sirolimus and Cardiomyopathy--Hypertrophic

Topics: Adenosine Monophosphate; AMP-Activated Protein Kinases; Cardiomyopathy, Hypertrophic; Carrier Proteins; Case-Control Studies; DNA Mutational Analysis; Enzyme Activation; Fibroblasts; Genetic Predisposition to Disease; HEK293 Cells; Humans; Infant, Newborn; Intracellular Signaling Peptides and Proteins; Models, Molecular; Mutation, Missense; Myocytes, Cardiac; Phenformin; Phenotype; Phosphoproteins; Phosphorylation; Protein Conformation; Protein Kinase Inhibitors; Ribosomal Protein S6 Kinases, 70-kDa; Signal Transduction; Sirolimus; Structure-Activity Relationship; TOR Serine-Threonine Kinases; Transfection

The role of phosphatase and tensin homolog deleted from chromosome 10 (PTEN) in the maintenance of cardiac homeostasis still remains controversial. This study was designed to evaluate the role of cardiomyocyte-specific PTEN in the maintenance of cardiac homeostasis and the underlying mechanisms involved with a focus on autophagy, an evolutionarily conserved pathway for protein degradation. Cardiomyocyte-specific PTEN((flox/flox))/α-myosin heavy chain Cre mice, henceforth referred to as CM-PTENKO, were generated by crossing the floxed PTEN mice with α-myosin heavy chain Cre mice driven by a Cre recombinase promoter. The adult PTEN(-/-) mice displayed the phenotype of established hypertrophic cardiomyopathy, including unfavorable geometric, functional, and histological changes. Furthermore, cardiomyocyte-specific PTEN knockout mice exhibited increased cardiac mammalian target of rapamycin although suppressed autophagy. Treatment with rapamycin (2 mg/kg per day, IP), an inhibitor of mammalian target of rapamycin, for 1 month effectively reversed the established hypertrophic cardiomyopathy in CM-PTENKO mice. With rapamycin treatment, autophagy activity was significantly restored in the heart of CM-PTENKO mice. Taken together, our results demonstrate an essential role for cardiomyocyte PTEN in maintaining cardiac homeostasis under physiological condition. Cardiomyocyte-specific deletion of PTEN results in the development of hypertrophic cardiomyopathy possibly through a mechanism associated with mammalian target of rapamycin hyperactivation and autophagy suppression.

Topics: Animals; Autophagy; Cardiomyopathy, Hypertrophic; Disease Models, Animal; Homeostasis; Integrases; Male; Mice; Mice, Knockout; Myocardium; Myocytes, Cardiac; PTEN Phosphohydrolase; Signal Transduction; Sirolimus; TOR Serine-Threonine Kinases; Ventricular Myosins

The identification of mutations in PTPN11 (encoding the protein tyrosine phosphatase Shp2) in families with congenital heart disease has facilitated mechanistic studies of various cardiovascular defects. However, the roles of normal and mutant Shp2 in the developing heart are still poorly understood. Furthermore, it remains unclear how Shp2 loss-of-function (LOF) mutations cause LEOPARD Syndrome (also termed Noonan Syndrome with multiple lentigines), which is characterized by congenital heart defects such as pulmonary valve stenosis and hypertrophic cardiomyopathy (HCM). In normal hearts, Shp2 controls cardiomyocyte size by regulating signaling through protein kinase B (Akt) and mammalian target of rapamycin (mTOR). We hypothesized that Shp2 LOF mutations dysregulate this pathway, resulting in HCM. For our studies, we chose the Shp2 mutation Q510E, a dominant-negative LOF mutation associated with severe early onset HCM. Newborn mice with cardiomyocyte-specific overexpression of Q510E-Shp2 starting before birth displayed increased cardiomyocyte sizes, heart-to-body weight ratios, interventricular septum thickness, and cardiomyocyte disarray. In 3-mo-old hearts, interstitial fibrosis was detected. Echocardiographically, ventricular walls were thickened and contractile function was depressed. In ventricular tissue samples, signaling through Akt/mTOR was hyperactivated, indicating that the presence of Q510E-Shp2 led to upregulation of this pathway. Importantly, rapamycin treatment started shortly after birth rescued the Q510E-Shp2-induced phenotype in vivo. If rapamycin was started at 6 wk of age, HCM was also ameliorated. We also generated a second mouse model in which cardiomyocyte-specific Q510E-Shp2 overexpression started after birth. In contrast to the first model, these mice did not develop HCM. In summary, our studies establish a role for mTOR signaling in HCM caused by Q510E-Shp2. Q510E-Shp2 overexpression in the cardiomyocyte population alone was sufficient to induce the phenotype. Furthermore, the pathomechanism was triggered pre- but not postnatally. However, postnatal rapamycin treatment could still reverse already established HCM, which may have important therapeutic implications.

Topics: Age Factors; Aging; Animals; Animals, Newborn; Cardiomyopathy, Hypertrophic; Cell Size; Cells, Cultured; Disease Models, Animal; Fibrosis; Mice; Mice, Transgenic; Mutagenesis, Site-Directed; Mutation; Myocardial Contraction; Myocytes, Cardiac; Protein Kinase Inhibitors; Protein Tyrosine Phosphatase, Non-Receptor Type 11; Proto-Oncogene Proteins c-akt; Rats; Signal Transduction; Sirolimus; TOR Serine-Threonine Kinases; Transfection; Ventricular Function, Left

LEOPARD syndrome (LS) is an autosomal dominant "RASopathy" that manifests with congenital heart disease. Nearly all cases of LS are caused by catalytically inactivating mutations in the protein tyrosine phosphatase (PTP), non-receptor type 11 (PTPN11) gene that encodes the SH2 domain-containing PTP-2 (SHP2). RASopathies typically affect components of the RAS/MAPK pathway, yet it remains unclear how PTPN11 mutations alter cellular signaling to produce LS phenotypes. We therefore generated knockin mice harboring the Ptpn11 mutation Y279C, one of the most common LS alleles. Ptpn11(Y279C/+) (LS/+) mice recapitulated the human disorder, with short stature, craniofacial dysmorphia, and morphologic, histologic, echocardiographic, and molecular evidence of hypertrophic cardiomyopathy (HCM). Heart and/or cardiomyocyte lysates from LS/+ mice showed enhanced binding of Shp2 to Irs1, decreased Shp2 catalytic activity, and abrogated agonist-evoked Erk/Mapk signaling. LS/+ mice also exhibited increased basal and agonist-induced Akt and mTor activity. The cardiac defects in LS/+ mice were completely reversed by treatment with rapamycin, an inhibitor of mTOR. Our results demonstrate that LS mutations have dominant-negative effects in vivo, identify enhanced mTOR activity as critical for causing LS-associated HCM, and suggest that TOR inhibitors be considered for treatment of HCM in LS patients.

Topics: Animals; Cardiomyopathy, Hypertrophic; Catalysis; Echocardiography; Female; Humans; Immunosuppressive Agents; LEOPARD Syndrome; Male; Mice; Mutation; Phenotype; Protein Tyrosine Phosphatase, Non-Receptor Type 11; Signal Transduction; Sirolimus; TOR Serine-Threonine Kinases

Chronic kidney disease is often complicated by uremic cardiomyopathy that consists of left ventricular hypertrophy and interstitial fibrosis. It is thought that hypertension and volume overload are major causes of this disease, but here we sought to identify additional mechanisms using a mouse model of chronic renal insufficiency. Mice with a remnant kidney developed an elevated blood urea nitrogen by 1 week, as expected, and showed progressive cardiac hypertrophy and fibrosis at 4 and 8 weeks even though their blood pressures were not elevated nor did they show signs of volume overload. Cardiac extracellular signal-regulated kinase (ERK) was activated in the uremic animals at 8 weeks. There was also an increased phosphorylation of S6 kinase, which is often mediated by activation of the mammalian target of rapamycin (mTOR). To test the involvement of this pathway, we treated these uremic mice with rapamycin and found that it reduced cardiac hypertrophy. Reduction of blood pressure, however, by hydralazine had no effect. These studies suggest that uremic cardiomyopathy is mediated by activation of a pathway that involves the mTOR pathway.

Topics: Animals; Blood Pressure; Cardiomegaly; Cardiomyopathy, Hypertrophic; Carrier Proteins; Extracellular Signal-Regulated MAP Kinases; Hydralazine; Mice; Phosphotransferases (Alcohol Group Acceptor); Ribosomal Protein S6 Kinases; Sirolimus; TOR Serine-Threonine Kinases

Tacrolimus (Tac)-related hypertrophic cardiomyopathy (HCM) has been reported to be an unusual but serious complication affecting pediatric patients after solid organ transplantation. Herein, we present a case of young liver transplant recipient with Tac-induced HCM, treated by discontinuation of Tac followed by conversion to rapamycin (Rap). Our case report points out the potential but rather low risk of HCM during Tac immunosuppression in pediatric liver transplants and demonstrates that replacement of calcineurin inhibitors with mammalian target of Rap (mTOR) inhibitors may be an efficacious therapeutic tool to effect regression of established cardiac hypertrophy.

Topics: Cardiomyopathy, Hypertrophic; Female; Humans; Immunosuppressive Agents; Infant; Liver Transplantation; Sirolimus; Tacrolimus; Ultrasonography

Topics: Adult; Angioplasty, Balloon, Coronary; Cardiomyopathy, Hypertrophic; Combined Modality Therapy; Coronary Disease; Drug Implants; Dyspnea; Ethanol; Heart Septum; Humans; Magnetic Resonance Imaging; Male; Mitral Valve Insufficiency; Physical Exertion; Recurrence; Sclerosing Solutions; Sirolimus; Stents; Tomography, Spiral Computed; Ultrasonography

Hypertrophic obstructive cardiomyopathy (HOCM) associated with the use of tacrolimus is a rare complication of liver and intestinal transplantation seen almost exclusively among pediatric patients. Reduction of tacrolimus dosage or conversion to cyclosporin A (CsA) has been used as an effective treatment in reviewed cases. We present three pediatric transplant recipients who developed hypertrophic obstructive cardiomyopathy while under tacrolimus immunosuppression and were treated with conversion to sirolimus (Rapamycin). The patients (ages 6 yr, 12 yr and 11 months) were transplant recipients (liver, n = 2; liver and intestine, n = 1) who developed significant cardiomyopathy 15 and 96 months post-transplant. One patient died of post-transplant lymphoproliferative disorder 21 days after starting sirolimus. One patient had received two liver transplants and had been on CsA for 12 yr before conversion to tacrolimus at 60 months post-transplant for acute and chronic rejection. The surviving patients were receiving mycophenolate mofetil, tacrolimus and steroids at the time of diagnosis. Dose reduction of tacrolimus and treatment with beta blockers failed to alleviate the hemodynamic changes. The patients were converted to sirolimus 1.6, 37 and 148 months post-transplant and maintained a whole-blood trough level of 15-20 ng/mL 21 days after starting sirolimus. Repeat echocardiograms in the surviving patients showed improvement in cardiomyopathy. One patient had one rejection episode (intestinal biopsy, mild acute cellular rejection) after starting sirolimus that responded to a transient increase in steroids. The early demise of the third patient after sirolimus conversion prevented an adequate assessment of cardiomyopathy. Conversion to sirolimus was associated with a reduction in the cardiomyopathy of the two surviving patients while still providing effective immunosuppression. To our knowledge this observation has not been previously reported.

Topics: Acute Disease; Cardiomyopathy, Hypertrophic; Child; Chronic Disease; Graft Rejection; Humans; Immunosuppressive Agents; Infant; Intestine, Small; Liver Transplantation; Sirolimus; Tacrolimus