Panagiotis Efentakis1,2,3, Aimilia Varela4, Evangelia Chavdoula4, Fragiska Sigala5, Despina Sanoudou6, Roxane Tenta7, Katerina Gioti7, Nikolaos Kostomitsopoulos4, Andreas Papapetropoulos1,4, Androniki Tasouli8, Dimitrios Farmakis9,10, Costantinos H Davos4, Apostolos Klinakis4, Thomas Suter11, Dennis V Cokkinos4, Efstathios K Iliodromitis9, Philip Wenzel2,3, Ioanna Andreadou1. 1. National and Kapodistrian University of Athens, Laboratory of Pharmacology, Faculty of Pharmacy, Panepistimiopolis, Zografou, Athens 15771, Greece. 2. Center of Cardiology, Cardiology 2, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany. 3. Center of Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany. 4. Biomedical Research Foundation, Academy of Athens, Clinical, Experimental Surgery & Translational Research Center, Athens, Greece. 5. First Department of Surgery, National and Kapodistrian University of Athens Medical School, Athens, Greece. 6. 4th Department of Internal Medicine, Clinical Genomics and Pharmacogenomics Unit, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece. 7. School of Health Sciences and Education, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece. 8. Onassis Cardiac Surgery Center, Athens, Greece. 9. Second Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Athens University Hospital "Attikon", Athens, Greece. 10. School of Medicine, European University of Cyprus, Nicosia, Cyprus. 11. Department of Cardiology, Bern University Hospital, Bern, Switzerland.
Abstract
AIMS: Levosimendan (LEVO) a clinically-used inodilator, exerts multifaceted cardioprotective effects. Case-studies indicate protection against doxorubicin (DXR)-induced cardiotoxicity, but this effect remains obscure. We investigated the effect and mechanism of different regimens of levosimendan on sub-chronic and chronic doxorubicin cardiotoxicity. METHODS AND RESULTS: Based on preliminary in vivo experiments, rats serving as a sub-chronic model of doxorubicin-cardiotoxicity and were divided into: Control (N/S-0.9%), DXR (18 mg/kg-cumulative), DXR+LEVO (LEVO, 24 μg/kg-cumulative), and DXR+LEVO (acute) (LEVO, 24 μg/kg-bolus) for 14 days. Protein kinase-B (Akt), endothelial nitric oxide synthase (eNOS), and protein kinase-A and G (PKA/PKG) pathways emerged as contributors to the cardioprotection, converging onto phospholamban (PLN). To verify the contribution of PLN, phospholamban knockout (PLN-/-) mice were assigned to PLN-/-/Control (N/S-0.9%), PLN-/-/DXR (18 mg/kg), and PLN-/-/DXR+LEVO (ac) for 14 days. Furthermore, female breast cancer-bearing (BC) mice were divided into: Control (normal saline 0.9%, N/S 0.9%), DXR (18 mg/kg), LEVO, and DXR+LEVO (LEVO, 24 μg/kg-bolus) for 28 days. Echocardiography was performed in all protocols. To elucidate levosimendan's cardioprotective mechanism, primary cardiomyocytes were treated with doxorubicin or/and levosimendan and with N omega-nitro-L-arginine methyl ester (L-NAME), DT-2, and H-89 (eNOS, PKG, and PKA inhibitors, respectively); cardiomyocyte-toxicity was assessed. Single bolus administration of levosimendan abrogated DXR-induced cardiotoxicity and activated Akt/eNOS and cAMP-PKA/cGMP-PKG/PLN pathways but failed to exert cardioprotection in PLN-/- mice. Levosimendan's cardioprotection was also evident in the BC model. Finally, in vitro PKA inhibition abrogated levosimendan-mediated cardioprotection, indicating that its cardioprotection is cAMP-PKA dependent, while levosimendan preponderated over milrinone and dobutamine, by ameliorating calcium overload. CONCLUSION: Single dose levosimendan prevented doxorubicin cardiotoxicity through a cAMP-PKA-PLN pathway, highlighting the role of inotropy in doxorubicin cardiotoxicity. Published on behalf of the European Society of Cardiology. All rights reserved.
AIMS: Levosimendan (LEVO) a clinically-used inodilator, exerts multifaceted cardioprotective effects. Case-studies indicate protection against doxorubicin (DXR)-induced cardiotoxicity, but this effect remains obscure. We investigated the effect and mechanism of different regimens of levosimendan on sub-chronic and chronic doxorubicincardiotoxicity. METHODS AND RESULTS: Based on preliminary in vivo experiments, rats serving as a sub-chronic model of doxorubicin-cardiotoxicity and were divided into: Control (N/S-0.9%), DXR (18 mg/kg-cumulative), DXR+LEVO (LEVO, 24 μg/kg-cumulative), and DXR+LEVO (acute) (LEVO, 24 μg/kg-bolus) for 14 days. Protein kinase-B (Akt), endothelial nitric oxide synthase (eNOS), and protein kinase-A and G (PKA/PKG) pathways emerged as contributors to the cardioprotection, converging onto phospholamban (PLN). To verify the contribution of PLN, phospholamban knockout (PLN-/-) mice were assigned to PLN-/-/Control (N/S-0.9%), PLN-/-/DXR (18 mg/kg), and PLN-/-/DXR+LEVO (ac) for 14 days. Furthermore, female breast cancer-bearing (BC) mice were divided into: Control (normal saline 0.9%, N/S 0.9%), DXR (18 mg/kg), LEVO, and DXR+LEVO (LEVO, 24 μg/kg-bolus) for 28 days. Echocardiography was performed in all protocols. To elucidate levosimendan's cardioprotective mechanism, primary cardiomyocytes were treated with doxorubicin or/and levosimendan and with N omega-nitro-L-arginine methyl ester (L-NAME), DT-2, and H-89 (eNOS, PKG, and PKA inhibitors, respectively); cardiomyocyte-toxicity was assessed. Single bolus administration of levosimendan abrogated DXR-induced cardiotoxicity and activated Akt/eNOS and cAMP-PKA/cGMP-PKG/PLN pathways but failed to exert cardioprotection in PLN-/- mice. Levosimendan's cardioprotection was also evident in the BC model. Finally, in vitro PKA inhibition abrogated levosimendan-mediated cardioprotection, indicating that its cardioprotection is cAMP-PKA dependent, while levosimendan preponderated over milrinone and dobutamine, by ameliorating calcium overload. CONCLUSION: Single dose levosimendan prevented doxorubicincardiotoxicity through a cAMP-PKA-PLN pathway, highlighting the role of inotropy in doxorubicincardiotoxicity. Published on behalf of the European Society of Cardiology. All rights reserved.
Authors: Panagiotis Efentakis; Michael Molitor; Sabine Kossmann; Magdalena L Bochenek; Johannes Wild; Jeremy Lagrange; Stefanie Finger; Rebecca Jung; Susanne Karbach; Katrin Schäfer; Andreas Schulz; Philipp Wild; Thomas Münzel; Philip Wenzel Journal: Eur Heart J Date: 2022-02-10 Impact factor: 29.983