Sheet-Like Remodeling of the Transverse Tubular System in Human Heart Failure Impairs Excitation-Contraction Coupling and Functional Recovery by Mechanical Unloading
Background—Cardiac recovery in response to mechanical unloading by left ventricular assist devices (LVADs) has been demonstrated in subgroups of chronic heart failure (HF) patients. Hallmarks of HF are depletion and disorganization of the transverse tubular system (t-system) in cardiomyocytes. Here, we investigated remodeling of the t-system in human end-stage HF and its role in cardiac recovery.
Methods—Left ventricular biopsies were obtained from 5 donors (CTRL) and 26 chronic HF patients undergoing implantation of LVADs. Three-dimensional confocal microscopy and computational image analysis were applied to assess t-system structure, density, and distance of ryanodine receptor (RyR) clusters to the sarcolemma, including the t-system. Recovery of cardiac function in response to mechanical unloading was assessed by echocardiography during turn-down of the LVAD.
Results—The majority of HF myocytes showed remarkable t-system remodeling, particularly sheet-like invaginations of the sarcolemma. Circularity of t-system components was decreased in HF vs CTRL (0.37±0.01 vs 0.46±0.02, p<0.01), and the volume/length ratio was increased in HF (0.36±0.01µm2 vs 0.25±0.02µm2, p<0.0001). T-system density was reduced in HF, leading to increased RyR-sarcolemma distances (0.96±0.05µm vs 0.64±0.1µm, p<0.01). Low RyR-sarcolemma distances at time of LVAD implantation predicted high post-LVAD left-ventricular ejection fractions (EF, p<0.01) and EF increase during unloading (p<0.01). EF in patients with pre-LVAD RyR-sarcolemma distances larger than 1µm did not improve following mechanical unloading. Additionally, calcium transients were recorded in field-stimulated isolated human cardiomyocytes and analyzed with respect to local t-system density. Calcium release in HF myocytes was restricted to regions proximal to the sarcolemma. Local calcium upstroke was delayed (23.9±4.9ms vs 10.3±1.7ms, p<0.05) and more asynchronous (18.1ms±1.5ms vs 8.9±2.2ms, p<0.01) in HF cells with low t-system density versus cells with high t-system density.
Conclusions—The t-system in end-stage human HF presents a characteristic novel phenotype consisting of sheet-like invaginations of the sarcolemma. Our results suggest that the remodeled t-system impairs excitation-contraction coupling and functional recovery during chronic LVAD unloading. An intact t-system at time of LVAD implantation may constitute a precondition and predictor for functional cardiac recovery following mechanical unloading.
- Received July 13, 2016.
- Revision received November 3, 2016.
- Accepted December 14, 2016.