UvA-DARE (Digital Academic Repository) Molecular therapies for cardiac arrhythmias Boink, G.J.J. Publication date 2013 Link to publication Citation for published version (APA): Boink, G. J. J. (2013). Molecular therapies for cardiac arrhythmias. [Thesis, fully internal, Universiteit van Amsterdam]. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl) Download date:11 Feb 2023 GENE AND CEll THERAPIES IN THE TREATMENT OF BRADy- AND TACHyARRHyTHMIAS 1 Gerard JJ Boink1,2 1Heart Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, and 2Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands. Parts of this chapter have been published in the following manuscript: Boink GJJ and Rosen MR. Regenerative therapies in electrophysiology and pacing: introducing the next steps. Journal of Interventional Cardiac Electrophysiology 2011; 31:3-16 14 PArT I: CHAPTer 1 ABSTRACT 1 Morbidity and mortality of cardiac arrhythmias are major international health concerns. Drug and device therapies have made inroads, but because of their shortcomings alternative approaches are being sought. For example, gene and cell therapies have been explored for treatment of brady- and tachyarrhythmias, and proof-of-concept has been obtained for both biological pacing in the setting of heart block and gene therapy for treating ventricular tachycardias. This chapter discusses the state-of-the- art developments with regards to gene and cell therapies for cardiac arrhythmias. In doing so, it will provide a general introduction to this thesis. GeNe ANd Cell THerAPy for CArdIAC ArrHyTHMIAs 15 INTRODuCTION Cardiac arrhythmias are a major burden on society in developed countries. Ventricular 1 tachycardia/ventricular fibrillation (VT/VF) are the predominant causes of cardiac arrest, accounting for approximately 340.000 deaths annually in the United States alone.1 Anti-arrhythmic drugs have largely failed to reduce mortality.2 Radiofrequency catheter ablation has provided a more targeted approach, but success rates are moderate and recurrence rates high. Therefore, only implantable cardioverter/defibrillators provide a reliable safeguard to otherwise lethal arrhythmias. However, these devices are associated with significant morbidity as they terminate rather than prevent arrhythmias, and they are a physical and psychological burden to many patients.2 The slow heart rates that characterize bradyarrhythmias necessitate nearly 200.000 electronic pacemaker implantations annually in the United States.3 Although such pacemakers are mature therapies, important limitations remain, including an inadequate response to autonomic modulation, and impulse initiation from non- physiological sites that may induce significant cardiac remodeling.4, 5 Furthermore, they are inappropriate for many pediatric patients, and up to 5% of all pacemaker implantations result in serious complications that require surgical or endovascular revision.6 Hence, in the fields of both brady- and tachyarrhythmias, there is a pressing need to improve currently available therapies. The inadequacy of conventional therapies to treat arrhythmias stems in part from problems related to targeting therapies to the appropriate sites within the heart. For example, electronic pacemakers are typically implanted in the right ventricular apex at sites that optimize stable lead position, but these sites induce a non-physiological contraction pattern of the cardiac muscle, which may result in adverse remodeling of the heart. Different pacing sites (including His, para-His and the right ventricular outflow tract) to generate a more physiological contraction wave have been explored for years. Yet, these approaches are still hampered by difficult placement procedures, unstable lead positioning and higher risks for complications. Pacing from the right ventricular apex has therefore remained the standard method of care.7 On the other hand, antiarrhythmic drugs typically target ion channels that are expressed throughout the heart. Such an approach lacks specific targeting to the pathophysiologic substrate and has been complicated by proarrhythmic side-effects. Gene and cell therapy may provide important improvements because virtually every site within the heart is readily accessible for construct injection. Furthermore, in contrast to approaches that use radiofrequency (RF) catheter ablation to locally destroy arrhythmogenic areas, gene and cell therapy have the potential to prevent arrhythmias without doing further damage, and they may even regenerate cardiac muscle. To better understand the rationale behind the various molecular therapies proposed for cardiac arrhythmias, I begin this chapter by discussing the basic concepts of cardiac rhythm and the various tools available for gene and cell therapy. Next, I summarize achievements in the area of arrhythmia research. Finally, I will address the major goals in this thesis. 16 PArT I: CHAPTer 1 BASIC CONCEPTS IN THE GENERATION AND MAINTENANCE OF 1 CARDIAC RHyTHM In the right atrium, close to the entry site of the superior vena cava, a small group of cells present in the sinoatrial node (SAN) depolarizes spontaneously providing a nidus of impulse initiation to pace the heart (Figure 1A). Activation spreads from the SAN through the atria and activates the atrioventricular node (AVN), where impulse propagation is delayed. This delay allows the ventricle to fill during atrial contraction. From the AVN, activation proceeds rapidly through the His-Purkinje system to activate ventricular myocardium. The spontaneous action potentials generated in the SAN drive the heart throughout life in healthy individuals with only rare moments of failure. In the diseased heart, however, bradycardia may occur due to SAN dysfunction or due to failure of impulse propagation from atria to ventricle. In these instances, residual pacemaker activity in the AVN and the distal conducting system may be revealed, as these tissues have intrinsically slower firing frequencies than the SAN.8 Although these secondary pacemakers maintain a cardiac rhythm, in most instances the bradycardia which develops requires implantation of an electronic pacemaker. To better understand the electrical phenomena behind cardiac impulse initiation and propagation, major processes in cellular electrophysiology will be discussed. The greatest electrophysiological differences among cardiac myocyte types are those between SAN and ventricular cells (Figure 1B). In SAN cells, spontaneous action potentials (APs) are generated by slow diastolic depolarization. Important contributors to this process include the hyperpolarization activated cyclic nucleotide-gated (HCN) channels encoding the pacemaker current (“funny” current”, I) and the T-type Ca2+- f channels.A more complete discussion on the various mechanisms contributing to SAN pacemaking is provided below. When the threshold for activation of voltage- gated L-type Ca2+ channel opening is reached, phase 0 depolarization commences which initiates the regenerative action potential in the SAN cell and is a stimulus for propagation of impulses to neighboring cells. Impulse propagation from a cell to its neighbors primarily occurs through low-resistance intercellular connections provided by gap-junction channels. Following depolarization of the membrane, voltage-gated K-channels open and generate an outward current that repolarizes the cell to its maximal diastolic potential (MDP; Figure 1C).9 Voltage-gated Na+-channels (primarily encoded by the α-subunit SCN5A) are the predominant driver of phase 0 membrane depolarization in cells of the working myocardium. Following the AP notch (caused by initial repolarization carried by the transient outward current I ), ventricular myocytes manifest a plateau phase during to which inward (Ca2+) and outward (K+) currents are largely in balance. Next, membrane repolarization is driven by voltage-gated K+ channels (Figure 1D).10 There are a number of additional differences between SAN and ventricular myocytes: 1) The inward rectifier current (I ) in ventricle generates a more hyperpolarized and K1 stable resting membrane potential than does SAN, in which I is virtually absent. K1 GeNe ANd Cell THerAPy for CArdIAC ArrHyTHMIAs 17 1 Figure 1. Basic properties in cardiac electrophysiology. A, Schematic drawing of cardiac anatomy and its functional relation with the electrocardiogram (ECG). B, Differences in action potential morphology in cells isolated from sinus node, atrium and ventricle and their relationship to the ECG. C-D, Schematic drawing of the action potential shape and underlying currents of in sinus node (C) and ventricular myocyte (D). Modified from reference 155, with permission. 18 PArT I: CHAPTer 1 This difference primarily stems from the higher expression levels of the Kir2 family of genes encoding I in ventricle compared to SAN. The strong I in ventricle clamps the 1 K1 K1 membrane at a negative potential and limits the membrane depolarization that would be induced by inward currents.11-13 2) I current density in ventricular cells is much f smaller than in cells of the SAN. This difference is the result from both differences in expression levels of HCN channels and differences in activation kinetics of I. In f SAN cells, HCN expression levels are much higher and I activates at more positive f potentials than in ventricular cells. The positively shifted activation kinetics stem in part from the elevated baseline cAMP levels in SAN versus ventricle, but other contextual factors contribute as well, e,g., the β-subunit minK-related protein 1.14 3) I  only minimally contributes to phase 0 depolarization of SAN cells, as the Na depolarized membrane potentials in SAN cells inactivate the voltage dependent I . Na The low expression levels of SCN5A in central SAN cells further increase this difference with ventricular myocytes.10 4) Intracellular Ca2+-handling also differs. In SAN cells, spontaneous local Ca2+ release events importantly contribute to spontaneous activity. In ventricular myocytes, these local release events occur randomly and generally do not generate spontaneous activity.15 Furthermore, the intracellular Ca2+-apparatus in ventricular myocytes is linked to a well- developed sarcoplasmic reticulum (SR), which supports contraction. In SAN cells, this apparatus contributes to pacemaking, but is underdeveloped with regards to the generation of contractile force.16 Other cardiac myocytes have phenotypes that are more or less in between the extremes of a SAN and a ventricular cell. As compared to their ventricular counterparts, atrial myocytes harbor fewer I channels, but still have a hyperpolarized K1 resting membrane potential and lack spontaneous activity. Cells within the specialized conduction system harbor slow spontaneous activity that gradually decreases in the proximal to distal direction while the membrane remains relatively hyperpolarized.17 Finally, a key difference between SAN and Purkinje cells is that the latter harbor abundant Na+-channels and connexins. These differences facilitate the rapid conduction that characterizes the ventricular conduction system.10, 18 Endogenous pacemaker function Decades of research have fueled our knowledge of mechanisms contributing to slow diastolic depolarization and pacemaker function within the SAN. Ever since the discovery of HCN channels and the I current which they generate,19, 20 high importance f has been assigned to their role in SAN function.21, 22 Indeed, these channels are predominantly expressed in the pacemaker regions of the heart23 and their biophysical properties predict the generation of an inward current that flows during diastole as these channels open upon hyperpolarization.19, 20 Furthermore, HCN channels can bind cAMP, thus facilitating direct autonomic modulation.24 The notion that I is the unique determinant of pacemaker function (as shown in f Figure 1C) has been challenged by the demonstration of a coupled-clock system.25, 26 Ca2+ is cycled in a process of SR release and reuptake (designated “Ca2+-clock”), which GeNe ANd Cell THerAPy for CArdIAC ArrHyTHMIAs 19 1 Figure 2. Schematic diagram of the various sarcolemmal ion channels, Ca2+-cycling proteins and intracellular pathways involved in sinoatrial node pacemaker function. Given the high degree of redundancy in the various contributing mechanisms, there is not one primary source that ignites the oscillator. Rather, several systems contribute, including: I-channels, I -channels and f Ca spontaneous sarcoplasmic Ca2+-releases that primarily generate inward current through the Na+/ Ca2+-exchanger. Abbreviations: CAMKII, Ca2+/calmodulin-dependent protein kinase II; cAMP, cyclic AMP; GPCR, G-protein-coupled receptor; HCN, hyperpolarization-activated cyclic nucleo- tide-gated channel; NCX, Na+/Ca2+ exchanger; PLB, phospholamban; RYR, ryanodine receptor; SERCa2a, sarcoplasmic reticulum Ca2+ ATPase. Modified from reference 156, with permission. in turn facilitates membrane depolarization via a variety of ion channels and exchangers in which the Na+/Ca2+-exchanger plays a significant role. Although there is agreement that both I- and the Ca2+-clock contribute to SAN activity, ongoing disagreement exists f on the relative contributions of these systems and whether one of these systems can be considered primary rather than secondary to the other.27 This ongoing discussion is particularly fueled by dissimilar outcomes in different species (e.g., Ca2+-clock based mechanisms appear more important in guinea pig than in canine SAN), in different modes of pacemaking (i.e., in the absence or presence of autonomic stimulation/ inhibition), and in different pacemaker tissues (e.g., I based pacemaking appears to f- be predominant in Purkinje fibers).28 In addition, I and Ca2+-clock based pacemaker f mechanisms may in fact be highly interlinked. Evidence in favor of this hypothesis was recently provided by Yaniv and colleagues in experiments on isolated rabbit SAN cells. Here, they found 3 µM ivabradine to specifically block I without having f direct effects on other membrane currents or Ca2+ cycling. However, indirect effects associated with the reduced AP firing rate in the presence of ivabradine did appear 20 PArT I: CHAPTer 1 to orchestrate reduced Ca2+ handling and prolongation of the period of spontaneous local Ca2+ releases.29 1 The persistent function of the SAN under a large variety of pathological and experimental conditions suggests significant redundancy within the contributing systems. Indeed, regardless of which system is considered as primary, it is the interaction among mechanisms that contributes to the final pacemaker outcome. These mechanisms involve regulatory elements executed by G proteins and cyclic nucleotides, exchangers (the Na+/K+ exchanger is particularly important in secondary pacemakers) and several ion channels including the L- and T-type Ca2+-channels, Na+- channels and K+-channels.30 The involvement of Na+-channels largely depends on a hyperpolarized membrane potential. These channels critically contribute to the excitation of the SAN periphery, the atrial and ventricular muscle and the His-Purkinje system.31 In the more depolarized cells of the central SAN and AVN, Ca2+-channels are the primary charge carriers for membrane excitation (Figure 1C). The involvement of K+-channels is complex as reductions in outward current during diastole will facilitate phase 4 depolarization. However, increases in outward current during phases 2 and 3 of the action potential will accelerate repolarization; a resultant shorter action potential duration in the setting of a constant phase 4 depolarization slope has the potential to increase the rate of impulse initiation. The most important processes contributing to SAN pacemaking are summarized in Figure 2. A final key element to cardiac pacing is the electrical coupling between the SAN and surrounding atrial cells. Appropriate cell-to-cell coupling is important, because too-weak coupling will result in failure to excite adjacent atrial cells, while too-strong coupling would transmit too much hyperpolarizing current from atrial cells, which would tend to silence pacemaker activity.32 Protecting the SAN from hyperpolarizing effects of surrounding atrial cells is provided by its partial encapsulation with connective tissue and blood vessels, limiting the number of exit pathways.33 Furthermore, absence of the fast-conducting connexins Cx40 and Cx43 within the SAN together with presence of the more slowly conducting connexins Cx45 and Cx30.2 (mice) or Cx31.9 (human) contribute to a lesser degree of cell-cell coupling within the node and at the interface with atrial myocardium.23 Mechanisms underlying tachyarrhythmias In general, three mechanisms are considered important in the pathophysiology of tachyarrhythmias: 1) reentry, 2) triggered activity, and 3) abnormal automaticity. Reentry is the leading cause of arrhythmias complicating ischemic heart disease.34 The occurrence of reentry is determined at the tissue level, where functional barriers (e.g., tissue that is coupled electrically with cardiomyocytes, but unexcitable such as fibroblasts, or myocardial tissue that remains unexcited at certain heart rates or activation patterns) or structural barriers (e.g., infarct scar) may cause the activation wavefront to persist in a circular pattern. Further requirements for reentry include the GeNe ANd Cell THerAPy for CArdIAC ArrHyTHMIAs 21 1 Figure 3. Mechanisms of cardiac arrhythmias. A, Upper left panel shows normal impulse prop- agation under healthy conditions. Upper right panel shows moderate conduction slowing as indicated by the crowding of isochrones around the black bar that represents myocardial tissue damage. For reentry to occur, another prerequisite is the occurrence of unidirectional conduction block represented by the black jagged line in the lower left panel. The subsequent lower panels show the initiation and maintenance of a tachycardia circling around the area of myocardial damage. Modified from reference 157, with permission. B, Early afterdepolarizations in cardiac Purkinje fibers. In the left panel, the solid line represents a normal action potential (AP), the dashed line (arrow) represents AP prolongation that can predispose to single afterdepolariza- tions (EADs, arrow; middle panel) or a train of EADs (arrow; right panel). C, Left panel, stimulated APs followed by subthreshold delayed afterdepolarizations (DAD; arrow). Right panel, when the stimulation cycle length is shortened, DAD amplitude increases to reach threshold and induce triggered activity (arrow). In B and C, each trace shows a drawing based on original recordings. Modified from reference 38, with permission.