Abstract Background Cardiac lymphatic systems play an important role in maintaining myocardial fluid homeostasis during inflammation. We have recently reported the epicardial adipose tissue (EAT)-derived factor induces inflammation and fibrosis in atrial myocardium, which lead to atrial fibrillation (AF). However, the direct effect of EAT on the cardiac lymphatic endothelial cells (LECs) remains unknown. Objective To elucidate the effect of EAT on cardiac LECs, as one of the potential causes of AF. Methods Human EAT samples were collected from 18 consecutive patients with or without AF patients during cardiovascular surgery. They were categorized into the sinus rhythm (SR) group (n=9, 72.7±8.6 years) and the AF group (n=9, 73.3±7.4 years). Preadipocytes were extracted from EAT by homogenization and collagenase treatment, and cultured to confluence. After differentiation to mature adipocytes, cell culture supernatant was collected, and cultured with human LECs. Cell permeability was measured by using FITC-dextran assay. Tube forming ability was analyzed by seeding LECs on the extracellular matrix gels. Metabolomic profiling of LECs was performed by GC-MS system. Results RT-PCR analysis revealed that cell culture supernatant from mature adipocytes of AF patients significantly increased mRNA expression of mesenchymal marker, TAGLN/SM22a (p<0.01) in human LECs, whereas mRNA expression of lymphatic endothelial markers, LYVE1 (p=0.0552) and PROX1 (p=0.0231) were decreased in human LECs, compared to those from mature adipocytes of SR patients. These data suggest cell culture supernatant from mature adipocytes of AF patients highly induce endothelial-to-mesenchymal transition (EndMT) of LECs. When assessing the endothelial barrier function by using FITC-dextran, cell culture supernatant from mature adipocytes of AF patients significantly decreased cell barrier function (p<0.01) compared to those from mature adipocytes of SR patients. Furthermore, cell culture supernatant from mature adipocytes of AF patients significantly decreased the tube forming ability of LECs (p<0.01) compared to those from mature adipocytes of SR patients. To assess the metabolomic changes in human LECs by EAT-secretome, we conducted the GC/MS analysis. Cell culture supernatant from mature adipocytes of AF patients significantly decreased several amino acids including branched-chain amino acid (BCAA; valine, leucine and isoleucine), compared to those from mature adipocytes of SR patients. Conclusion Our study with human EAT and LECs demonstrated that EAT-secretome from AF patients altered metabolomic profile in LECs, and highly caused EndMT in LECs, leading to impaired barrier function and the tube forming ability. Defects of lymphangiogenesis could be a therapeutic target for atrial cardiomyopathy.

Abstract Background Glucose fluctuations (GF) is known to be the significant factor related to poor cardiovascular outcome in the diabetic patients. We investigated the potential impact of GF on paracrine effect of human epicardial adipocyte on cardiomyocyte. Methods Human EAT biopsies obtained during surgery and isolated preadipocyte/adipocytes were used to evaluate the direct impact of GF on the adipocytes. Matured adipocytes were exposed to the media containing normal glucose (100 mg/dl, NG), high glucose (300 mg/dl, HG), or high-low glucose (75-300 mg/dl, GF) for 1 week. Transcriptomic profiling of the cultured matured adipocyte was performed using microarray analysis. The impact of GF on the paracrine effect of adipocyte was evaluated using a co-culture with human iPS-derived atrial cardiomyocytes and the adipocytes. Clinical association study verified the validity of the findings. Results GF for 1 week altered the expression of 595 differentially expressed genes (up-regulated or down-regulated) with an effect size of >50% or `−50% and a significant statistical difference (P < 0.05) in human epicardial adipocytes, while the continuous HG for 1 week altered the expression of only 182 differentially expressed genes. Of the genes affected by GF, top 3 most affected genes included IL1β, IL33, IL8. Regarding the other major pro-inflammatory cytokines, IL1α, CCL2 and IL6 were also significantly increased in the adipocyte treated with GF, however these were not increased in the adipocyte treated with HG. Co-culture of human iPS cell-derived atrial cardiomyocytes and adipocytes treated with NG, HG and GF revealed that GF-treated adipocyte strikingly increased oxidative stress in the cardiomyocyte through the paracrine effect. In the real-world clinical association study, IL1β mRNA expression in human epicardial adipose tissue showed significant positive correlation with the severity of GF during hospitalization and oxidative stress in the left atrial myocardium. Conclusions GF adversely affect the paracrine secretome profile of human epicardial adipocyte. IL1β may be a critical epicardial adipocyte-derived adipokine that is enhanced by GF.

Abstract Background Cardiac lymphatics maintains myocardial fluid and immune cell homeostasis. Downregulation of cardiac lymphatics leads to cardiac dysfunction through impairment of inflammation and edema. On the other hand, it is well known that adipose tissue accumulation causes lymphatic dysfunction and impairs lymphedema. Purpose We evaluated the expression of atrial lymphatics in human left atrial appendage (LAA) histologically and biologically. Subsequently, we examined secretomes from epicardial adipose tissue (EAT)-derived adipocytes and validated if they change atrial lymphatics expression using ex vivo Organo-culture system. Methods Human LAA samples were collected from forty-two patients during cardiovascular surgery. They were categorized into the sinus rhythm (SR) group (n=16, 73.1±10.4 years), the paroxysmal AF (PAF) group (n=13, 69.8±12.6 years) and the persistent AF (PeAF) group (n=13, 71.2±6.5 years). Human EAT were also excised from patients with and without AF (SR; n=5, AF; n=11) during cardiovascular surgery. Preadipocytes were extracted from EAT by homogenization and collagenase treatment, and cultured to confluence. After differentiation and maturation to adipocytes, cell culture supernatant (CCS) was collected, and was dropped onto the epicardial side of left atrial tissues excised from 8 weeks old male rats for 7 days using an ex vivo organo-culture system. Results In human LAA samples, mRNA expression of lymphangiogenesis-related genes (LYVE1, PROX1, VEGFC, and VEGFR3) was significantly lower in the PeAF group compared to the SR group (p=0.0370, <0.0001, 0.0157, and 0.0009). The number of LYVE1-positive atrial lymphatic endothelial cells (LECs) was also significantly lower in the PeAF group compared to the SR group and the PAF group (p=0.0186 and 0.038). There was a negative correlation between the number of LYVE1-positive atrial LECs and the area percentage of atrial myocardial fibrosis (r=-0.5350, p<0.001). In the experiment using organo-culture system, lymphangiogenesis-related genes expression (Lyve1, Prox1, Vegfc, and Vegfr3) of rat atria treated with CCS of adipocytes from AF patients was significantly lower than those from SR patients (p=0.0391, 0.0100, 0.0034, and 0.0338). Furthermore, the CCS of adipocytes from AF patients contained higher protein levels of leptin, which is known to suppress lymphangiogenesis (p=0.0357). Leptin treatment (100ng/ml) on rat atria also decreased lymphangiogenesis-related genes expression such as Lyve1, Prox1, Vegfc, and Vegfr3 (p=0.0413, < 0.0001, <0.0001, and 0.0190). Conclusions Our study with human LAA demonstrated that atrial lymphatics interact with atrial myocardial fibrosis/progression of AF. Furthermore, our findings indicate that secretomes from EAT-derived adipocytes regulate atrial lymphatics expression, and leptin plays an important role in modulating atrial lymphangiogenesis.

Abstract Background Postoperative atrial fibrillation (POAF) occurs in 20-50% after cardiovascular surgery and is associated with the short and long-term morbidity/mortality. The epicardial adipose tissue (EAT) may have a potential role to regulate the incidence of POAF. Purpose We explored the possible role of human epicardial adipocyte-derived adipokines in the regulation of the myocardial redox state and POAF. Methods We prospectively evaluated 149 patients without known AF who underwent scheduled open-heart cardiovascular surgery between May 2020 and November 2022. They were divided into POAF or Non-POAF group and followed up after discharge (476.6 ± 290.0 days). POAF was defined as AF lasting more than 30 seconds after the surgery. Human EAT samples were obtained from these patients during surgery and the preadipocytes were isolated. Preadipocytes were terminally differentiated to mature adipocytes and mRNAs were extracted. Genome-wide expression profiling of 6 vs. 6 matched samples of the POAF and Non-POAF groups was performed using Microarray analysis, and the results were validated with qPCR in all the cohort samples. The effects of secreted adipokines on the cardiomyocytes were assessed in terms of oxidative stress. Superoxide and whole reactive oxygen species (ROS) were evaluated with luminometry and live-cell fluorescent probes respectively. As the oxidative stress associated signalling, the phosphorylation of ERK and p38-MAPK were evaluated with western blotting. Angiotensin II (Ang-II) was used to induce oxidative stress and phosphorylation of MAPK. Results POAF was observed in 53 patients (36%). Microarray analysis (n = 6) revealed that there were 132 down- or up-regulated cording genes in epicardial adipocytes of the POAF group compared to the Non-POAF group. Of these genes, 11 genes cording secretable molecules were validated by qPCR (n = 69), showing that only SPARCL1 had significantly downregulated in the POAF group compared to the Non-POAF group (P = 0.005). Superoxide and ROS were induced by Ang II (P < 0.01) and attenuated by SPARCL1 dose-dependent manner (P < 0.01) in neonatal rat cardiomyocytes. The phosphorylation of ERK and p38-MAPK were induced by Ang II (P < 0.01) and attenuated by SPARCL1 (P < 0.01) dose-dependently. Co-culture of human induced pluripotent stem cell-derived atrial cardiomyocytes (iPS-ACM) and human epicardial adipocytes revealed that the adipocytes derived from Non-POAF group suppressed the superoxide (P = 0.002) and ROS (P = 0.02) in iPS-ACM compared to POAF group. Kaplan-Meier survival analysis revealed that the POAF group (P = 0.01) and low SPARCL1 expression in epicardial adipocytes (P = 0.018) were associated with a higher incidence of long-term adverse cardiovascular events after surgery. Conclusion: SPARCL1 derived from epicardial adipocytes may play an important role in the suppression of POAF and long-term cardiovascular events via improving the myocardial redox state.

Abstract Background/Introduction Cardiac lymphatics maintain myocardial fluid and immune cell homeostasis, but its effects on atrial fibrosis and atrial fibrillation (AF) have not been clarified. Purpose To address this issue, we first evaluated the left atrial appendage (LAA) in humans histologically and biologically. We then studied mice to elucidate the mechanisms. Methods Human LAA samples were collected from 34 consecutive AF patients during cardiovascular surgery. They were assigned to the paroxysmal AF (PAF) group (n=17, 70.9±11.6 years) and the persistent AF (PeAF) group (n=17, 72.1±7.2 years). In the mouse experiments, 8-week-old male C57BL/6 mice were administrated subcutaneously with vehicle or Angiotensin II (AngII) (2.0 mg/kg/day) for 4 weeks. In some mice, VEGFC, a pro-lymphangiogenesis inducer, was administrated subcutaneously at a dose of 50 μg/kg/day simultaneously with AngII. AF was induced by transesophageal burst pacing in vivo, and by burst pacing in isolated perfused hearts using a Langendorff apparatus. Results In human LAA samples, mRNA expression of lymphangiogenesis-related genes (LYVE1, PROX1, and VEGFR3) was significantly lower in the PeAF group compared to the PAF group (p=0.037, 0.029, and 0.041). The number of LYVE1-positive atrial lymphatic endothelial cells (LECs) was also significantly lower in the PeAF group compared to the PAF group (p=0.026). There was a negative correlation between the number of LYVE1-positive atrial LECs and the area percentage of atrial myocardial fibrosis (r=-0.609, p<0.001). In mouse experiments, continuous infusion of AngII suppressed the mRNA expression of lymphangiogenesis-related genes, including Lyve1, Prox1, and Vegfr3 (n=6 in each group, p<0.001, p=0.003, and p<0.001, respectively). AngII infusion reduced the number of LYVE1-positive atrial LECs (p<0.001) and increased the mRNA expression of fibrosis-related genes (Tgfb, Col1a1, and Col3a1). The area percentage of fibrosis in atrial myocardium was also increased by AngII. Treatment with VEGFC for 4 weeks effectively reversed the effects of AngII, i.e., suppression of lymphangiogenesis-related genes expression, reduction of LYVE1-positive atrial LECs, increase in fibrosis-related genes expression, and increase in atrial fibrosis. Additionally, VEGFC treatment attenuated AngII-induced enhancement of vulnerability to AF in in vivo experiments (n=8 in each group, p=0.007) and in isolated perfused hearts (n=8 in each group, p=0.007). Conclusions Our study with human LAA demonstrated a strong association between atrial lymphatics and atrial myocardial fibrosis/progression of AF. Our mouse study showed that VEGFC reversed AngII -induced increase in atrial myocardial fibrosis and vulnerability to AF, possibly via promotion of lymphangiogenesis. Defects of lymphangiogenesis may be involved in atrial myocardial fibrosis and AF, and may be a therapeutic target for atrial cardiomyopathy.

Abstract Background Reactive oxygen species (ROS) inhibits the nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway in the patients with advanced heart failure (HF) and contributes to the prognosis of HF. Vericiguat stimulates sGC independently of NO and reduced morbidity/mortality for HF patients with reduced ejection fraction. However, the effects of vericiguat on the cardiomyocyte in terms of ROS is unclear. Purpose We explored the cardioprotective effects of vericiguat focusing on the oxidative stress. Methods Cardiomyocytes isolated from the whole heart of neonatal rats were incubated with vericiguat (0μM as control, 0.1μM, 1.0μM, 10μM) for 72 hours. Administration of angiotensin II (1.0μM) was used to induce excessive ROS. Superoxide was quantified using luminometry, and whole ROS or mitochondria-derived superoxide was evaluated by using live-cell fluorescent probes. ERK 1/2 signaling pathway activity were evaluated with western blot analysis. Results Nicotinamide adenine dinucleotide phosphate (NADPH)-stimulated superoxide was significantly increased by the treatment of angiotensin II (40208 ± 6107 reactive light unit (RLU) / mg, p = 0.0009) and the angiotensin II-induced superoxide was significantly attenuated by vericiguat at doses of 0.1μM (28240 ± 6507 RLU / mg, p = 0.03) , 1.0μM (25221 ± 6496 RLU / mg, p = 0.007) and 10μM (8230 ± 2568 RLU / mg, p < 0.0001). Corrected total cell fluorescence value of live-cell fluorescent probes revealed that whole ROS and mitochondria-derived superoxide were significantly increased by angiotensin II treatment (525.3 ± 119.6, p = 0.004 and 945.3 ± 153.0, p <0.0001), which were attenuated by vericiguat (0.1μM, 431.2 ± 45.7, p = 0.48 and 548.1 ± 103.9, p = 0.0004; 1.0μM, 336.1 ± 109.0, p = 0.04 and 421.3 ± 111.9, p < 0.0001; 10μM, 270.0 ± 44.4, p = 0.005 and 157.7 ± 48.3, p < 0.0005) dose-dependently. Angiotensin II-induced phosphorylation of ERK 1/2 was suppressed by vericiguat at doses of 1.0μM (fold change 0.58, p = 0.04) and 10μM (fold change 0.45, p = 0.006) treatment. Conclusion Our results indicated that vericiguat could suppress the oxidative stress induced by angiotensin II and following activation of ERK 1/2 signaling. Suppressing the oxidative stress could lead to further activation of NO-sGC-cGMP pathway not only the stimulation by vericiguat and favorable cardio-protective cycle is expected.Quantification of superoxideQuantification of ROS or superoxide