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Ann Thorac Surg 1999;68:1949-1953
© 1999 The Society of Thoracic Surgeons

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I. Pathophysiology of Ischemic Reperfusion Injury

Treating myocardial ischemia-reperfusion injury by targeting endothelial cell transcription

^a Divisions of Cardiothoracic Surgery, and Trauma and Critical Care, Department of Surgery, University of Washington, Seattle, Washington, USA

Address reprint requests to Dr Verrier, Division of Cardiothoracic Surgery, University of Washington, Box 356310, 1959 NE Pacific, Seattle, WA 98195-6310
e-mail: edver{at}u.washington.edu

Presented at the International Symposium on Myocardial Protection From Surgical Ischemic-Reperfusion Injury, Asheville, NC, Sept 21–24, 1997.

Abstract

Exacerbation of, rather than improvement in, a hypoxic injury after reperfusion of ischemic tissues is recognized as the specific clinicopathologic entity referred to as ischemia/reperfusion (I/R) injury. Arguably, one of the most common forms of I/R injury occurs during cardiac surgery, which has a mandatory period of myocardial ischemia required to allow surgery in a bloodless, motionless field, followed by coronary artery reperfusion after removal of the aortic cross-clamp. In this review, we examine the endothelial cell activation phenotype that initiates and propagates myocardial I/R injury. Emphasis is given to the biology of one transcription factor, NF-B, that has the principal role in the regulation of many endothelial cell genes expressed in activated endothelium. NF-B-dependent transcription of endothelial cell genes that are transcribed in response to I/R injury may be a favorable approach to preventing tissue injury in the setting of I/R. Elucidating safe and effective therapy to inhibit transcription of endothelial cell genes involved in promoting injury after I/R injury may have wide applicability to the patients with heart disease and other forms of I/R injury.

Tissue ischemia, resulting in cellular hypoxia, is the primary manifestation of many cardiovascular diseases. Paradoxically, therapy to restore oxygen delivery often intensifies cellular injury, particularly after acute episodes of oxygen deprivation. Exacerbation of, rather than improvement in, a hypoxic injury after reperfusion of ischemic tissues is recognized as the specific clinicopathologic entity referred to as ischemia/reperfusion (I/R) injury. Arguably, one of the most common forms of I/R injury occurs during cardiac operation, which has a mandatory period of myocardial ischemia required to allow operation in a bloodless, motionless field, followed by coronary artery reperfusion after removal of the aortic cross-clamp. In our laboratory, we have focused on gene regulation in human endothelium to determine the mechanisms that regulate the host response to myocardial I/R injury. Specifically, we examine an endothelial cell activation phenotype that initiates and propagates myocardial I/R injury. In this review, we give emphasis to the biology of one transcription factor, NF-B, that has the principal role in the regulation of many endothelial cell genes expressed in activated endothelium. We postulate that by blocking the function of NF-B, the transcription of endothelial cell activation genes can be inhibited, the expression of a full endothelial cell activation phenotype obviated, and the complications attributable to I/R injury in large part prevented. An important feature of NF-B is the pleiotropic effects this ubiquitous transcription factor has in human endothelial cell function. In addition to the cellular response to the oxidative stress of I/R injury, NF-B regulates the transcription of genes involved in cellular responses to microbial invasion and mechanical stress, and required for tissue repair. NF-B is now recognized to have a potential role in programmed cell death (apoptosis) and the adaptive response to stress. NF-B may also mediate other cytoprotective functions such as preconditioning. Therefore, we anticipate that successful targeting of NF-B-regulated gene transcription, to prevent myocardial I/R injury, will require identification of molecular pathways that are specific to the cellular response to oxidative stress. Delineating these pathways may allow the targeting of endothelial cell activation during I/R injury while preserving the capability of the vascular endothelium to respond to other threats to homeostasis.

Gene expression

Although all cells of the human body contain the same set of genes, specific cells, under different conditions, utilize unique combinations of these genes that determine a specific cell phenotype. In general, individual human cells, including cells that have highly specialized phenotypes, express only 10% to 15% of the total number of genes in the genome. The remaining genes of the cells are inactive and do not produce specific protein products. A basic paradigm in endothelial cell biology, involving genomic responses to specific extracellular signals, is the transcriptional activation of genes that are not transcribed under normal conditions. Extracellular signals bind highly specific receptors on the cell plasma membrane, and this ligand-receptor interaction triggers a cascade of kinases and sequential phosphorylation events that transduces the signal to the nucleus. Depending on the signal and the signaling pathways that are activated, an array of transcription factors are induced to bind to unique DNA sequences, usually 8 to 16 base pairs in length, that promote transcription [1]. In endothelial cells responding to cytokines or oxidative stress, these DNA-protein interactions commonly involve NF-B [2].

Endothelial cell phenotypes

Quiescent endothelial cells transcribe a distinct set of genes that produce a nonthrombogenic endothelial lining of blood vessels; also, unperturbed endothelial cells do not interact with circulating blood cells or platelets. For example, endothelial cells normally express thrombomodulin, which promotes anticoagulation by enzymatically activating protein C [3]. Under normal conditions, endothelial cells also express vasoactive molecules, including nitric oxide, prostacyclin, and adenosine, that promote vasodilation and inhibit platelet and leukocyte adherence, enhancing blood flow [4]. Many of these endothelial cell-derived substances also prevent smooth muscle cell contraction or proliferation.

Hypoxic endothelial cells maintain viability and basic biosynthetic mechanisms, but undergo alterations in function, including decreased thrombomodulin expression and increased barrier permeability [5]. When endothelial cells are activated, as occurs during I/R injury or after exposure to inflammatory mediators, such as tumor necrosis factor (TNF), interleukin-1 (IL-1), or gram-negative bacterial lipopolysaccharides (LPS; endotoxin), a new set of genes are transcriptionally activated that allow endothelial cells to contribute significantly to an acute inflammatory reaction. The protein products of these genes include E-selectin, ICAM, VCAM, and IL-8, which promote neutrophil rolling, aggregation, adhesion, and transendothelial cell migration. Full expression of an endothelial cell activation phenotype therefore causes intravascular microthrombosis, reduced blood flow, and activation of inflammatory cells (Fig 1).

View larger version (18K): [in this window] [in a new window]   Fig 1. Endothelial cell activation.

Endothelial cell activation is regulated by NF-B

The endothelial cell lining of the microvasculature responds to oxidative stress, cellular injury, and infection by activating molecular pathways that transmit signals through the cytoplasm to the nucleus. These signals result in new gene transcription and translation, and deployment of proinflammatory, procoagulant, and vasoactive molecules that characterize endothelial cell activation [2]. Deletional and mutational analyses of several genes that are activated in this process (IL-1, E-selectin, VCAM, ICAM, IL-8, MCP-1, and tissue factor) indicate that these genes are transcriptionally regulated in a process that requires DNA binding of a transcription factor, NF-B [8]. (For a more complete list of genes activated by NF-B see Table 1.) NF-B is composed of subunits from the NF-B/Rel family of transcription factors. Five distinct DNA-binding proteins of the family, p50, p52, p65 (also known as RelA), c-Rel, and RelB, are involved in mammalian transcription. Members of this family are defined by the presence of a highly conserved region of approximately 300 amino acids called the "rel homology domain," which bears the DNA binding site, located in the amino-terminus half of the domain. The consensus DNA binding sequence for NF-B is 5'-GGGPuNNPyCC-3'; the slight asymmetry of this binding motif causes preferential localization of different subunits to either end of the element. The carboxy-terminus of the rel homology domain in each family member contains a highly specific cluster of positively charged amino acids that function as nuclear localization signals. The carboxy-terminus of some NF-B family members contain transactivating domains; proteins lacking these structures, such as p50, do not activate transcription. The p65 subunit, in association with p50 or c-Rel, is the most common heterodimer, subserving the transcriptional activation of many genes involved in immunologic and inflammatory responses [9].

View this table: [in this window] [in a new window]   Table 1. Genes Transcriptionally Activated by NF-Ba

In that NF-B is activated by diverse stimuli and regulates the transcription of several genes, the function of NF-B represents a convergence point in the molecular processes of cellular activation. Because of this central position NF-B holds, the biologic complexity of this transcription factor notwithstanding, it may be an ideal therapeutic target to block endothelial cell-mediated I/R injury.

IB regulates NF-B activation

Cytoplasmic latency of NF-B is regulated by the IB family of proteins. Phosphorylation of IB into a substrate for ubiquitinating enzymes. Ubiquitinated IB is degraded by proteasomes (multisubunit protease complexes that selectively degrade intracellular proteins), liberating NF-B for translocation to the nucleus [11]. Multiple forms of IB create the potential for multiple pathways to NF-B activation [12]. For example, some IB members are active in a transient and an immediate NF-B response, while others are involved with a slower more persistent activation of NF-B. Although the biology of IB is currently understood in considerable detail, very little is known about the biological behavior of the other members of the IB family proteins.

NF-B transcriptionally activates its own inhibitor

After a period of stimulation, new inactive IB complexes can be detected in the cytoplasm with an accompanying loss of active NF-B in the nucleus [13]. Analysis of the sequence of the IB promoter reveals multiple binding sites for NF-B. This suggests that IB is transcriptionally activated by NF-B, a process that could function as a negative feedback mechanism [14]. Recent studies demonstrate that newly formed IB translocates to the nucleus to bind to NF-B and disrupt NF-B/DNA binding [15]. Although not proven, it is likely that newly formed IB then escorts NF-B out of the nucleus into the cytoplasm, limiting the proinflammatory transcriptional response. Overexpression of IB with a dominant negative mutant prevents endothelial cell activation, further demonstrating the inhibitory nature of this protein [16]. Further insight into the complex NF-B/IB interactions may lead to an improved understanding into the process of resolution of acute inflammation as well as to novel approaches to control this response.

Reactive oxygen intermediates signal IB phosphorylation

An intracellular redox state is maintained by a balance between normal oxidant scavenging enzyme systems, such as superoxide dismutase, catalase, and glutathione, and intracellular oxidant production. Disruption of this balance, either by reducing the capacity of intracellular scavenging systems or by increasing the production of reactive oxygen intermediates (ROIs), leads to toxic accumulations of ROIs, referred to as oxidative (or oxidant) stress. Reperfusion of ischemic tissue is characterized by an extreme amount of oxidative stress. Human endothelial cells respond to oxidative stress by developing an activation phenotype similar to that induced by TNF or IL-1. Hydrogen peroxide (H₂O₂), an intracellular reactive oxygen intermediate (ROI), activates endothelial cells in vitro, inducing expression of endothelial cell procoagulant and proinflammatory activities, and antioxidants, which enhance recovery of myocardial function after ischemia in vivo, prevent endothelial cell activation in vitro [17].

Recently, we have found that there may be a fundamental difference in the way that oxidative stress and cytokine or LPS induced NF-B activation in endothelial cells. For example TNF- and LPS stimulation of human umbilical vein endothelial cells (HUVEC) results in rapid serine phosphorylation of IB, followed by ubiquination and degradation [18]. It has now been demonstrated that IB can be phosphorylated on a tyrosine residue at position 42 of IB, in close proximity to the two serine phosphoacceptor sites. There is some evidence that tyrosine phosphorylated IB is protected from TNF-induced degradation, although the mechanism of this protective effect is not known. Recently, it was noted that oxidative stress activates a signaling pathway that results in tyrosine phosphorylation of IB rather than serine phosphorylation induced by TNF and LPS [19]. We have found that tyrosine phosphorylation causes IB to dissociate from NF-B in human endothelial cells activated by oxidative stress, but unlike serine phosphorylation, does not signal IB degradation. Thus, it appears that the central difference between oxidative stress and infectious stimuli appears to be a fundamental difference in IB phosphorylation, which, in the setting of oxidative stress, does not result in IB or IBß degradation (Fig 2). These findings lead us to postulate that oxidative stress generated in I/R activates NF-B through an independent and distinct signal transduction pathway that leads to the tyrosine phosphorylation of IB. A separate and distinct oxidative stress pathway or pathways dependent upon tyrosine phosphorylation raises the possibility of several new therapeutic strategies to specifically block ischemia reperfusion injury without effecting the cell’s ability to respond to infectious stimuli. If this proves true, this might allow one to target and block the proinflammatory transcriptional response to oxidative stress, as occurs in I/R, and still leave the endothelial cell’s ability to respond to infection or cytokines intact.

View larger version (28K): [in this window] [in a new window]   Fig 2. Alternative pathways of NF-B activation. (Top) Septic stimuli, such as TNF-a or IL-1, active transmembrane signaling pathways in responsive cells leading to the phosphorylation of a serine/threonine kinase, IB. This kinase, in turn, phosphorylates IB on serine residues 32 and 36. IB is an inhibitor of NF-B, but upon phosphorylation undergoes degradation. Degradation of Ser-phosphorylated IB requires the addition of ubiquitin molecules that target proteins for degradation in proteasomes. After IB degradation, NF-B translocates to the nucleus, where it binds to specific DNA sequences of several genes that encode proteins mediating inflammatory reactions. Of interest, NF-B regulates transcription of new IB which functions in a negative feedback loop to downregulate this particular cellular response. (Bottom) Reactive oxygen intermediates activate signaling pathways yet to be determined that lead to tyrosine phosphorylation of IB. The tyrosine kinase responsible for this reaction has not yet been identified. Tyr-phosphorylated IB, in contrast to Ser-phosphorylated IB, dissociates from NF-B without degradation. NF-B subsequently translocates to the nucleus to promote transcription of a similar set of genes, as shown in A, including IB. This figure shows the molecular basis for the inflammatory reaction induced by I/R injury, or any other injury in which reactive oxygen intermediates are formed. The figure also indicates that it may be possible to suppress an inflammatory reaction associated with I/R injury that may be detrimental to the patient, without blocking the patient’s ability to generate an inflammatory reaction, when required, to contain microbial invasion.

Current insights from inhibiting NF-B

A variety of strategies have been utilized to inhibit NF-B in experimental settings. Most approaches have been devised for cell culture; consequently, little is known of the consequences of NF-B inhibition in animal models. Inhbiting NF-B-IB disassociation in endothelial cells with antioxidants including pyrrolidine dithiocarbamate, vitamin E, and N-acetyl-L-cysteine, protease inhibitors, proteasome inhibitors, and hypothermia has been described [20–22]. Other approaches targeting transcription include preventing the action of NF-B in the nucleus, for example, by increasing cAMP levels. Activators of cAMP-dependent protein kinase A (PKA), such as prostaglandin E₂ or the drug forskolin, have been shown to inhibit NF-B [23]. These studies demonstrate the feasibility of inhibiting endothelial cell activation in vitro by targeting NF-B.

Newer strategies more specifically target NF-B-mediated transcription in vitro and in vivo. Overexpression of mutated forms of IB or transdominant p65, transfected into cultured cells with adenoviral vectors, effectively blocks NF-B translocation to the nucleus and endothelial cell activation in vitro [24]. In vivo, myocardial infarction is ameliorated by synthetic double-stranded DNA with high affinity for NF-B that is introduced into rat hearts. These DNA strands function as "decoy" cis elements that sequester the transcriptional factor in the cytoplasm, and thereby block the transcriptional activation of genes regulated by NF-B in the nucleus [25]. These studies demonstrate that by specifically targeting NF-B, endothelial cell activation can be prevented, especially in the setting of I/R injury.

Clinical significance

Despite advances in understanding the pathophysiology and treatment of I/R injury, prevention of I/R injury clinically has not been routinely attained. Several therapeutic approaches focus on inhibition of the principal effector cell of I/R injury, the neutrophil. Although effective, this form of immunosuppression may predispose patients to infectious complications [26]. It seems that multiple molecular pathways are activated in the endothelium in response to I/R injury, and that whereas the neutrophil is the effector cell, the endothelial cell is the regulator of I/R injury. Moreover, it is likely that endothelial cells recruit neutrophils to sites of I/R injury with cellular mechanisms different from those activated to recruit neutrophils to sites of septic threats to homeostasis. Therefore, it may be possible to exploit recent advances in gene-directed therapy, for example, to downregulate the response of endothelium to oxidative stress while still preserving other functions of this critical component of the vasculature. Based on our studies and others, we believe that a favorable target for such therapy is NF-B-dependent transcription of endothelial cell genes that are transcribed in response to I/R injury. Elucidating safe and effective therapy to inhibit transcription of endothelial cell genes involved in promoting injury after I/R injury may have wide applicability to the patients with heart disease and other forms of I/R injury.

References

1. Hill C.S., Treisman R. Transcriptional regulation by extracellular signals. Cell 1995;80:199-221.[Medline]
2. Boyle E.M., Jr, Pohlman T.H., Cornejo C.J., Verrier E.D. Endothelial cell injury in cardiovascular surgery. Ann Thorac Surg 1996;62:1868-1875.[Abstract/Free Full Text]
3. Esmon C.T. The regulation of natural anticoagulant pathways. Science 1987;235:1348-1352.[Abstract/Free Full Text]
4. Sellke F.W., Boyle E.M., Jr, Verrier E.D. Endothelial cell injury in cardiovascular surgery. Ann Thorac Surg 1996;62:1222-1228.[Abstract/Free Full Text]
5. Pinsky D.J., Yan S.F., Lawson C., et al. Hypoxia and modification of the endothelium. Semin Cell Biol 1995;6:283-294.[Medline]
6. Winn R.K., Ramamoorthy C., Vedder N.B., et al. Leukocyte-endothelial cell interactions in ischemia-reperfusion injury. Ann NY Acad Sci 1997;832:311-321.[Medline]
7. Weiss S.J. Tissue destruction by neutrophils. N Engl J Med 1989;320:365-376.[Medline]
8. Collins T., Read M.A., Neish A.S., et al. Transcriptional regulation of endothelial cell adhesion molecules. FASEB J 1995;9:899-909.[Abstract]
9. Baeuerle P.A., Henkel T. Function and activation of NF-kappa B in the immune system. Ann Rev Immunol 1994;12:141-179.[Medline]
10. Collins T., Read M.A., Neish A.S., et al. Transcriptional regulation of endothelial cell adhesion molecules. FASEB J 1995;9:899-909.
11. Finco T.S., Baldwin A.S. Mechanistic aspects of NF kappa B regulation. Immunity 1995;3:263-272.[Medline]
12. Verma I.M., Stevenson J.K., Schwarz E.M., et al. Rel/NF-kappa B/I kappa B family. Genes Dev 1995;9:2723-2735.[Free Full Text]
13. Sun S.C., Ganachi P.A., Ballard D.W., Greene W.C. NF kappa B controls expression of inhibitor I kappa B alpha. Science 1993;295:1912-1915.
14. Read M.A., Whitley M.Z., Williams A.J., Collins T. NF-kappa B and I kappa B alpha. J Exp Med 1994;179:503-512.[Abstract/Free Full Text]
15. Read M.A., Neish A.S., Gerritsen M.E., T C. Postinduction trascriptional repression of E-selectin and vascular cell adhesion molecule-1. J Immunol 1996;157:3472-3479.[Abstract]
16. Goodman D.J., von Albertini A.M., McShea A., Wrighton C.J., Bach F.H. Adenoviral mediated overexpression of I (kappa) B (alpha) in endothelial cells inhibits natural killer cell mediated endothelial cell expression. Transplantation 1996;62:967-972.[Medline]
17. Golino P., Ragni M., Cirillo P., et al. Effects of tissue factor induced by oxygen free radicals on coronary flow during reperfusion. Nat Med 1996;2:35-40.[Medline]
18. Broze G.J., Jr, Likert K., Higuchi D. Inhibition of factor VIIa/tissue factor by antithrombin III and tissue factor pathway inhibitor. Blood 1993;82:1679-1681.[Free Full Text]
19. Imbert V., Rupec R.A., Livolsi A., et al. Tyrosine phosphorylation of I kappa B-alpha activates NF-kappa B without proteolytic degradation of I kappa B-alpha. Cell 1996;86:787-798.[Medline]
20. Marui N., Offermann M.K., Swerlick R., et al. Vascular cell adhesion molecule-1 (VCAM-1) gene transcription and expression are regulated through an antioxidant-sensitive mechanism in human vascular endothelial cells. J Clin Invest 1993;92:1866-1874.
21. Haddix T.L., Pohlman T.H., Noel R.F., et al. Hypothermia inhibits human E-selectin transcription. J Surg Res 1996;64:176-183.[Medline]
22. Chen C.C., Rosenbloom C.L., Anderson D.C., Manning A.M. Selective inhibition of E-selectin, vascular cell adhesion molecule-1, and intercellular adhesion molecule-1 expression by inhibitors of I kappa B-alpha phosphorylation. J Immunol 1995;155:3538-3545.[Abstract]
23. Ollivier V., Parry G.C.N., Cobb R.R., et al. Elevated cyclic AMP inhibits NF-kappaB-mediated transcription in human monocytic cells and endothelial cells. J Biol Chem 1996;271:20828-20835.[Abstract/Free Full Text]
24. Anrather J., Csizmadia V., Brostjan C., et al. Inhibition of bovine endothelial cell activation in vitro by regulated expression of a transdominant inhibitor of NF-kappa B. J Clin Invest 1997;99:763-772.[Medline]
25. Morishita R., Sugimoto T., Aoki M., et al. In vivo transfection of cis element "decoy" against nuclear factor-kappaB binding site prevents myocardial infarction. Nature Med 1997;3:894-899.[Medline]
26. Sharar S.R., Winn R.K., Murry C.E., et al. A CD18 monoclonal antibody increases the incidence and severity of subcutaneous abscess formation after high-dose Staphylococcus aureus injection in rabbits. Surgery 1991;110:213-220.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Edward D. Verrier Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boyle, E. M. Articles by Verrier, E. D. Search for Related Content PubMed PubMed Citation Articles by Boyle, E. M., Jr Articles by Verrier, E. D.