocardium, NOS3 expression is more abundant in patients on ß-blocker therapy,19 probably because of increased transcription and subcellular targeting to plasmalemmal caveolae of NOS3 as a result of reduced myocardial cAMP content.23 24
In patients with dilated cardiomyopathy, upregulated myocardial NOS2 activity or gene expression was reported by most2 3 4 11 19 but not all20 investigators. In a previous study,3 upregulated myocardial NOS2 gene expression was more frequently observed in patients in NYHA class II than in NYHA class IV. This finding corresponds with the present observation of higher NOS2 gene expression in patients with moderate LV dysfunction. The concordance between both studies, despite the use of LV tissue in the present study and right ventricular tissue in the previous one, supports regulation of myocardial NOS2 expression not by local mechanical stresses but by humoral factors, such as cytokines and neurohormones. No differences in the intensity of NOS2 gene expression were observed in patients receiving digitalis.
Low Myocardial NOS Gene Expression in Severe LV
Dysfunction
In the present study, both NOS2 and NOS3 gene expression were
lower in patients with low LV stroke volume and low LV stroke work. The
parallel reduction of NOS2 and NOS3 mRNA in patients with severe LV
dysfunction could have resulted from faster degradation of mRNA in
biopsies from this patient group. The procedure of biopsy procurement
was, however, identical for all patients and, therefore, not
responsible for the observed difference. In cardiac myocytes,
regulators of gene expression of NOS isoenzymes usually produce
opposite effects on NOS2 and NOS3 mRNA. Cytokines increase NOS2
mRNA, and interferon-
and interleukin-1ß decrease NOS3
mRNA.1 cAMP stimulates NOS2 mRNA stability25
and downregulates transcription of NOS3 mRNA.23 These
regulators are, therefore, probably not involved in the observed
parallel reduction of gene expression of NOS isoenzymes in patients
with low LV stroke work. A possible explanation for the parallel
reduction of gene expression of NOS isoenzymes in severe LV dysfunction
could be depletion of the myocyte population because of
apoptotic cell death triggered by high myocardial
concentrations of NO or catecholamines.26 Such
a depletion of the viable myocyte population could explain both the
parallel reduction of gene expression of NOS isoenzymes and the
impairment of LV contractile performance.
Myocardial NOS Gene Expression and LV Preload Reserve
In the present study, linear correlations were observed
between LV stroke volume or LV stroke work and intensity of myocardial
NOS2 or NOS3 gene expression. Patients with dilated
cardiomyopathy are highly dependent on preload
recrutable LV stroke work to compensate for reduced inotropic
reserve.27 This enhancement of preload recrutable LV
stroke work results from a rightward displacement of the
diastolic LV pressure-volume relation. In the present
study, an intracoronary infusion of substance P, which releases
NO from the coronary
endothelium,15 induced an acute rightward
displacement of the LV end-diastolic pressure-volume
relation and an increase in LV stroke volume and LV stroke work when LV
filling pressures were elevated. This short-term, NO-induced increase
in LV diastolic distensibility, LV stroke volume, and LV
stroke work supports a myocardial action of NO to mediate the observed
correlations between myocardial NOS gene expression and LV stroke
volume or LV stroke work. A similar myocardial action of NO on LV
preload reserve was recently observed in isolated guinea pig
hearts.9 In this preparation, adding
NG-monomethyl-L-arginine,
a specific inhibitor of NOS, to the coronary
perfusate resulted in a leftward displacement of the
diastolic LV pressure-volume relation and a reduction of LV
stroke volume. Similar actions of NO or its second messenger, cGMP, on
diastolic myocardial properties have been observed in
isolated rat cardiomyocytes28 29 and in
isolated rabbit cardiomyocytes.30 In isolated
rat cardiomyocytes, an increase in diastolic
cell length was observed after exposure to a cGMP
analogue28 or a NO donor.29 In isolated
rabbit cardiomyocytes, exposure to
lipopolysaccharides30 altered cell volume through
an NO- and cGMP-mediated mechanism. Beneficial effects of NO on
diastolic LV properties could result not only from
short-term cGMP-mediated myocardial actions but also from long-term
effects on the LV interstitium because of altered extracellular matrix
metalloproteinase activity and collagen turnover.31
Myocardial NOS Gene Expression and ß-Adrenoceptor
Stimulation
The present study also demonstrated a significant
correlation between the dobutamine-induced abbreviation of
LV contraction and NOS2 mRNA expression. In a previous study using
isolated muscle strips from explanted human
cardiomyopathic hearts, a similar correlation was
observed between NOS2 activity measured by citrulline formation and
ß-agonist–induced changes in the timing of isometric force
decline.11 In the present study population, no
relation was found at baseline between the duration of LV contraction
and myocardial NOS mRNA expression, despite the elevated adrenergic
drive and the presence of such a relation during
intravenous infusion of dobutamine. This
suggests that the myocardial effects of elevated plasma
catecholamines in heart failure may be offset by a
simultaneous reduction in myocardial ß1-receptors and/or
a simultaneous increase in myocardial
Gi-proteins.
Study Limitations
The myocardial presence of NOS was established in the present
study by demonstrating NOS mRNA by quantitative RT-PCR and not by
directly demonstrating NO or cGMP in the myocardium. This
would provide more definite proof of NOS presence and activity
because of earlier reports of posttranscriptional and posttranslational
modification of NOS.24 In the present study, the
effects of NO on LV stroke volume or on LV stroke work were reproduced
during intracoronary infusion of substance P, which releases NO
from the coronary endothelium.
Intracoronary infusion of specific NOS antagonists,
which was not performed in the present study, could provide further
evidence for NO contributing to LV preload reserve in these
cardiomyopathic hearts. To address the issue of
homogeneous endomyocardial expression
of NOS isoenzymes, multiple biopsies were obtained from different LV
sites in 5 patients. In these patients, the variability of NOS2 and
NOS3 mRNA concentrations in the different biopsy samples was,
respectively, 7±2% and 15±3%.
Conclusions
In the present study, which was the first to analyze
gene expression of NOS isoenzymes in LV transvascular biopsies from
dilated cardiomyopathy patients, the intensity of
NOS2 and NOS3 gene expression was linearly correlated with LV stroke
volume and LV stroke work. Intracoronary infusions of substance
P, which releases NO from the coronary
endothelium, revealed that these correlations could
have resulted from a NO-mediated rightward shift of the LV
end-diastolic pressure-volume relation and a concomitant
increase in LV preload reserve. Future studies should be directed at
identifying the mechanisms responsible for the fall in gene expression
of NOS isoenzymes in patients with severe
cardiomyopathic LV dysfunction, because the present
study suggests NO exerts a beneficial hemodynamic
effect in the failing human heart through maintenance of the
Frank-Starling response.
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Acknowledgments |
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The authors are indebted to Dr Sophie Nadaud, Paris, for providing the NOS2 and NOS3 mRNA internal standards and to INSERM for providing study support.
Received December 11, 1998; revision received March 24, 1999; accepted March 30, 1999.
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