Soothing a Broken Heart

HomeArteriosclerosis, Thrombosis, and Vascular BiologyVol. 40, No. 7Soothing a Broken Heart Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBSoothing a Broken HeartCan Therapeutic Cross-Talk Between Lymphatics and the Immune Response Improve Recovery From Myocardial Infarction? Rae H. Farnsworth and Steven A. Stacker Rae H. FarnsworthRae H. Farnsworth Correspondence to: Rae H. Farnsworth, Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia, Email E-mail Address: [email protected] From the Tumour Angiogenesis and Microenvironment Program, Peter MacCallum Cancer Centre (R.H.F., S.A.S.), Victoria, Australia. The Sir Peter MacCallum Department of Oncology, The University of Melbourne (R.H.F., S.A.S.), Victoria, Australia. Search for more papers by this author and Steven A. StackerSteven A. Stacker Steven A. Stacker, Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia, Email E-mail Address: [email protected] From the Tumour Angiogenesis and Microenvironment Program, Peter MacCallum Cancer Centre (R.H.F., S.A.S.), Victoria, Australia. The Sir Peter MacCallum Department of Oncology, The University of Melbourne (R.H.F., S.A.S.), Victoria, Australia. Victorian Comprehensive Cancer Centre, and the Department of Surgery, The University of Melbourne (S.A.S.), Victoria, Australia. Search for more papers by this author Originally published24 Jun 2020https://doi.org/10.1161/ATVBAHA.120.314666Arteriosclerosis, Thrombosis, and Vascular Biology. 2020;40:1611–1613This article is a commentary on the followingLymphatic and Immune Cell Cross-Talk Regulates Cardiac Recovery After Experimental Myocardial InfarctionSee accompanying article on page 1722Lymphatic vessels permeate almost all organs of the body, where they serve critical roles in absorbing and transporting fluid and immune cells extravasated from the blood vascular circulation. Recent studies have revealed a complex and intimate interrelationship between lymphatic vessels and immune cells in numerous pathologies such as inflammation, bacterial and viral infections, wound healing, lymphedema, autoimmunity, transplant rejection, and cancer.1–4 Appropriate abundance and function of local lymphatic vessels are critical for restoring fluid balance and chemokine-mediated immune cell trafficking to local lymph nodes. Conversely, leukocytes recruited to the site of insult via blood vessels regulate lymphatic vessel growth (lymphangiogenesis), remodelling and function via secretion of prolymphangiogenic or antilymphangiogenic factors.1–4Although the full diversity of molecules regulating lymphatics is still being uncovered,5 the best-studied are VEGF (vascular endothelial growth factor)-C and VEGF-D. These promote proliferation and migration of lymphatic (and blood vascular) endothelial cells by binding to cell-surface receptors VEGFR-3 or VEGFR-2, VEGFR-3 being more restricted to lymphatics.6 A range of strategies have been used to target this signaling pathway therapeutically, including neutralizing antibodies, soluble receptor ligand traps, and variants of VEGF-C or VEGF-D with restricted receptor affinity.4,7,8 Whether therapeutic promotion or inhibition of lymphatic vessel growth is beneficial in any disease depends on the pathophysiological mechanisms involved. In this issue of Arteriosclerosis, Thrombosis and Vascular Biology, Houssari et al9 provide important insight into the therapeutic potential of modulating lymphatics and the immune response in myocardial infarction (MI).MI is known to induce local lymphangiogenesis and lymphatic remodeling as part of the attendant inflammatory response.10 However, this new network is inadequate for drainage due to deleterious narrowing of larger lymphatics in adjacent tissue.11 The authors showed previously in rats that intramyocardial administration of an engineered variant of rat VEGF-C that selectively binds VEGFR-3 (VEGF-CC152S) promoted re-establishment of a functional lymphatic network, leading to improved cardiac function.11 In the present study, adeno-associated viral vectors (AAV) were used to systemically deliver either human VEGFR-3-specific VEGF-CC156S, or soluble VEGFR-3 (sVEGFR-3), in murine coronary artery ligation models of MI.These experiments showed that AAV-VEGF-CC156S enhanced cardiac lymphangiogenesis and lymphatic drainage function (frequency of open lymphatics11) post-MI. This accelerates fluid resorption and clearance of proinflammatory immune cells, thus limiting edema, fibrosis and other destructive effects of chronic inflammation.10–12 Concomitantly, AAV-VEGF-CC156S improved multiple parameters of cardiac function measured 3 weeks after MI, in line with similar previous studies.11,13,14The most intriguing insights come from dissecting the mechanistic involvement of immune cell subsets in MI. Along with M1-polarized macrophages,11,12 a substantial T cell infiltrate was observed from day 3, comprising roughly equal proportions of CD8+ and CD4+ cells, with Tregs (regulatory T cells) representing only 2% to 5% of the latter. AAV-VEGF-CC156S reduced accumulation of both macrophages and T cells. Interestingly, T cell accumulation and lymphangiogenesis were spatially linked: AAV-VEGF-CC156S both increased lymphangiogenesis and decreased T cell accumulation only in the adjacent viable ventricle wall, not in the infarct itself.The authors next depleted specific circulating leukocyte subsets pharmacologically or genetically to define their impact on the endogenous lymphatic response to MI. Fingolimod, clinically approved for treatment of multiple sclerosis, prevents egress of lymphocytes from lymphoid organs into circulation by interfering with sphingosine-1-phosphate receptor signaling.15 Depletion of circulating T cells by Fingolimod treatment in the 48 hours immediately following MI substantially enhanced lymphatic vessel density and frequency of open vessels in both the infarct and the adjacent ventricle wall. Depletion of either CD4+ or CD8+ subsets using antibodies gave a similar effect, suggesting a mechanism common to both. Antibodies to IFN (interferon)-γ, abundantly secreted by effector T cells and known to inhibit lymphangiogenesis,16 partially improved lymphatic vessel density and ameliorated loss of open lymphatic vessels. Importantly, Fingolimod improved cardiac function and remodeling. These results implicated T cells as being deleterious to cardiac lymphangiogenesis and lymphatic function subsequent to MI.Some unexpected findings came from animals treated with AAV-VEGFR-3, which acts as a ligand trap to bind and sequester VEGF-C and VEGF-D, thus preventing their endogenous signaling through VEGFR-3 or VEGFR-2. Unlike AAV-VEGF-CC156S, this treatment had no effect on peri-infarct lymphatics but decreased both lymphatic vessel abundance and T cell accumulation in the infarct. This led to surprising improvements in cardiac function and infarct remodeling, apparently exceeding those seen with AAV-VEGF-CC156S for some parameters, in both mouse and rat models.The observation that both therapeutically promoting and inhibiting lymphangiogenesis can reduce T cell infiltration and improve MI recovery at first appears paradoxical. The inverse relationship between immune cell accumulation and lymphangiogenesis, seen also previously,11 is attributed to accelerated lymphatic-mediated clearance of extravasated immune cells.12 The effects of AAV-sVEGFR-3 may also involve nonlymphatic cell types that respond to endogenous VEGF-C or VEGF-D.9 However, diminished T cell recruitment and adaptive immune responses are also observed when lymphatic function is endogenously or artificially inhibited in multiple disease settings, including cancer17 and cardiac transplantation.18 Insufficient lymphatic transport of antigen-presenting cells to local lymph nodes impairs expansion of antigen-specific T cell responses, to the benefit or the detriment depending on T cell type and disease pathogenesis. Indeed, trafficking of specific dendritic cell subsets via lymphatics to the mediastinal lymph nodes draining the heart is involved in generation of both Tregs in maintenance of peripheral tolerance and pathogenic Th1/Th17 effector T cells in MI.19The present study further highlights the importance of biological context when developing novel proof-of-principle therapies. At a microenvironmental level, the effects of AAV-VEGF-CC156S and AAV-sVEGFR-3 were dichotomized between the infarct and the adjacent tissue. Sustained VEGF-CC156S stimulation, not achieved with either adenoviral or recombinant VEGF-CC156S, was required to maintain expanded cardiac lymphangiogenesis. Interestingly, while Houssari et al9 observed protective effects of sVEGFR-3 in female mice, other studies using male mice or mixed-sex cohorts showed that VEGFR-3 blockade decreased recovery and survival from experimental MI.14,20 Male mice are more susceptible to fatal cardiac rupture after experimental MI, likely due to sex-dependent differences in the dynamics of infarct scar maturation.21,22 Responses to therapy post-MI may, therefore, be dependent on sex-, strain-, and species-specific factors, as well as timing of treatment.9,21,22 Gender-related differences in MI pathophysiology have also been documented in humans, although the reasons for poorer survival in women are complex.23Houssari et al have presented a thought-provoking contribution to understanding regulation of the understudied cardiac lymphatics and their interrelationship with T lymphocytes in MI. While therapeutic delivery of VEGF-C has proven beneficial to MI recovery in multiple preclinical studies,11,13,14 the delivery methods used (eg, implanted particles, recombinant protein, viral vectors) may be technically challenging to apply in human patients. Nonetheless, sophisticated adenoviral delivery of a proangiogenic and prolymphangiogenic form of VEGF-D (VEGF-DΔNΔC) improved cardiac perfusion in human patients with refractory angina.24 However, the possibility of administering approved, orally bioavailable immunomodulatory agents such as Fingolimod immediately after MI to enhance lymphangiogenesis and improve recovery is an intriguing possibility that warrants further investigation. Listening closely to the conversation between lymphatics and the immune system may be key to more effective therapies across a multitude of diseases.Sources of FundingThe authors were supported by funding from the National Health and Medical Research Council, Australia.DisclosuresS.A. Stacker has ownership interest in Opthea Ltd. that develops therapeutics in vascular biology. R.H. Farnsworth reports no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 1612–1613.Correspondence to: Rae H. Farnsworth, Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia, Email rae.[email protected]orgSteven A. Stacker, Victorian Comprehensive Cancer Centre, 305 Grattan Street, Melbourne, Victoria 3000, Australia, Email steven.[email protected]orgReferences1. Farnsworth RH, Karnezis T, Maciburko SJ, Mueller SN, Stacker SA. The Interplay Between Lymphatic Vessels and Chemokines.Front Immunol. 2019; 10:518. doi: 10.3389/fimmu.2019.00518CrossrefMedlineGoogle Scholar2. Betterman KL, Harvey NL. The lymphatic vasculature: development and role in shaping immunity.Immunol Rev. 2016; 271:276–292. doi: 10.1111/imr.12413CrossrefMedlineGoogle Scholar3. Yuan Y, Arcucci V, Levy SM, Achen MG. Modulation of Immunity by Lymphatic Dysfunction in Lymphedema.Front Immunol. 2019; 10:76. doi: 10.3389/fimmu.2019.00076CrossrefMedlineGoogle Scholar4. Schwager S, Detmar M. Inflammation and Lymphatic Function.Front Immunol. 2019; 10:308. doi: 10.3389/fimmu.2019.00308CrossrefMedlineGoogle Scholar5. Williams SP, Odell AF, Karnezis T, Farnsworth RH, Gould CM, Li J, Paquet-Fifield S, Harris NC, Walter A, Gregory JL, et al. Genome-wide functional analysis reveals central signaling regulators of lymphatic endothelial cell migration and remodeling.Sci Signal. 2017; 10:eaal2987. doi: 10.1126/scisignal.aal2987CrossrefMedlineGoogle Scholar6. Karaman S, Leppanen V, Alitalo K. Vascular endothelial growth factor signaling in development and disease.Development. 2018; 145:dev151019. doi: 10.1242/dev.151019CrossrefMedlineGoogle Scholar7. Dieterich LC, Detmar M. Tumor lymphangiogenesis and new drug development.Adv Drug Deliv Rev. 2016; 99(Pt B):148–160. doi: 10.1016/j.addr.2015.12.011CrossrefMedlineGoogle Scholar8. Rissanen TT, Rutanen J, Ylä-Herttuala S. Gene transfer for therapeutic vascular growth in myocardial and peripheral ischemia.Adv Genet. 2004; 52:117–164. doi: 10.1016/S0065-2660(04)52004-7CrossrefMedlineGoogle Scholar9. Houssari M, Dumesnil A, Tardif V, Kivelä R, Pizzinat N, Boukhalfa I, Godefroy D, Schapman D, Hemanthakumar KA, Bizou M, et al. Lymphatic and immune cell cross-talk regulates cardiac recovery after experimental myocardial infarction.Arterioscler Thromb Vasc Biol. 2020; 40:1722–1737. doi: 10.1161/ATVBAHA.120.314370LinkGoogle Scholar10. Brakenhielm E, Alitalo K. Cardiac lymphatics in health and disease.Nat Rev Cardiol. 2019; 16:56–68. doi: 10.1038/s41569-018-0087-8CrossrefMedlineGoogle Scholar11. Henri O, Pouehe C, Houssari M, Galas L, Nicol L, Edwards-Lévy F, Henry JP, Dumesnil A, Boukhalfa I, Banquet S, et al. Selective Stimulation of Cardiac Lymphangiogenesis Reduces Myocardial Edema and Fibrosis Leading to Improved Cardiac Function Following Myocardial Infarction.Circulation. 2016; 133:1484–97; discussion 1497. doi: 10.1161/CIRCULATIONAHA.115.020143LinkGoogle Scholar12. Vieira JM, Norman S, Villa Del Campo C, Cahill TJ, Barnette DN, Gunadasa-Rohling M, Johnson LA, Greaves DR, Carr CA, Jackson DG, et al. The cardiac lymphatic system stimulates resolution of inflammation following myocardial infarction.J Clin Invest. 2018; 128:3402–3412. doi: 10.1172/JCI97192CrossrefMedlineGoogle Scholar13. Klotz L, Norman S, Vieira JM, Masters M, Rohling M, Dubé KN, Bollini S, Matsuzaki F, Carr CA, Riley PR. Cardiac lymphatics are heterogeneous in origin and respond to injury.Nature. 2015; 522:62–67. doi: 10.1038/nature14483CrossrefMedlineGoogle Scholar14. Shimizu Y, Polavarapu R, Eskla KL, Pantner Y, Nicholson CK, Ishii M, Brunnhoelzl D, Mauria R, Husain A, Naqvi N, et al. Impact of Lymphangiogenesis on Cardiac Remodeling After Ischemia and Reperfusion Injury.J Am Heart Assoc. 2018; 7:e009565. doi: 10.1161/JAHA.118.009565LinkGoogle Scholar15. Chun J, Hartung HP. Mechanism of action of oral fingolimod (FTY720) in multiple sclerosis.Clin Neuropharmacol. 2010; 33:91–101. doi: 10.1097/WNF.0b013e3181cbf825CrossrefMedlineGoogle Scholar16. Kataru RP, Kim H, Jang C, Choi DK, Koh BI, Kim M, Gollamudi S, Kim YK, Lee SH, Koh GY. T lymphocytes negatively regulate lymph node lymphatic vessel formation.Immunity. 2011; 34:96–107. doi: 10.1016/j.immuni.2010.12.016CrossrefMedlineGoogle Scholar17. Fankhauser M, Broggi MAS, Potin L, et al. Tumor lymphangiogenesis promotes T cell infiltration and potentiates immunotherapy in melanoma.Sci Transl Med. 2017; 9:eaal4712. doi: 10.1126/scitranslmed.aal4712CrossrefMedlineGoogle Scholar18. Nykänen AI, Sandelin H, Krebs R, Keränen MA, Tuuminen R, Kärpänen T, Wu Y, Pytowski B, Koskinen PK, Ylä-Herttuala S, et al. Targeting lymphatic vessel activation and CCL21 production by vascular endothelial growth factor receptor-3 inhibition has novel immunomodulatory and antiarteriosclerotic effects in cardiac allografts.Circulation. 2010; 121:1413–1422. doi: 10.1161/CIRCULATIONAHA.109.910703LinkGoogle Scholar19. Van der Borght K, Scott CL, Nindl V, Bouché A, Martens L, Sichien D, Van Moorleghem J, Vanheerswynghels M, De Prijck S, Saeys Y, et al. Myocardial infarction primes autoreactive T cells through activation of dendritic cells.Cell Rep. 2017; 18:3005–3017. doi: 10.1016/j.celrep.2017.02.079CrossrefMedlineGoogle Scholar20. Vuorio T, Ylä-Herttuala E, Laakkonen JP, Laidinen S, Liimatainen T, Ylä-Herttuala S. Downregulation of VEGFR3 signaling alters cardiac lymphatic vessel organization and leads to a higher mortality after acute myocardial infarction.Sci Rep. 2018; 8:16709. doi: 10.1038/s41598-018-34770-4CrossrefMedlineGoogle Scholar21. Fang L, Gao XM, Moore XL, Kiriazis H, Su Y, Ming Z, Lim YL, Dart AM, Du XJ. Differences in inflammation, MMP activation and collagen damage account for gender difference in murine cardiac rupture following myocardial infarction.J Mol Cell Cardiol. 2007; 43:535–544. doi: 10.1016/j.yjmcc.2007.06.011CrossrefMedlineGoogle Scholar22. Gao XM, Xu Q, Kiriazis H, Dart AM, Du XJ. Mouse model of post-infarct ventricular rupture: time course, strain- and gender-dependency, tensile strength, and histopathology.Cardiovasc Res. 2005; 65:469–477. doi: 10.1016/j.cardiores.2004.10.014CrossrefMedlineGoogle Scholar23. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson MN, Lindley KJ, Vaccarino V, Wang TY, Watson KE, et al; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association.Circulation. 2016; 133:916–947. doi: 10.1161/CIR.0000000000000351LinkGoogle Scholar24. Hartikainen J, Hassinen I, Hedman A, Kivelä A, Saraste A, Knuuti J, Husso M, Mussalo H, Hedman M, Rissanen TT, et al. Adenoviral intramyocardial VEGF-DΔNΔC gene transfer increases myocardial perfusion reserve in refractory angina patients: a phase I/IIa study with 1-year follow-up.Eur Heart J. 2017; 38:2547–2555. doi: 10.1093/eurheartj/ehx352CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Blei F (2020) Update August 2020, Lymphatic Research and Biology, 10.1089/lrb.2020.29088.fb, 18:4, (381-397), Online publication date: 1-Aug-2020. Related articlesLymphatic and Immune Cell Cross-Talk Regulates Cardiac Recovery After Experimental Myocardial InfarctionMahmoud Houssari, et al. Arteriosclerosis, Thrombosis, and Vascular Biology. 2020;40:1722-1737 July 2020Vol 40, Issue 7 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/ATVBAHA.120.314666PMID: 32579475 Originally publishedJune 24, 2020 Keywordsgene therapyinflammationmyocardial infarctionleukocyteslymphatic vesselsEditorialsPDF download Advertisement SubjectsFunctional Magnetic Resonance Imaging (fMRI)HypertensionImagingMyocardial InfarctionNuclear Cardiology and PETPreeclampsiaTransplantation