Heart failure due to ischemic and dilated cardiomyopathy is a large and expanding public health problem, and ventricular arrhythmias are a common and potentially fatal complication of this condition. Despite extensive investigation, the mechanisms of ventricular arrhythmias in cardiomyopathy remain incompletely understood. This thesis examines these mechanisms, particularly with reference to the potential role of the underlying electrophysiologic substrate. It also evaluates the validity and utility of some of the tools commonly used to assist in the mapping and catheter ablation of ventricular arrhythmias. / The central rationale of this thesis is that the mechanisms of ventricular arrhythmogenesis in cardiomyopathy are optimally studied by comparing ischemic and dilated cardiomyopathy patients with spontaneous (rather than inducible) ventricular tachycardia to otherwise similar heart failure patients who have never developed clinical arrhythmias. This has been done in the two largest projects herein. In the setting of ischemic cardiomyopathy, it is demonstrated that there are large differences in the electrophysiologic substrate between the groups such that patients with clinical ventricular tachycardia have substantially greater endocardial scarring as inferred by the presence of low-voltage zones and scar-related electrograms compared to control cardiomyopathy patients with no spontaneous arrhythmias. Furthermore, there appear to be fundamental differences in the nature of the scarring process with ventricular tachycardia patients having more abnormal electrograms per unit area of low-voltage and more scar-related putative conducting channels (which may form critical diastolic isthmuses in tachycardia). / This was accompanied by a lower rate of ventricular tachycardia inducibility in the control patients. Taken together these findings point to a major role for the electrophysiologic substrate in ventricular arrhythmogenesis in the setting of ischemic cardiomyopathy. The situation in dilated cardiomyopathy is more complicated and although significant endocardial substrate differences were again seen in this context, there was marked heterogeneity in the group with ventricular tachycardia with some patients having extensive low-voltage zones and others having normal endocardial voltage. As the pericardium could not be accessed for ethical reasons in control patients with no clinical arrhythmia, the precise role of an abnormal epicardial substrate was not able to be defined in this study. Another project in this thesis examines potential improvements (in the form of a multielectrode mapping catheter) to a widely used electroanatomic mapping system that can assist in mapping ventricular tachycardia circuits and the substrates underlying them. A further project compares magnetic resonance imaging and electroanatomic substrate mapping in defining ventricular scarring in the context of cardiomyopathy. And finally, electroanatomic mapping is used to look at endocardial activation patterns and electrical dyssynchrony in cardiomyopathy patients with and without left bundle branch block. The demonstrated variability in these factors may underlie the significant non-response rates to cardiac resynchronization therapy. / In summary, it is apparent from this work that the electrophysiologic substrate plays a crucial role in mechanism of the ventricular arrhythmias seen in heart failure patients with ischemic and dilated cardiomyopathy. An improved understanding of these mechanisms may in turn lead to better diagnosis, risk stratification and ultimately management of heart failure patients suffering from, or at risk of developing these potentially lethal arrhythmias.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 5 uppsatser.

Rationale/Background: The adult mammalian heart has a very limited potential for regeneration due to cardiomyocyte cell cycle withdrawal which occurs shortly after birth. One potential avenue to repair the heart following stress/injury is to reprogram pre-existing cardiomyocytes to re-enter the cell cycle. The E2F family is a group of transcription factors which ubiquitously regulate the cell cycle, but it has previously been difficult to fully appreciate their role in the post-natal myocardium due to either redundancy or embryonic lethality of genetic models. Thus we generated a dominant negative model of the E2F/Rb pathway via expression of the unique transcriptional repressor E2F6 in postnatal myocardium. E2F6 transgenic (Tg) mice developed dose dependent Dilated Cardiomyopathy (DCM) and sudden death without hypertrophy or apoptosis. This was accompanied by the partial loss of E2F3 (critical for cardiac development) and connexin-43 important for metabolic and electrical coupling. Methods/Results: In this thesis E2F6-Tg mice were examined for markers of cardiac differentiation/ function and exposed to stressors to evaluate the capacity for the E2F pathway to regulate cardiomyocyte growth (isoproterenol) and death (doxorubicin and cobalt chloride). E2F6-Tg mice were twice as sensitive to isoproterenol as their Wt counterparts due to the observed activation of a β2-adrenergic survival pathway. Cardiac hypertrophy in E2F6-Tg mice was accompanied by the rescue of E2F3 expression. Treatment of neonatal cardiomyocytes isolated from Wt and E2F6-Tg pups with cobalt chloride revealed a protective effect for E2F6 against apoptosis. Doxorubicin exposure led to the loss of E2F6 protein and abolished its protective effect. Examination of neonatal hearts and cardiomyocytes isolated from them demonstrated a shift in the cell cycle and metabolic profiles of E2F6-Tg myocardium. Tg cardiomyocytes show decreased glycolysis and a dramatic increase in the regulator of ketolysis, β-hydroxybutyrate dehydrogenase (BDH1), prior to DCM. The substrate of BDH1 (β-hydroxybutyrate) was demonstrated to influence the levels of CX-43 in cardiomyocytes. E2F6 also deregulated expression of T-cap which has been linked to human DCM. Conclusions: I provide evidence that the E2F pathway can regulate growth, death, and differentiation through a variety of mechanisms which link the cell cycle and metabolism to growth and survival to critically govern post-natal cardiac function. Furthermore, I reveal a new biomarker (BDH1) for early DCM which may be useful in diagnosis/ treatment of idiopathic cases of disease.

In 1980, the World Health Organization task force first sought to define and classify cardiomyopathies. They defined cardiomyopathies as "heart muscle diseases of unknown cause" with three main classifications including: hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), and restrictive cardiomyopathy [1]. Over the next three decades it became patently obvious that this simple definition was not sufficient to describe the complex heterogeneity of diseases present in the patient population. More robust definitions were necessary for mechanistic links to be established and meaningful therapeutics to be developed. Since then the accepted definition of a cardiomyopathy has evolved and the classifications have greatly expanded. The most recent definition from the American Heart Association Council on Clinical Cardiology states: Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation and are due to a variety of causes that frequently are genetic. Cardiomyopathies either are confined to the heart or are part of generalized systemic disorders, often leading to cardiovascular death or progressive heart failure–related disability [2]. This latest definition (2006) reflects the growing recognition of molecular genetics as a key factor in the development of cardiomyopathies and highlights the ever-growing complexity of disease classification. Today the genetic basis of HCM and DCM is widely recognized yet our understanding of the precise mechanisms underlying the disease remains unclear. To add to this disconnect, by the time patients become symptomatic, pathology has progressed past the initial phase, where meaningful treatment could occur, to advanced end-stage pathology. By this time often the only treatment options available become "blunt sword" therapeutics that are non-specific and used primarily for symptom management. In fact, over the last 3 decades there has been a marked decline in the innovation of cardiovascular pharmaceuticals owed partially to the vast complexity of disease presentation and progression [3]. In this dissertation, I will focus on a genetic sarcomeric DCM caused by a mutation in alpha-tropomyosin (Tm). Using novel accurate mouse models as a tool we will define the mechanism by which it leads to disease, investigate how disease severity due to the mutation is modified in an age-dependent manner, and examine what this mechanism could mean in the larger picture of cardiomyopathic disease progression. I hope to convince you that by using accurate models of this DCM at multiple levels of biological complexity to tease out the precise mechanisms of disease we can establish meaningful genotype-phenotype relationships that could lead to the development of specific novel therapeutics.

Introduction Russell-Silver Syndrome (RSS) is a genetically determined condition characterized by severe intrauterine and postnatal growth retardation; relative macrocephaly; a small, triangular face; and fifth-finger clinodactyly. The etiology of RSS involves epigenetic regulation through either uniparental disomy or genomic imprinting via DNA methylation. There has been no documented association between RSS and cardiomyopathy. Methods We present an original case of a 32-year-old woman with RSS with dilated a cardiomyopathy who on cardiac biopsy showed occasional hypertrophic and atrophic myocytes with no evidence of inflammation, abnormal sarcomeres and disintegration of the Z bands on ultrastructural analysis, abnormal desmin, and normal C9 immunoreactivity. Conclusion This case represents the first reported association between RSS and cardiomyopathy. Given the complex mechanisms of disease etiology in RSS, this novel case provides insights into the mechanism of progressive dilated cardiomyopathy in an older individual with RSS.

No description available.

Dilated cardiomyopathy (DCM) or round heart disease is a muscle disease of the heart which is characterized by ventricular dilatation and abnormal systolic and diastolic left ventricular function. In animals, including turkeys and humans, DCM is the major cause of morbidity and mortality which results from heart failure. In the turkey, DCM can be idiopathic or induced. Since idiopathic or spontaneous DCM occurs in about 1-4% of normal turkeys, it is of significant concern to the poultry industry. In this study, it was proposed that the incidence and severity of DCM in the turkey may have a genetic basis. To test this hypothesis, I investigated differences in the incidence and severity of DCM in five domesticated turkey varieties including Blue Slate (BS), Bourbon Red (BR), Narragansett (N), Royal Palm (RP) and Spanish Black (SB). Preliminary investigations tested the reliability of echocardiography (ECHO) as a non-invasive and non-destructive technique for diagnosing DCM in a large number of birds from hatch to four weeks-of-age. One-day-old poults for both the preliminary and hypothesis testing investigations were obtained from Privett Hatcheries (Portales, New Mexico). The birds were raised under standard management conditions. In the preliminary investigation and to test my hypothesis, DCM was induced by feeding birds ad libitum standard diets containing 700 parts per million furazolidone. Results of the preliminary investigations showed that left ventricular end-diastolic dimension (LVEDD) and left ventricular end-systolic dimension (LVESD) were the most consistent ECHO indicators of DCM from hatch to 4 weeks-of-age. Variety differences in response to furazolidone were evaluated using these parameters as well as percent mortality. At 9 days-of-age, differences between control and treatment birds for percent mortality and LVESD were significant in the RP variety only but significant for LVEDD in RP and SB. At 29 and 33 days-of-age, all the pair-wise comparisons between control and treatment birds were significant for both LVEDD and LVESD. On average, the BR variety had the smallest dilatation of the heart and lowest mortality at 33 days-of-age when compared to other varieties. The results described in this thesis show, for the first time, variety differences in the turkey's response to diets containing furazolidone. They provide strong evidence that, like previous reports for idiopathic DCM, an animal's response to Fz-induced DCM has a strong genetic component. / Master of Science

Cardiomyopathies are often initiated by diastolic dysfunction, and treatment of diastolic dysfunction remains empirical with an emphasis on prevention. This dissertation focuses on the mechanism of cardiomyopathy and diastolic dysfunction during aging and immune dysfunction. The governing hypothesis is that altered cytokine release such as that seen during aging and immune dysfunction can lead to diastolic dysfunction and myocardial fibrosis. Our first study examined the role of aging and immunosenescence on the cardiac extracellular matrix (ECM) and left ventricular stiffness. We demonstrated age-related immune dysfunction, myocardial fibrosis, and diastolic dysfunction. We also found that exogenous dehydroepiandrosterone (DHEA), an adrenal steroid hormone popular due to its anti-aging effects, partially reversed these pathologies in aged mice. In this model, fibrosis and its reversal were associated with altered regulation of matrix metalloproteinases (MMP) and collagen cross-linking. We propose two mechanisms for the protective effects of DHEA: (1) a direct effect on cardiac fibroblasts, or (2) downstream effects of immune modulation. In the subsequent study, we found that DHEA is capable of directly altering cardiac fibroblasts, suggesting a mechanism for the effects of DHEA on cardiac function. Due to pleiotropic effects of DHEA, we decided to specifically target the immune system using T-cell receptor peptides during murine AIDS(mAIDS). Mice with mAIDS suffer from cardiomyopathy in the absence of myocarditis and opportunistic pathogens. We demonstrated that reversal of immune dysfunction in mAIDS was associated with reversal of myocardial fibrosis and ventricular stiffness. In conclusion, we have demonstrated age- and immune-related diastolic dysfunction that can be reversed by modulation of the T-cells of the immune system. Immune modulation should be further investigated as a therapeutic target to treat diastolic dysfunction during immune dysfunction. We also found that MMPs and collagen cross-linking are highly involved in extracellular matrix regulation in the models used in this dissertation.

Objectives: The purpose of this study was to investigate a family of Great Danes with known dilated cardiomyopathy (DCM) using serial echocardiographic evaluation. Animals, Materials, and Methods: Twenty-two dogs were included in this study. They were split into two groups, clinically normal and those with DCM. The dogs were scanned using 2D and M-mode echocardiography every thirty to sixty days beginning at approximately14-20 days of age. Data were collected and analyzed using generalized additive mixed regression, linear regression, and non-linear regression. Results: All dogs demonstrated progressive echocardiographic changes. The Great Danes with DCM showed several echocardiographic differences when compared to the normal dogs. They included differences in left ventricular diameter, left atrial diameter, interventricular septal thickness, ejection fraction, and fractional shortening. Conclusions: The present study shows that progressive echocardiographic changes occur in both clinically normal Great Danes and those with DCM as they mature. Additionally, the two groups differed with regards to left ventricular diameter, left atrial diameter, interventricular septal thickness, ejection fraction, and fractional shortening.

<p>Traditional <italic>Drosophila</italic> hearts screens have focused on early patterning and development, and adult heart phenotypes have only recently been pursued due to difficulty in accurately measuring cardiac function in adult <italic>Drosophila</italic>. For my dissertation I performed a screen in <italic>Drosophila</italic> using optical coherence tomography (OCT) to phenotype cardiac function in awake, adult <italic>Drosophila</italic>, in order to discover novel disease-causing and disease-modifying genes for heart failure. I initiated a screen of X chromosome deficiency stocks for mutants displaying abnormal cardiac function in the adult, and I identified two mutant strains from the X chromosome with the phenotype of dilated cardiomyopathy. These deficiencies of 125kb and 92kb each correspond to 10 and 16 deleted genes in each, respectively. Interestingly, the candidate genes did not include any sarcomeric proteins, nor any proteins previously implicated in heart function. Utilizing genetic tools including customized deletions, RNAi constructs, and transgenic rescues, I identified the causative gene in each deficiency. I show that cardiomyopathic genes can be identified in adult <italic>Drosophila</italic> using genetics and noninvasive phenotyping methodologies.</p> / Dissertation