Inflammation in heartfailure: Focus on fibroblasts · Carsten Tschöpe. Kardiologie, Campus Benjamin Franklin. Inflammation in heartfailure: Focus on fibroblasts. Berlin

Carsten Tschöpe

Kardiologie, Campus Benjamin Franklin

Inflammation in heart failure:

Focus on fibroblasts

Berlin

nach Owan T et al. N Engl J Med 2006;

Prognosis and heart failure

HFREF

HFREF(Heart failure with reduced ejection fraction)

Deswal et al. Circulation 2001

Inflammation is a negative predictorin inflammatory cardiomyopathy

Kindermann et al. Circulation 2008

Basal

6 Monatsverlauf



HFREF HFPEF

HFPEF HFREF(Heart failure with reduced ejection fraction) (Heart failure with preserved ejection fraction)

Volume

Pres

sure

Mitral valveopen

Mitral Valveocclusion

Filling

Aortic Valveocclusion Ejection

Aortic valveopen

ContractionR

elax

atio

n

Cardiac Working Diagram(Pressure-Volume Relationship)

Volume

Pres

sure

Diastolic

Systolic

Cardiac Working Diagram(Pressure-Volume Relationship)

LVEDPTau

Dp/

dt m

in

Conductance Catheter

LV pressure and volume measurement

All signals

V. Cava Occlusion for transient preload reductionto evaluate end-diastolic pressure-volume

relationship(LV stiffness)

Direct measurment of LV stiffnessEnd-diastolic pressure-volume relationship

control HFNEF0.00

0.01

0.02

0.03

0.04st

iffne

ss c

onst

ant

*n =70/ Gruppe, *P<0.05Control HFPEF Control HFPEF

EF*

0

20

40

60

80

%

LV Stiffness

Conductance catheter(Pressure-Volume-Curves)

Hemodynamic characterisation of HFPEF

Kasner et al, Circulation 2007 Westermann et al, Circulation 2008

Aufzeichnungvon Druck-Volumen Schleifen

LVEDPSteifigkeit

LV Stiffness:Mechanismens

Matrix

C. Tschöpe

HFPEFKontrolle

LV Stiffness and collagen index in HFPEF

Kasner et al, JACC 2011 Westermann et al, Circulation 2008

.

p=0.001

Siriu

s re

d, C

VF (

%)

0

10

20

30

Col

lage

n C

ross

-Lin

king

p=0.007

0,0

1,0

2,0

3,0

4,0

HFPEFKontrolle HFPEFKontrolle

Kontrolle HFPEF0

5

10

15

cells

/ m

m2

Makrophages(CD68+)

Kontrolle HFPEF0

5

10

15

20

cells

/ m

m2

*

T-Lymphocytes(CD3+)

*

CD 3

TGFß

Colocalisation ofTNF- a / CD 68 cells

Colocalication ofTGF-b / CD 3 cells

TNF

CD 68

Inflammation in endomyocardial biopsies of patients with HFPEF

Westermann et al, Circulation HF 2011

n=50* = p < 0.05

Correlation: Matrix - inflammation?

Primary human fibroblast cell culture

7 days 14 days

P4HB+Vimentin +Desmin –CD 31-a SMA-

Des

min

Vim

entin

P4H

BC

D31

α-SM

A

Linder et al, Biochem Res Int 2012

Role of growth Factor-b (TGF- b)

*

n=8* p < 0.05

HFPEF – TGF-ß

HFPEF + TGF-ß*

*

Myofibroblast Kollagen IConnective Tissue growth factor


In vitro Fibroblastafter TGF-b Stimulation (alpha-SMA)

- TGF-ß + 5ng/ml TGF-ß, 24h + 5ng/ml TGF-ß, 72h

Risc factors forHF

Activation of inflammatory cells

CytokinesActivation of fibroblasts

Myofibroblasts

Collagen Akkumulation

Diastolic Dysfunction /Wall Stress

C. Tschöpe

Mechanism in heart failure:Fibrosis and Inflammation

Mechanic stress activates myofibroblasts

0% 2.5% 7.5% 10%

Strech intensity

Production of collagen


Mechanic stress induces chemokine production

2.5% 5% 7.5% 10%

0.0

0.5

1.0

1.5

2.0

2.5

3.0

ns

** ***

flexercell stretch, frequency 1 Hz

MC

P-1

m-R

NA

expr

essi

on le

vel

(x-fo

ld o

ver u

nstre

tche

d co

ntro

l)

2.5% 5% 7.5% 10% 12.5%

0.0

0.5

1.0

1.5

2.0

2.5

3.0

*

****

ns

flexercell stretch, frequency 1 HzM

CP-

3 m

-RN

A ex

pres

sion

leve

l(x

-fold

ove

r uns

tretc

hed

cont

rol)

Westermann et al 2012

Migration of lymphocytes following the supernatant of myofibroblasts


Increased actin polymerization of PBMCs as a sign of increased cell mobility after incubation with the supernatant of myofibroblasts

Incubated with medium

Supernatant of fibroblasts

Supernatant of myofibroblasts

Ph

allo

ido

n-F

ITC

vo

n h

um

ane

n L

ymp

ho

zyte

n

unpublished

* *

Direct adhesion of monocytes (THP-1) on myofibroblasts

Fibroblasts

Myofibroblasts

unpublished

Monocytes (Th1-Zellen) produce MMP-9 after treatement with the supernatant of myofibroblasts

α-SMA P4HB DAPI

MCP2-mRNA

*

control HFNEF0.000

0.005

0.010

0.015

0.020

gene

exp

ress

ion

MMP-2-mRNA

*

control HFNEF0.00

0.02

0.04

0.06

0.08

0.10

gene

exp

ress

ion

Identification of myofibroblasts in humanen cardiac biopsies

Control DHF

Controll DHF

Myofibroblasts

Migration and Chemotaxis

α-SMA P4HB DAPI

Myofibroblast

Number of myofibroblastscorrelates with the number of

invaded inflammatory cells


n = 75D EF: 27%

Identification of myofibroblasts in humanen cardiac biopsies

Riskfactors for HF


Myofibroblasts

FibrosisChemokines


ChemotaxisDegradationAdhesion

C. Tschöpe

CytokinseActivation of Fibroblasts

Fibrosis and Inflammation as a Circulus vitiosus

Increased expression of adhesionsmolecules after incubation of endothelial cells with the supernatant of myofibroblasts

VCAM

control CM c-FB CM c-myoFB

0

2

4

6

8

0

2

4

6

8***

treated HMEC cells

rela

tive m

RN

A level

[x-f

old

ove

r co

ntr

ol]

P<0.01, R=0.82

VCAM-1alpha-SMA

Endothelzellen für 24h behandelt mit konditioniertem Überstand


Endothelial dysfunction in vitro after stimulation with the supernatant of myofibroblasts

2.5%

2.5%

* vs. co


C. Tschöpe

Riscfactors for HF

Cardiac DysfunctionWall Stress

Activation ofinflammatory cells

Myofibroblasts

FibrosisChemokine

ChemotaxisDegradation

Adhesion

CytokinesActivated fibroblasts

Endothelial Activation

Myofibroblast and vascular in heart failure

LV Stiffness:Mechanisms

Matrix

Endothelium

Basal Ergonovine

C. Tschöpe

Myocyt

Titin function and inflammatory Stress

Paulus & Tschöpe JACC 2013

*

*

Myofibroblasts

TitinPhosphorylation

N =6 / group; *P<0,05

*

*

Becher et al, BRC in press

PLX restore hypophosphorylation of titin N2BA and N2B in STZ-induced diabetic mice

N2B

A ph

osph

oryl

atio

n%

PBS PLX

P<0.001P<0.001

P<0.001

Titin N2BAN

2B p

hosp

hory

latio

n%

PBS PLX

P<0.001P<0.001

P<0.001

Titin N2B

N2BA (3.3 MDa)

N2B (3.0 MDa)

N2BA (3.3 MDa)

N2B (3.0 MDa)

Control+PBS Control+PLXSTZ+PBS STZ+PLX

Phosphoprotein

Total protein

Passive force

C. Tschöpe

C. Tschöpe

Riscfactors for HF



Myofibroblasts

FibrosisChemokine


Adhesion

CytokinesOxidative Stress

TitinDephosphorylation



Myofibroblast and Inflammation in heart failure



HFPEF

HFPEF (Heart failure with preserved ejection fraction)

Adapted Fischer M Eur J Heat Fail 2002

Etiology of isolated diastolic dysfunction

26%

24%16%

14%

12%8%

LVHMIHyper-

tension

DMObesity

?

HFPEF

200 ml100500

160

80mm

Hg

C

200 ml100500

160

80mm

Hg

D

Tschöpe et al, Circulation 2005

Endothelial Dysfunction

LVEDPSteifigkeit

ABV:28 ABV:62

Basal Acethylcholine (7.2 µg/min)

Regular endothelial function

ABV:20 ABV:21

Endothelial Dysfunction

ABV: Average peak velocities

Reduced flow reserve and endothelial dysfunction in cardiacParvovirus B19 Infection

Vaskulotropism of PVB 19(In situ Hybridization)

Kandolf et al.

Apoptose zirkulierendermaturer Endothelzellen

p =0.004

Apop

totis

mat

ure

endo

thel

ial c

ells

(in

% o

f PM

NC

)

PV B19Kontrolle

0,07

0,06

0,05

0,04

0,03

0,02

0,01

0,00

Tschöpe et al, Circulation 2005

N = 60 /Gruppe; * p< 0.05

PVB 19 – infected endothelial progenitor cells

Schmidt-Lucke et al, 2012

Parv

oviru

sB

19 c

opie

s/ µ

g ge

nom

icD

NA

EBM Blut KM EBM Blut KM

CD 34+ CD34+KDR+

CD 34+ CD34+KDR+

CD 34+ CD34+KDR+

CD 34+ CD34+KDR+

5000

1000

015

000 KM

Endotheliale ProgenitorZellen

Nicht re-endotheliasierte Arealeder Carotis Läsion

0

500

1000

1500

2000

2500

3000

3500

4000

KontrolleEPC´s

B19VEPC´s

***

Den

udie

rte

Area

le d

er C

arot

is(a

rbitr

ary

units

)

Zobel et al, 2012

Endotheliale ProgenitorZellen

KM: Knochenmark; N = 15 Gruppe; kein Nachweis von PVB in CD 34 - Zellen EPC: endotheliale Progenitorzelle; n = 10 Gruppe; *** P< 0.001

Impact on impaired endothelial regeneration

26 nm

Elektronenmikroskopischer Nachweis von PVB 19in einer endothelialen Progenitorzelle

Vascular density and clinical symptoms in PV B 19 patients

Kontrolle

0,00

250,00

500,00

750,00

Gef

äßdi

chte

/cki

t+K

DR

+

n/m

m2

PV B19 mit

Angina

pectoris

PV B19 ohne

Angina

pectoris

P<0.05

Vascular density

P<0.05

Vascular densiry and anginapectors symptoms

Kontrolle

PVB19 pos

1:400

Schmidt-Lucke et al , 2012 in press

P<0.001

1:400

1 3

0.00

0.10

0.20

0.30

CD

106/

VC

AM

1

1 30.0

0.5

1.0

1.5

2.0

CD

54/IC

AM

1 ce

lls/m

m2

Control PVBDD

Control PVBDD

No myocardial inflammation in patients with and without diastolic dysfunction and viral persistance

Tschöpe, Noutsias et al. 2005

VCAM ICAM

ns ns

Mechansims ?

Fibrosis ?Inflammation ?

Endothelial Dysfunction ?

P < 0,033

1.0 2.0 3.0

0.0100

0.0200

0.0300

0.0400

0.0500

0.0600

Sti

ffne

ss

CO PVB+DD

PVB-DD

Cardiac passive stiffness Total collagen content

1.0 2.0 3.0

0.50

1.00

1.50

2.00

Sir

ius

Red

CO PVB+DD

PVB-DD

P < 0,006

LV stiffness and cardiac fibrosis in patients with and without diastolic dysfunction and viral persistance

Tschöpe, Westermann, Pauschinger et al. 2005

N=50 N=50 N=50N=18 N=50

% o

f tis

sue

N=18

P < 0,033

ns ns

VP1 Expression CD106/VCAM-1

Transgene Mausmodelle:Parvovirus B19 - induzierte Kardiomyopathie

Bock et al. 2012

*

IHC: Collagen I

VP1-Co

VP1-Dox

0.0000

0.0005

0.0010

0.0015

0.0020

AF in

%

Kollagen I

Model of inflammatory cardiomyopathy

Infektion and impaired EPC

imapired EPC / Apoptosis

EndothelialDysfunktion

EndothelialRegeneration

Reducedvascular density

Chronic IischemiaMigration of

myocytes

Fibroses/ Myocyte dysfunction

DCMi

Diastolic Dysfunction

Systolic Dysfunction

ChangedGenexpression

Viral Replication

C. Tschöpe

C. Tschöpe

Riscfactors for HF



Myofibroblasts

FibrosisChemokine


Adhesion

CytokinesOxidative Stress

TitinDephosphorylation



Myofibroblast and Inflammation in heart failure

Regeneration / Vessel density

Cardiac inflammation

Li et al. Eur J Pharmacol 2007Koch et al. Int Immunopharm 2010Riad et al. J Immunol 2011

Innate Immunsystem

TLR-4, -9TRIF, MYD-88

NOD2S100 A8/A9

Westermann et al. Circulation 2011Van Linthout et al. Eur Heart J 2011

Savvatis et al. PlosOne 2012

Regeneration

Development of new anti-inflammatory and antifibrotictherapy options for the future

MesenchymaleStromazelle

T reg´sCAP´s

IL: Interleukin, TNF; Tumor Nekrose faktor, TLR: Toll-like Rezeptor, NOD: Nucleotide-binding oligomerization domain-containing protein, MMP: Metalloproteinase,MSC: Mesenchymale Stromazelle, Treg´s: regulatve T-Zelle; CAP´s: cardiac derived adherent proliferating cell

Virustoxizity

Interferon ßTelvibudine

PV B19Coxsacki B

Cytokine-System

IL1β, IL2, IL4, IL6, IL10, IL23, TNFα

Matrix Proteine(MMP´s)

MMP-2, MMP-9Biglycan

Myofibroblast as a therapeutic target ?

CTGF (CCN2) upregulation in fibroblast after strech in vitro

Cooperation AG Poller, Charite, unpublished

New anti-CTGF intervention option in the futurevia cardiac RNA interefrence


Anti-CTGF RNAi knockdown normalizes chemokine production



Anti-CTGF RNAi knockdown normalizes collagen and MMP expression

Conclusion

1. Myofibroblasts are chemo-active, activates lymphocytes and can incuse endothelial dysfunction.

2. The number of myofibroblasts correlate with the degree of collagen expression as well as with the number of invading inflammatory cells in the heart.

3. Therefore, myofibroblasts are inflammatory supporter cells

4. They are a therapeutic target to modulate cardiac fibrosis and inflammation.

Thank you for your attention

Charite, Campus Benjamin Franklin, Kardiologie

Thanks

DankeDirk WestermannDiana LindnerChristine ZietschNadine OrinKerstin Puhl

Funded by:SFB TR 19 „Inflammatory Cardiomyopathy“EU FP7-call „Diastolic Heart Failure“

modifiziert nach: O`Neill et al., Nat Rev Immunol 2007,

Zellmembran/Endosommembran

Typ-I-Interferone(z.B. IFN-ß)

bakterielle und virale FragmenteOxidativer Stress

MyD88 TRIF TIR

IRAK

TRAF-6

NFkBIRFs

IRFs-P

pro-inflammatory cytokines(z.B. TNF-α, IL-1ß)

TLR1 TLR5 TLR6TLR2 TLR10TLR4TLR3

Innate Immunsystem:Toll-Like Receptors

http://images.google.de/imgres?imgurl=http://noe.chemie.at/welt/images/doppelhelix_gezeichnet.gif&imgrefurl=http://noe.chemie.at/welt/leben.htm&h=414&w=200&sz=21&hl=de&start=10&tbnid=3E8Ok0EtPbCvQM:&tbnh=125&tbnw=60&prev=/images?q=doppelhelix&gbv=2&ndsp=20&hl=de&sa=N




IschämieOxidativer Stress

MyD88 TRIFTIR

IRAK

TRAF-6

NFkBIRFs

IRFs-P

pro-inflammatorische Zytokine (z.B. TNF-α, IL-1ß)


Toll like Rezeptor 4 bei der ischämischen Kardiopathie


Das TLR System als kritischer Mortalitätsfaktorbeim Myokardinfarkt: Toll-like Rezeptor 4

C57BL/10ScN

Riad & Tschöpe et al. Journal of Immunology 2008

0 10 20 300

50

100

TLR4-/-

Wildtypen

p<0.0001

Tage post Herzinfarkt

Übe

rlebe

n in

Pro

zent

TLR4

TLR4 -/-

TLR4 -/-

n = 25 / Gruppe

Immunzellen

AKT

Apoptose(Tunnel)

JNK

Projektförderung: TR-SFB 19: B5/Z3




bakterielle und virale Fragmente

MyD88 TRIF TIR

IRAK

TRAF-6

NFkBIRFs

IRFs-P

pro-inflammatorische Zytokine (z.B. TNF-α, IL-1ß)


TIR domain-containing adaptor inducing IFN-ß (TRIF)bei der viralen Myokarditis


TIR domain-containing adaptor inducing IFN-ß (TRIF) bei der viralen Myokarditis

Riad & Tschöpe et al. Journal of Immunology 2011

0 20 40 60 800

25

50

75

100 WT-CVB3

KO-CVB3*

Days

Perc

ent s

urvi

val

TRIF-/-Coxsackievirus (5*105 PFU i.p.)

0 20 40 60 800

25

50

75

100 WT-CVB3

KO-CVB3

KO-CVB3-IFN

*

#

Days

Perc

ent s

urvi

val

Co-3d

TRIF-3d

Co-3d-C

VB3

TRIF-3d-C

VB30

3.5×10 -7

7.0×10 -7 *

IFN

-ß m

RN

A/1

8S

TRIF-/-CBV

TRIF+/+CVB

Kardiale Entzündungsreaktion

Projektförderung: TR-SFB 19: B5/Z3

TRIF+/+

http://www.funkfoto.ch/Bilder/Still Life/spritze_01.JPG

Mögliche zukünftige therapeutische Ansätze

B1 AntagonistenTLR Rezeptor Antagonisten

Interferone

Stress

Endotheliale Aktivierung

Pro-inflammatorischeZytokine

Spezifische Immun-reaktion

Kardiale Dysfunktion

RemodelingHypertophie,

Fibrose,Apoptose

Zelltherapeutischen Ansatz ?

ZytokininhibitorenNO Enhancer

p38 Inhibitorenselekt. MMP-Inhibitoren

Immunmodulatorische Effekte von mesenchymalen Stammzellen

Diabetes mellitusPneumonie

ArthritisMultiple Sklerose

TransplantationNiereninsuffizienz

Infarkt

Review: Abdi et al. Diabetes 2008

Role of mechanic stress

0% 2.5% 7.5% 10%

Stretch

Stimulation ofcollagene production

Stretch

2.5% 5% 7.5% 10% 12.5%

0.0

1.0

2.0

3.0

4.0

ns

*****

*

flexercell-stretch, frequence 1Hz

MC

P-1

pro

tein

con

tent

(x-f

old

over

uns

tret

ched

con

trol

)

Stimulation ofchemokines production


Myofibroblast and endothelial activation

VCAM

control CM c-FB CM c-myoFB

0

2

4

6

8

0

2

4

6

8***

treated HMEC cells

rela

tive m

RN

A level

[x-f

old

ove

r co

ntr

ol]


P<0.01, R=0.82

α-SMA P4HB DAPI

Endothelial Dysfunction in vitro

2.5%

2.5%

* vs. co


Riskfactors for HF


Myofibroblasts

FibrosisChemokines


ChemotaxisDegradationAdhesion

C. Tschöpe

CytokinseActivation of Fibroblasts

Fibrosis and Inflammation as a Circulus vitiosus Identification of myofibroblasts in humanen cardiac biopsies

When is the Parvo B19 infection ofthe heart of clinical significance?

n=297/498 (59.6%) n=176/498 (35.3%)

709 +/-828

392 +/-317

84 +/-49

n= 7/91 (7.7%)

3,2x105 +/-8,2x105

P<0,0001

n= 25/498 (5.0%)

***

******

chronic

Myocarditis

dilated

Cardiomyopathycontrols

acute

Myocarditis

B19

V G

E /

µg N

A

P<0,0001

P<0,0001

Kardiale Parvovirus B19 – DNA Last von Patienten mitMyokarditis oder inflammatorischer dilatativer Kardiomyopathie

500

GE

/µg

Bock et al NEJM 2010

1.0×10 0

1.0×10 1

1.0×10 2

1.0×10 3

1.0×10 4

1.0×10 5

1.0×10 6

1.0×10 7

Virus Typen spezfische Reaktion auf eine Interferon-Therapie

n “Clearance” Virus Last Reduktion

Gesamt 88 40 (46%) 57 (65%)

Enterovirus 24 24 (100%)

Adenovirus 9 9 (100%)

Parvovirus 55 7 (14%) 17/55 (31%)

Kühl et al 2012

B19

V VP

1 m

RN

AM Mac

ute

myo

card

itis

iCM

P>5

00 G

E/µg

DC

M<5

00 G

E/µg

DC

M<1

00 G

E/µg

nega

tive

cont

rol

1118

501

242190

147

110

bp

Nachweis von Parvovirus B 19 mRNA in endomyokardialen BiopsienHinweis auf aktive Replikation

Bock et al 2010Kühl et al 2012

0255075

100125150175200225250

%

Erythrovirus negativ Erythrovirus positiv ohne Replikation

Regulation der Genexpression bei transkribierter Parvovirus-RNA

C. Tschöpe

PVB19-Rezeptor

Zytokine AtmungskettengeneAdiponectinCarnitin

0255075

100125150175200225250

%

Erythrovirus negativ Erythrovirus positiv ohne Replikation Erythrovirus positiv mit Replikation

Regulation der Genexpression bei transkribierter Parvovirus-RNA

PVB19-Rezeptor

Zytokine AtmungskettengeneAdiponectinCarnitin

** *

**

*

* *

*

*

*

**

*

*

**

*

*

C. Tschöpe

Neue Therapie Option ?

Nucleosid Analogon:

Telbivudine

C. Tschöpe

Telbivudine Treatment of

Parvovirus B19-positive

Cardiomyopathy

Pilotstudie

C. Tschöpe

Baseline biopsy Follow up biopsy pB19V load (copies/µg DNA)

2543 1188 <0.05

B19V mRNA (copies/µg RNA)

249 0 <0.01

B19V load in patients with silencedtranscriptional activity (B19V-mRNA) during Telbivudine treatment

Effekt von Telvibudine in behandeltenPatienten mit chronischer kardialer Parvovirus B19 Infektion

n = 30

C. Tschöpe

Telbivudine Treatment of Parvovirus B19-positive Cardiomyopathy

Phase II Studie

Berlin

Göttingen

LübeckHamburg

Heidelberg

Greifswald

ToPIC - Study

C. Tschöpe

Kiel

DCM (EF < 45%; > 6 Monate)PVB mRNA positiv

N = 100

DCMPVB mRNA positiv

N = 50

DCMPVB mRNA positiv

N = 50 Plazebo Telbivudine

DCMPVB mRNA positiv

N = 50

DCMPVB mRNA positiv

N = 50 PlazeboTelbivudine

Nach 6 Monaten:Prim. Endpunkt : EF (Echo / Core Lab)

Sek. Endpunkt : QOL (KK-Score), PVB-Virus Replikation / Entzündung ( Re Biopsie)

Follow up nach 6 Monaten:Prim. Endpunkt : EF (Echo / Core Lab)

Sek. Endpunkt : QOL (KK-Score), PVB-Virus Replikation / Entzündung ( Re Biopsie)

Telbivudine Treatment of Parvovirus B19-positive Cardiomyopathy

C. Tschöpe

Owan T et al. N Engl J Med 2006;

Heart failure treatment today?

HREF HFPEF

Identification of new mechanismsPersonalized medicine / Biopsy-guided

Genetic/EpigenticSysteme medicine

Task

Merci

Kooperationspartner/Funding:

TR-SFB 19: inflammatorischeKardiomyopathieBCRT/BMBF: Immunsystem u. HerzEU FP7: Diabetes mellitus u. diastolische Herzinsuffizienz EU FP7: Stammzelle u. Diabetes mellitusDZHK: InflammatorischeKardiomyopathie

PVB19 genomes were predominant in patients with unexplainedisolated diastolic dysfunction in our study group.

A strong association with the incidence of endothelial dysfunctionwas obvious, consistent with the hypothesis that PVB19-inducedendothelial dysfunction may be a possible pathomechanismunderlying diastolic dysfunction.

Summary and Conclusion

AdiponectinCarnitin

PVB19Rezeptor

Zytokine Atmungsketten-Enzyme ApoptoseMitochondrium

Gegenregulation der Gene nach Abklingen der PVB19-mRNA (Follow-up Biopsien)

C. Tschöpe

AdiponectinCarnitin

PVB19Rezeptor

Zytokine Atmungsketten-Enzyme ApoptoseMitochondrium

Gegenregulation der Gene nach Abklingen der PVB19-mRNA (Follow-up Biopsien)

*

C. Tschöpe

Inflammatory Cardiomyopathy Conclusion I

-The detection of viral genome and or inflammation in the myocardium has been shown by multivariate regression analysis to be an independent predictorof clinical outcome.

- This cannot be detected by echo/MRI

- However, any rational immunomodulatory therapeutic regimen for inflammatory cardiomyopathy must consider the underlying pathogenesis based on

- histological, - immunohistological and - viral

evaluation of endomyocardial biopsies.

Inflammatory Cardiomyopathy Conclusion III

Cardiac Adherent Proliferating Cells (CAP´s):

Haag et al. J Cell Biochemistry 2010

Gen Expressionsmuster und FACS Analyse

Anti-fibrotische und anti-entzündliche Effekte

Milteva et al. PLOS One 2011

FibroblastenProliferation

MyofibroblastTransdifferentiation

Kollagensynthese

FIBROSE

α-S

MA

DiO

+ ce

lls(%

gat

ed

cells

)

monoculture+CAPs

P<0.001

CAP cells

monoculture+CAPs

Teilu

ngs

ind

ex

P<0.001

Personalised medicine inDilated Cardiomyopathy

DCM

Virus negativeInflammation negative

Virus positive

inflammation positive

Perforin +

Perforin -

immun-suppr.

therapy

sympt. therapy

Interferon-level ↑

Interferon-level ↓

TLR-mutations

mi-RNAProfile

mutation-screening

sympt.therapy

antiviraetherapy

risc-stratification

sympt. and/orrisic adjusted

therapy

CoxsackieVirus

ParvoVirus

Interferon ß Telbivudine

Schultheiss et al EHJ, 2011

Susceptibility and inhibitory concentration (IC) of Telbivudine on parvovirus B19 replication in endothelial cell culture experiments

IC50 < 0.001 µg (2 µM)comparable to HBV

Proposed mechanisms of telbivudineDetermination of IC50 of telbivudine in cell cell culture

Telbivudine can probably interact with DNA-synthesis during rolling hairpinreplication

Telbivudine can probably interact with host immune system to control B19V replication

0,000

0,200

0,400

0,600

0,800

1,000

1,200

control 100 ng/ml 1 µg/ml 5 µg/ml 10 µg/ml 20 µg/ml 50 µg/ml

´re

l. co

nz. B

19V

VP2

mR

NA

IC50 ~ 2.5 µg/ml

P>0.001

conz. Telbivudine

Inhibition of Parvovirus B19 Replication by Telbivudine Treatment in B19V-infected endothelial Cell Culture (hMEC-1)

Clinical improvement of Telbivudine-treated patientswith subacute/chronic disease, n=7*

(Telbivudine treatment: 24 weeks, n=7)

Kardiale Inflammation

Zytokin-System

IL1β, IL2, IL4, IL6, IL10, IL23, TNFα

Li et al. Eur J Pharmacol 2007Koch et al. Int Immunopharm 2010Riad et al. J Immunol 2011

AngeboreneImmunsystem

TLR-4, -9TRIF, MYD-88

NOD2S100 A8/A9

Matrix Proteine(MMP´s)

MMP-2, MMP-9Biglycan

Westermann et al. Circulation 2011Van Linthout et al. Eur Heart J 2011

Savvatis et al. PlosOne 2012

Regeneration

Entwicklung neuer Interventionsziele zurTherapieoptimierung der Zukunft bei der Herzinsuffizienz

Virustoxizität

Interferon ßTelvibudine

MesenchymaleStromazelle

T reg´sCAP´s

PV B19Coxsacki B

IL: Interleukin, TNF; Tumor Nekrose faktor, TLR: Toll-like Rezeptor, NOD: Nucleotide-binding oligomerization domain-containing protein, MMP: Metalloproteinase,MSC: Mesenchymale Stromazelle, Treg´s: regulatve T-Zelle; CAP´s: cardiac derived adherent proliferating cell

Clinical improvement of Telbivudine-treated patientswith subacute/chronic disease, n=7*

(Telbivudine treatment: 24 weeks, n=7)

p = 0.080

LV-E

F (%

)

0

10

20

30

40

50

60

baseline week 4 week 12 week 24

LV-EF

Hemodynamic changes in Telbivudine-treated Patients with subacute/chronic disease

* Acute B19V infections excluded

Symptomatic improvement (QoL)

Lebensqualität - gesamt- ohne den (grau dargestellten) Patienten mit psych. Begleiterkrankung -

0

10

20

30

40

50

60

70

80

90

100

0 12 24

nied

riger

Pun

ktw

ert =

bes

sere

Leb

ensq

ualit

ät

Minnessota Quality of Life

0 12 24

Scor

e

Weeks of treatment

Susceptibility and inhibitory concentration (IC) of Telbivudine on parvovirus B19 replication in endothelial cell culture experiments

IC50 < 0.001 µg (2 µM)comparable to HBV

Determination of IC50 of telbivudine in cell cell culture

Veränderung der kardialen Genexpression ist assoziiert mit transkribierter Parvovirus-RNA

B19

V VP

1 m

RN

A

M Macut

em

yoca

rditi

siC

MP

>500

GE/

µgD

CM

<500

GE/

µgD

CM

<100

GE/

µgne

gativ

e co

ntro

l

1118

501

242190147110

bp

Nachweis von Parvovirus B 19 mRNA in endomyokardialen Biopsien:Hinweis auf aktive Replikation

In situ Hybridisierung(PVB DNA)

Bock et al 2010Kühl et al 2012

α-SMA P4HB DAPI

Nachweis von aktivierten Myofibroblasten in humanenendomyokardialen Biopsien

Myofibroblast

Myofibroblasten Anzahlkorreliert mit endomyokardialer

Inflammationsreaktion


n = 75D EF: 27%

Documents

Inflammation in heartfailure: Focus on fibroblasts · Carsten Tschöpe. Kardiologie, Campus Benjamin Franklin. Inflammation in heartfailure: Focus on fibroblasts. Berlin