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The severity of cardiac dysfunction predicts mortality in septic patients. In this thesis, I have investigated the pathophysiology and the novel therapeutic strategy to attenuate cardiac dysfunction in experimental sepsis. I have developed a model of cardiac dysfunction caused by lipopolysaccharide (LPS)/peptidoglycan (PepG) co-administration or polymicrobial sepsis in young and old, male and female mice. There is good evidence that females tolerate sepsis better than males. Here, I have demonstrated for the first time that the cardiac dysfunction caused by sepsis was less pronounced in female than in male mice; this protection was associated with cardiac activation of a pro-survival pathway [Akt and endothelial nitric oxide synthase], and the decreased activation of a pro-inflammatory signalling pathway [nuclear factor (NF)-κB]. Patients with chronic kidney disease (CKD) requiring dialysis have a higher risk of sepsis and a 100-fold higher mortality. Activation of NF-κB is associated with sepsis-induced cardiac dysfunction and NF-κB is activated by IκB kinase (IKK). Here, I have shown that 5/6th nephrectomy for 8 weeks caused a small, but significant, cardiomyopathy, cardiac activation of NF-κB and expression of inducible nitric oxide synthase (iNOS). When subjected to LPS or polymicrobial sepsis, CKD mice exhibited exacerbation of cardiac dysfunction and cardiac activation of NF-κB and iNOS expression, which were attenuated by a specific IKK inhibitor (IKK 16). Thus, selective inhibition of IKK may represent a novel therapeutic approach for the sepsis-induced cardiac dysfunction in CKD patients. Activation of transient receptor potential vanilloid receptor type 1 (TRPV1) improves outcome in sepsis/endotoxaemia. The identity of the endogenous activators of TRPV1 and the role of the channel in the cardiac dysfunction caused by sepsis/endotoxaemia is unknown. Here, I have shown that activation of TRPV1 by 12-(S)-HpETE and 20-HETE (potent ligands of TRPV1) leads to the release of calcitonin gene-related peptide (downstream mediator of TRPV1 activation), which protects the heart against the cardiac dysfunction caused by LPS.

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Phosphatidylcholine (PC) is made in all nucleated mammalian cells via the CDP-choline pathway. Another major pathway for PC biosynthesis in liver is catalyzed by phosphatidylethanolamine N-methyltransferase (PEMT). We have identified 3T3-L1 adipocytes as a cell culture model that expresses PEMT endogenously. Analysis of the proximal PEMT promoter in 3T3-L1 adipocytes revealed an important regulatory region. Sp1 binds to a GC-rich site within this section of the promoter and inhibits PEMT transcriptional activity. Tamoxifen is an anti-estrogen drug widely used for the treatment of hormone-responsive breast cancer but has a frequent side-effect of increasing accumulation of lipid in the liver (hepatic steatosis). Tamoxifen represses PEMT gene expression by promoting Sp1 binding to the promoter. However, decreased catalytic activity of PEMT was not a major initial contributor to tamoxifen-mediated hepatic steatosis. We found that increased de novo fatty acid synthesis is the primary event which leads to tamoxifen-induced steatosis in mouse liver. Tamoxifen did not significantly alter hepatic fatty acid uptake, triacylglycerol secretion or fatty acid oxidation. Finally, we provide evidence that deletion of the PEMT gene in a well-established mouse model of atherosclerosis (apolipoprotein E deficient) reduces the formation of aortic lesions and prevents the associated development of dilated cardiomyopathy. This beneficial effect is likely due a reduction of atherogenic lipoproteins. These results indicate that treatment strategies aimed at the inhibition of PEMT could prevent the development of atherosclerosis that predisposes individuals to heart failure.

This thesis showed that dogs with natural infection with B. canis had both renal and cardiac dysfunction, both of which can be classified as complications of babesiosis and would thus necessitate supportive therapy. This thesis demonstrated that RTE celluria, proteinuria, and variable enzymuria and azotaemia occur in dogs with babesiosis. However, these were all minimal changes and all could be consistent with hypoxia, reduced GFR, or reduced cardiac output This thesis showed that dogs with naturally occurring babesiosis had significant urine met-haemoglobin with no evidence of blood met-haemoglobin. The possibility would be that the urinary methaemoglobin was either produced in the kidney or possibly by oxidation of haemoglobin to met-haemoglobin in the bladder. It has been shown experimentally that met-haemoglobin can be toxic. The combination of reduced GFR, anaemic hypoxia, and met-haemoglobin can all act synergistically to cause renal damage. Renal haemodynamics are also much more likely to be abnormal when cardiac dysfunction is present Reduced renal blood flow and glomerular filtration rate are evidence of redistribution of blood flow that commonly occurs in early heart failure. An important finding in this thesis was that dogs with babesiosis had lower serum sodium than control dogs but there was no difference between mild, severe, or complicated cases of babesiosis. In addition, dogs with babesiosis had a lower fractional clearance of sodium than Clinically healthy control dogs, which can be interpreted as sodium retention by the kidneys. This sodium retention would also result in water retention , which will result in an expansion of the plasma volume. In the past heart lesions in canine babesiosis were regarded as rare complications, with the majority of lesions being reported as incidental findings at post-mortem examination of complicated babesiosis cases. This thesis has demonstrated that cardiac lesions to be common in canine babesiosis. This thesis showed that that ECG changes in babesiosis were similar to the pattern described for myocarditis and myocardial ischaemia, and together with the histopathological findings indicated that the heart suffers from the same pathological processes described in other organs in canine babesiosis, namely inflammation and hypoxia. As the clinical application of the ECG changes found in this thesis was limited, cardiovascular assessment should be based on functional monitoring rather than ECG. Using cardiac troponin as a marker of myocardial injury, this thesis showed that myocardial cell injury occurs with canine babesiosis. Cardiac troponins, especially troponin I, are sensitive markers of myocardial injury in canine babesiosis, and the magnitude of elevation of plasma troponin I concentrations appears to be proportional to the severity of the disease. ECG changes and serum cardiac troponin were correlated with histopathology. On cardiac histopathology from dogs that succumbed to babesiosis, haemorrhage, necrosis, inflammation and fibrin microthrombi in the myocardium were documented, all of which would have resulted in ECG changes and elevations in cardiac troponin. Myocardial infarction causes left ventricular failure, which will result in hypotension and an expansion of the plasma volume due to homeostatic mechanisms. This thesis showed that dogs with babesiosis had hypoalbuminaemia, which may be because of intravascular volume dilution due to fluid retention. In disease hypoalbuminaemia can occur as a negative acute-phase protein. In the light of the cardiac changes, hyponatraemia, and hypotension, a probable cause would be fluid retention due to myocardial disease. This thesis showed that dogs with babesiosis had left ventricular lesions, which can result in systolic heart failure. / Thesis (PhD)--University of Pretoria, 2005. / Veterinary Tropical Diseases / unrestricted

Cardiac remodeling involves changes in heart shape, size, structure, and function after injury to the myocardium. The proinflammatory adaptor protein myeloid differentiation protein 88 (MyD88) contributes to cardiac remodeling. To investigate whether excessive MyD88 levels initiate spontaneous cardiac remodeling at the whole-organism level, we generated a transgenic MyD88 mouse model with a cardiac-specific promoter. MyD88 mice (male, 20–30 g, n=~80) were born at the expected Mendelian ratio and demonstrated similar morphology of the heart and cardiomyocytes with that of wild-type controls. Although heart weight was unaffected, cardiac contractility of MyD88 hearts was mildly reduced, as shown by echocardiographic examination, compared with wild-type controls. Moreover, the cardiac dysfunction phenotype was associated with elevation of ANF and BNP expression. Collectively, our data provide novel evidence of the critical role of balanced MyD88 signaling in maintaining physiological function in the adult heart.

Myeloid differentiation protein-88 (MyD88) is a crucial adaptor protein in the innate immune response. A protective role for MyD88 in normal cardiac function has been proposed in a surgical hypertrophic model. To assess the in vivo role of MyD88 in cardiac remodeling, we generated transgenic mice with cardiac-restricted expression of a dominant negative mutant of MyD88 (dnMyD88). Surprisingly, dnMyD88 transgenic mice displayed characteristic features of heart failure; including heart weight increase, cardiomyocytes enlargement, interstitial fibrosis, and re-expression of "fetal" genes. Echocardiographic examination of dnMyD88 hearts revealed dilated chamber volume and reduced cardiac contractility. DnMyD88 mice died from heart failure before they were 7 months old, as shown by Kaplan-Meier analysis. Additionally, the heart failure phenotype of dnMyD88 mice was associated with abnormal activation of the Akt/GSK-3β signaling pathway. These data provide the first evidence that normal MyD88 signaling is crucial for maintaining the physiological function of the adult heart.

Cardiac dysfunction is a major consequence of septic shock and may be responsible for the high mortality of sepsis. We have reported that transgenic mice with cardiac-specific overexpression of heat shock protein 27 (Hsp27 Tg) exhibited the protection against doxorubicin-induced cardiac dysfunction. We hypothesized that overexpression of Hsp27 will attenuate cardiac dysfunction during endotoxemia. Hsp27 Tg and age-matched wild-type (WT) mice were injected with LPS. Cardiac function was evaluated by echocardiography, survival rate was carefully monitored, and activities of signaling pathways were determined by immunoblot. LPS administration significantly decreased cardiac function in WT mice. In Hsp27 Tg mice, LPS-induced cardiac dysfunction was significantly attenuated as evidenced by increased ejection fraction (27.3%) and fractional shortening (37.1%), respectively, compared with LPS-treated WT mice. Heat shock protein 27 Tg mice were more resistant to LPS-induced mortality than WT. The levels of phospho-Akt and phospho-glycogen synthase kinase 3β (phospho-GSK-3β) in the myocardium were significantly increased in Hsp27 Tg mice compared with WT after LPS administration. Nuclear factor κB-binding activity was significantly decreased in Hsp27 Tg mice compared with WT mice after LPS challenge. Similar results were observed in in vitro studies using Hsp27-transfected rat cardiomyoblasts. Importantly, phosphoinositide 3-kinase inhibition abolished the protective effect of Hsp27 in LPS-induced cardiac dysfunction and mortality of endotoxemia. Our results suggest that Hsp27 plays an important role in attenuation of cardiac dysfunction and mortality in endotoxemia and that the mechanisms of the protection may involve activation of the PI3K/Akt signaling pathway.

The intensive care unit treats the most critically ill patients in the hospital, and as such the clinical staff in the intensive care unit have to deal with complex, time-sensitive and life-critical situations. Commonly, patients present with multiple organ dysfunctions, require breathing and cardiovascular support, which make diagnosis and treatment even more challenging. As a result, clinical staff are faced with processing large quantities of often confusing information, and have to rely on experience and trial and error. This occurs despite the wealth of cardiovascular metrics that are available to the clinician. Computer models of the cardiovascular system can help enormously in an intensive care setting, as they can take the monitored data, and aggregate it in such a way as to present a clear and understandable picture of the cardiovascular system. With additional help that such systems can provide, diagnosis can be more accurate and arrived at faster, alone with better optimised treatment that can start sooner, all of which results in decreased mortality, length of stay and cost. This thesis presents a model of the cardiovascular system, which mimics a specific patient’s cardiovascular state, based on only metrics that are commonly measured in an intensive care setting. This intentional limitation gives rise to additional complexities and challenges in identifying the model, but do not stand in the way of achieving a model that can represent and track all the important cardiovascular dynamics of a specific patient. One important complication that comes from limiting the data set is need for an estimation for the ventricular time-varying elastance waveform. This waveform is central to the dynamics of the cardiovascular model and is far too invasive to measure in an intensive care setting. This thesis thus goes on to present a method in which the value-normalised ventricular time-varying elastance is estimated from only metrics which are commonly available in an intensive care setting. Both the left and the right ventricular time-varying elastance are estimated with good accuracy, capturing both the shape and timing through the progress of pulmonary embolism and septic shock. For pulmonary embolism, with the algorithm built from septic shock data, a time-varying elastance waveform with median error of 1.26% and 2.52% results for the left and right ventricles respectively. For septic shock, with the algorithm built from pulmonary embolism data, a time-varying elastance waveform with median error of 2.54% and 2.90% results for the left and right ventricles respectively. These results give confidence that the method will generalise to a wider set of cardiovascular dysfunctions. Furthermore, once the ventricular time-varying elastance is known, or estimated to a adequate degree of accuracy, the time-varying elastance can be used in its own right to access valuable information about the state of the cardiovascular system. Due to the centrality and energetic nature of the time-varying elastance waveform, much of the state of the cardiovascular system can be found within the waveform itself. In this manner this thesis presents three important metrics which can help a clinician distinguish between, and track the progress of, the cardiovascular dysfunctions of pulmonary embolism and septic shock, from estimations based of the monitored pressure waveforms. With these three metrics, a clinician can increase or decrease their probabilistic measure of pulmonary embolism and septic shock.