www.elsevier.com/locate/cardiores

Cardiovascular Research

Review

Myocardial proteases and matrix remodeling in inflammatory heart disease

Susanne Rutschow, Jun Li, Heinz-Peter Schultheiss, Matthias Pauschinger *

Department of Cardiology and Pneumology, Charite, University Medicine Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany

Received 1 June 2005; received in revised form 5 December 2005; accepted 9 December 2005

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Abstract

Recently, it has been demonstrated that myocardial inflammation plays a pivotal role in the development and progression of congestive

heart failure. The myocardial inflammatory reaction not only affects myocardial hypertrophy and apoptosis, but it has a major influence on

the regulation of extracellular matrix turnover. The balance between collagen synthesis and degradation is of crucial relevance in maintaining

the structural integrity of the heart. Therefore, the overwhelming inflammatory response, as seen in acute myocarditis or inflammatory

cardiomyopathy, could lead to a breakdown of this tightly regulated system. This is an additional key factor in the development and

progression of heart failure.

This review summarizes the importance of myocardial inflammation in respect to extracellular matrix remodeling and its possible patho-

physiological role in the development and progression of left ventricular dysfunction in inflammatory heart disease.

D 2006 European Society of Cardiology. Published by Elsevier B.V.

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Keywords: Myocarditis; DCM; Inflammation; MMP; Matrix

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1. Introduction

Myocarditis, an inflammatory disorder, which is most

commonly caused by viral infection (especially enterovirus

and parvovirus), is associated with acute left ventricular

dysfunction accompanied by myocardial inflammatory cell

infiltration and increased release of proinflammatory cyto-

kines [1]. The presence of viral genome in endomyocardial

biopsies of patients with dilated cardiomyopathy (DCM)

demonstrates an interrelationship between acute myocarditis

and DCM [2–4]. A similar frequency of intramyocardial

inflammation was found in patients with DCM, which

reflects the relevance of chronic inflammation in the

development of left ventricular dysfunction [5]. However,

not only viral persistence and chronic inflammatory

response seem to play an important role in the pathogenesis

of inflammatory cardiomyopathy. The latest investigations

advert to a momentous role of matrix metalloproteinases in

0008-6363/$ - see front matter D 2006 European Society of Cardiology. Publish

doi:10.1016/j.cardiores.2005.12.009

* Corresponding author. Tel.: +49 30 8445 2344; fax: +49 30 8445 3565.

E-mail address: matthias.pauschinger@charite.de (M. Pauschinger).

the disruption of the extracellular matrix (ECM) architecture

involving a pathological elevated myocardial collagen

turnover which leads to the loss of structural integrity of

the heart resulting in left ventricular dysfunction [1,6–8]. In

the latest investigations these factors have been shown to

play a crucial role in the disruption of the ECM architecture.

A pathologically elevated myocardial collagen turnover

leads to the loss of structural integrity of the heart and

ensuing left ventricular dysfunction.

Acute left ventricular dysfunction in experimental

induced acute myocarditis is associated with induction of

proinflammatory cytokines and an imbalance of the matrix

metalloproteinases (MMPs) and the tissue inhibitors of

MMPs (TIMPs) system [1]. Proinflammatory cytokines like

TNF-a and IL-1h contribute not only to depression of LV

function and cardiomyocyte loss by apoptosis, they also

play a critical role in maintaining the balance in ECM-

remodeling [9–11], showing the importance of chronic

inflammation in myocardial remodeling process as well as

in the development of DCM [12]. They regulate cardiac

fibroblast function with the expression of collagen types I

and III and fibronectin, and moreover also regulate the

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S. Rutschow et al. / Cardiovascular Research 69 (2006) 646–656 647

matrix degradation system by influencing the expression of

matrix metalloproteinases (MMPs), the tissue inhibitors of

MMPs (TIMPs) and their activators like urokinase type

plasminogen activator and tissue type plasminogen activator

(uPA, tPA) [12–15]. This seems to indicate that the

maintenance of the physiological myocardial matrix turn-

over involves a highly regulated interaction between cardiac

and noncardiac cells, in response to the release of

inflammatory mediators and components of the matrix

degradation system.

Fig. 1. (a) Significant correlation between myocardial mRNA abundance of

IL-1h and left ventricular endsystolic pressure (LVESP) in a murine model

of Coxsackievirus B3 induced acute myocarditis. R2>0.5 were considered

as significant; p <0.001. (b) Significant correlation between myocardial

mRNA abundance of TNF-a and left ventricular endsystolic pressure

(LVESP) in a murine model of Coxsackievirus B3 induced acute

myocarditis. R2>0.5 were considered as significant; p <0.001.

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2. Heart failure and cytokines

Chronic heart failure is a disease with multiple causes of

which an inflammatory reaction is the most important. Over

the past years inflammatory cytokines and neurohormones

have been shown to contribute to the development and

progression of left ventricular dysfunction. Congestive heart

failure is now commonly seen as a state of chronic

inflammation. Proinflammatory cytokines like TNF-a and

IL-6 are elevated in different entities of heart failure like

acute myocardial infarction, stable angina pectoris or acute

myocarditis with perpetuation of congestive heart failure

and relevance for prognosis of the disease [16–19]. For

instance, TNF-a has been shown to induce myocardial

hypertrophy and fibrosis [20], increase cardiac myocyte

apoptosis and induce activation of the inducible form of

nitric oxide synthase (iNOS) [21]. IL-1 has been demon-

strated to depress myocardial contractility in a dose-

dependent manner and to contribute to myocardial apoptosis

and hypertrophy. In collaboration with IL-1h, TNF-a also

promotes Coxsackievirus B3-myocarditis in resistant Balb/

c-mice [22]. In our previous investigations we could show a

close correlation between the development of left ventric-

ular dysfunction and the increase of myocardial mRNA

abundance of IL-1h and TNF-a in a murine model of CVB-

3 induced acute myocarditis (Fig. 1). Furthermore, Liu and

Zhao have demonstrated that heart function is improved by

declining circulating TNF-a concentration [23]. The neuro-

humoral activation and the elevated oxidative stress during

the development of left ventricular dysfunction in conges-

tive heart failure can be triggered by proinflammatory

cytokines. Increased free oxidative radicals are able to lead

to an activation of p38-MAP-kinase and nuclear factor

kappa B (NFnB). These directly affect left ventricular

dysfunction by inducing cardiomycytolysis and by the

negative inotropic effects of reduced calcium uptake by

the sarcoplasmatic reticulum [24,25]. Another important

pathophysiologic process in the development of congestive

heart failure concerns the sympathic nervous system with

increased levels of catecholamines, which may result in an

overwhelming inflammatory reaction. Murray et al. have

demonstrated that chronic h-adrenergic stimulation leads to

an increase of myocardial gene expression and protein

production of TNF-a, IL-1h and IL-6 [26]. This result

confirms previous studies showing that isoproterenol

advances myocardial hypertrophy [27], myocyte degenera-

tion and inflammatory cell infiltration [28]. This is also in

line with our investigation, as described below, which shows

that the treatment of acute myocarditis with a h-adrenergicreceptor blocker leads to a reduced inflammatory response,

modulated immune reaction and decreased ECM remodel-

ing as well as an improved left ventricular function [29].

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3. Myocarditis and dilated cardiomyopathy

Myocarditis, an inflammatory disease of the myocardi-

um, diagnosed by standardized histological and immuno-

histological methods [30], is caused by both infectious and

noninfectious agents [31]. However, the main cause is the

viral infection of the myocardium with cardiotropic viruses,

like enterovirus or parvovirus [32]. Previous investigations

on endomyocardial biopsies showed that several other viral

agents like adenovirus or parvovirus B19 are also involved

in the etiology of myocarditis [3,4]. For the pathogenesis of

myocarditis, Kawai described a triphasic model with an

acute, subacute and chronic phase [33]. During the acute

phase the myocardium mainly expresses proinflammatory

cytokines, such as IL-1h, TNF-a and Interferon-g [34,35].

These elevated proinflammatory cytokine levels are linked

to histological changes such as myocyte necrosis and

apoptosis [36,37]. In this early stage of disease there is

very little infiltration of natural killer cells and macrophages

in the myocardium [38,39]. This phase is characterized by a

dominance of direct pathogenicity of viral action and

myocyte apoptosis with direct alteration of myocardial

architecture by destroying dystrophin [40–43]. In the

subacute phase an increase in myocardial cell infiltration,

especially T-lymphocytes, natural killer cells and fibroblasts

follows [33]. The protective effect of natural killer cells is

based on their suppression of viral replication by the

perforin-induced disturbance of infected cardiomyocytes

[44,45]. The importance of early suppression of viral

replication is shown by the more severe myocarditis seen

in a murine myocarditis model with a defect of NK-cells

[46]. Seko et al. could detect a time-dependent release of

cytokines, with an initial increase of proinflammatory

cytokines (IL-1h, IL-6, TNF-a, Interferon-g) to the 7th

day after infection, followed by regulatory cytokines like

IL-2, IL-4 and IL-10 [47]. The outcome of the virus-

induced immune response is not straightforward and may

vary greatly. An efficient viral elimination through a radical

immune response is required for a better outcome of the

disease. For example, patients with myocarditis who have

higher cardiac specific IgG have better survival prospects

[48] and furthermore, acute fulminant myocarditis with an

initial massive inflammation and more pronounced cellular

injury has a better long-term outcome as compared with

acute nonfulminant myocarditis [49]. On the other hand an

uncontrolled immune response is associated with an

inefficient viral elimination, pathological myocardial in-

flammation, and initiating of cross-reacting antibodies,

which result in progressive cellular injury and matrix

remodeling. The increase of cardiac cell-infiltration and

release of inflammatory cytokines directly correlate to the

development of left ventricular dysfunction [50]. Viral

persistence and chronic inflammation may finally lead to

the third and chronic phase of myocarditis with the

development of dilated cardiomyopathy. Enteroviral ge-

nome could be detected in the myocardium up to 90 days

after viral infection in a murine model of myocarditis,

which indicates one causal step of chronic myocardial cell

infiltration [51,52]. The importance of latent or persistent

virus with induced chronic myocardial inflammation has

been demonstrated in persistent Cytomegalovirus-myocar-

ditis [53] and in the development of left ventricular

dilatation in mice with persistence of Coxsackievirus B3

[54]. The presence of viral genome in endomyocardial

biopsies of patients with dilated cardiomyopathy underlines

the relationship between myocarditis and the development

of left ventricular dysfunction [2]. Another important step in

the development and progression of acute left ventricular

dysfunction and dilatation is the initiation of an adverse

remodeling of the ECM by immune mediators. Chronic

myocardial inflammation induces the pathological collagen

turnover resulting in loss of structural integrity of the

myocardium and in the development of left ventricular

dysfunction.

4. The extracellular matrix—collagen and cytokines

Myocardial ECM (mainly collagen type I and III and

fibronectin, elastin, etc.) forms a three dimensional cross-

linked collagen-network which supports the cellular and

structural integrity of the heart. After secretion into the

ECM, the fibril-forming collagens aggregate spontaneously

after following the processing of procollagens into ordered

fibrillar network, stabilized by covalent cross-links. The

structural elements are dynamic and there is a complex

network of receptors and enzymes within the ECM which

controls the turnover of this tightly regulated system.

Collagen production and degradation is an important

process in the development of left ventricular dysfunction

in acute and chronic myocarditis and determines the

maintenance of cardiac architecture.

Collagen synthesis by cardiac fibroblasts is regulated by

multiple factors, including inflammatory cytokines like

TNF-a, IL-1h or TGF-h, TNF-a and IL-1h have been

shown to decrease the expression of procollagen type I and

III and increase the expression of fibronectin and non-

fibrillar procollagen type IV. Furthermore, several other

factors like aldosterone, TGF-h or mechanical stretch have

been shown to induce the mRNA synthesis of collagen [12].

The renin-angiotensine-system also partakes in the regula-

tion of collagen synthesis; angiotensin II induces ECM

protein synthesis and accumulation via AT1-receptor stim-

ulation, effects that are mediated by TGF-h1 and endothelin-

1 [55]. A rat model of myocardial infarction showed the

importance of this myocardial remodeling: ACE inhibition

prevented collagen accumulation and DNA synthesis and

furthermore completely inhibited collagen deposition with

AT1-receptor antagonism [56].

Fibrillar collagen turnover results from the equilibrium

between the synthesis and the degradation of collagen,

mainly types I and III. In the healthy left ventricle ECM

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replacement is about 5% to 9%, in pathological conditions,

e.g. after myocardial infarction, this figure can rise to 50%

[57]. Furthermore the rate of collagen synthesis per day is

much slower than of noncollagen proteins with a longer

half-life period of collagen, implying a fairly slow ECM

replacement after degradation and potential vulnerability for

adverse remodeling [58]. This additionally reduces the

ability to form the three dimensional network with collagen

cross-links, which leads to alteration in the composition and

structure of myocardial collagen.

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5. The MMP system

Collagen degradation is an important step in ECM

remodeling, mainly due to matrix metalloproteinases

(MMPs) and serine-proteinases. The matrix metalloprotei-

nases are a family of 20 different species of zinc-dependent

enzymes [59], which could be expressed under basal

conditions by fibroblasts and myocytes and also in response

to inflammatory reactions by infiltrating macrophages and

lymphocytes. One group of MMPs is secreted into the

extracellular space in a latent or proenzyme form and the

other group is membrane-bound. Regarding the catalytic

domain of MMPs, a large extracellular binding domain at the

C-terminus is responsible for the substrate specificity and the

specific binding to ECM proteins [59,60]. In addition, these

substrate specificities and functions classify the secreted

MMPs in three different groups. First the collagenases

(MMP-1, MMP-8, MMP-13) decompose the insoluble

collagen fibrils into soluble fragments [61]. The cleaving

of these soluble fragments is continued by gelatinases

(MMP-2, MMP-9), which are highly expressed in the left

Fig. 2. Simplified mechanism of regulation in the Matrix-Degr

ventricular myocardium [7,62]. Coker et al. showed an

isolated expression of these gelatinases in LV-myocytes,

which supports the possibility of a direct processing of

matrix remodeling by the synthesis and release of MMPs

[63]. MMP-2 is thereby constitutively expressed in the

myocardium, whereas MMP-9 is an inducible form of the

MMPs and becomes more relevant under inflammation with

inducible expression in neutrophils and macrophages

[64,65]. The third group, the stromelysine-like MMP-3,

degrades not only a wide range of components of the ECM, it

can also initiate the activation of the inactive pro-MMPs.

The group of membrane-bound MMPs (Membrane

Type-MMP, MT-MMP) plays also a critical role in matrix

remodeling, which on the one hand cleaves intact fibrillar

collagen and basement membrane components and on the

other hand directly activates different pro-MMPs [66].

However MMPs do not only play a role in the degradation

of the ECM-components, the final fragmented matrix

peptides also have biological activities and have been

shown to stimulate new collagen synthesis by cardiac

fibroblasts [67].

Beside the ECM components, the target substrates of the

MMPs also include nonmatrix proteins such as cytokines,

receptors and adhesions molecules [68–70]. This explains

additional functions of MMPs as for example regulating

growth, cell pathways, and angiogenesis [71]. The capabil-

ity of activated MMPs to degrade the complete ECM is

conditioned by a tightly controlled system. First, the control

at the transcriptional level by several cytokines or growth

factors; second the control of pro-MMP activation by serine

proteinases (Plasmin-system), MT-MMPs or stromelysines;

and last the inhibition of activated MMPs by the tissue

inhibitors of MMPs (TIMP1-4) (Fig. 2).

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5.1. Synthesis of MMPs

The synthesis of MMPs at the transcriptional level is

influenced by multiple cytokines, neurohormones and

growth factors [72]. Different signaling pathways have

been shown to be involved in regulation of the expression of

MMPs [73–80].

It could be demonstrated that proinflammatory cytokines

like IL-1h, TNF-a or IL-6 induce MMP-synthesis [12,13].

Furthermore, in mice with over expressing TNF-a, a

progressive development of left ventricular dilatation is

associated with increased MMP-activity [20]. In collabora-

tion with TNF-a, interferon-g enhances the MMP-1

synthesis in human monocytes and neutralizing antibodies

against TNF-a block the induction of MMP-1 by interferon-

g [81]. By contrast, TGF-h1 on the one hand decreases the

proteolytic activity of MMP-1 and MMP-3 by suppressing

MMP gene expression through the TGF-h inhibitory

element (TIE) and on the other hand increases the

expression of MMP-2 and MMP-9 [14,82]. Beside inflam-

matory cytokines, several other bioactive molecules also

influence the synthesis of MMPs. Angiotensin II plays a

pivotal role here: It has been demonstrated that angiotensin

II induces the expression of MMP-2, -9 and -14 in neonatal

rat fibroblast [83]. Its importance in this regulating process

is further shown by an improvement in left ventricular

function and myocardial geometry through reduced MMP-

synthesis after ACE-inhibition or AT-1 blockade [84,85].

Endothelin-1 enhances the production of MMP-2 and

MMP-9 and endothelin receptor blockade results in reduced

levels of MMP-2 and -9 [86]. Furthermore, natriuretic

peptides like BNP (brain natriuretic peptide) are able to

induce the MMP-synthesis in chronic heart failure and

myocardial remodeling [87].

5.2. Activation of MMPs

MT-MMPs and MMP-3 activate different members of

the MMP family by proteolytic cleavage of the MMP-

propeptide [15,66,88]. Even more important is the plasmin-

ogen system (plasminogen activators (PA), tissue-type PA

(t-PA), urokinase-type PA (uPA) and the PA-inhibitor

(PAI)), which activates the inactive proMMPs as described

above [88]. The importance of this system in disrupting the

cardiac collagen network has been previously demonstrated

in mice lacking uPA or mice with acute pressure overload

with PAI gene transfer showing improved left ventricular

function with reduced myocardial fibrosis and preserved

interstitial matrix [89]. Beside MMP-activation the PA are

also able to cleave matrix proteins like fibrin and

fibronectin. The expression of uPA [90], which has the

same transcription factor binding elements (AP-1, PEA3) in

the promotor region like MMP-1 and MMP-3 is induced by

IL-1h and TNF-a [91]. In fibroblasts, IL-1h increases not

only the protein and mRNA expression of uPA but also its

receptor uPAR [92]. Furthermore, there is a feedback

regulation between the MMPs and the plasmin-system;

MMP-3 has been demonstrated to cleave their physiological

inhibitor (PAI, a2-antiplasmin) resulting in neutralization

[93,94].

5.3. Inhibition of MMPs

Active MMPs are specifically inhibited by their endog-

enous inhibitors, the TIMPs that are composed of four

subtypes (TIMP-1-4) [81,95–97]. TIMPs bind to the active

site of MMP in a 1:1 stoichiometrie, blocking their access to

collagen substrate [15,98]. Furthermore they can bind latent

MMPs at the aminoterminus thereby preventing their

activation [99]. Some differences in the inhibitory properties

of the different TIMPs have been reported. TIMP-2 and

TIMP-3 have been proven to be effective inhibitors of

membrane-bound-MMPs, and TIMP-3 is the only TIMP

which can inhibit TNF-a converting enzyme [100,101].

Mice deficient of TIMP-1 gene develop increased left

ventricular mass and increased end diastolic volume

suggesting its important role in the prevented activation of

the protease cascade and in the maintenance of a dynamic

matrix balance. Inflammatory mediators also influence this

third step in the control of MMP-activity; IL-1 and TNF-a

can down regulate the expression of TIMP-1 [15]. Beside

this specific inhibition a2 macroglubulin and heparin

nonspecifically inhibit MMP-activity [102,103].

This widespread influence of inflammatory reaction on

the regulation of the matrix degradation system reflects a

deregulation in disease with pathologically elevated inflam-

matory mediators.

6. Extracellular matrix remodeling

6.1. ECM in acute myocarditis

Our previous investigations focused on the inflammatory

reaction in virus-induced acute myocarditis caused by

disruption of the collagen turnover and the resulting

changes in the ECM and its influence on left ventricular

dysfunction [1]. We could show that in the early phase of

myocarditis the main disruption of ECM is caused by

qualitative changes in the collagen network. Expression of

myocardial mRNA and protein abundance of collagen type

I was unchanged as was total collagen content measured by

picrosirius red staining. However Western blot analysis

demonstrated an increased fraction of soluble collagen,

suggesting an initial dominance of posttranslational colla-

gen variation contingent on an imbalance in the matrix

degradation system. Corroborating these findings, Wood-

iwiss et al. have demonstrated that a reduction in collagen

cross-links is responsible for the decreased native insoluble

or increased soluble collagen and is associated with left

ventricular dysfunction, remodeling and chamber dilatation

[104]. MMP-9, which depolimerizes the cross-linked

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polymers of collagen type I [105], seems to play an

important role. Furthermore, LV enlargement after myocar-

dial infarction could be prevented by deletion of the MMP-

9 gene [106]. CVB-3 infection of the myocardium caused a

significant release of proinflammatory cytokines such as IL-

1h, TNF-a and TGF-h on the 10th day post infection. This

was accompanied by an up regulated expression of MMP-3

and MMP-9 and reduced levels of their endogenous specific

inhibitors TIMP-1 and TIMP-4. Furthermore, our unpub-

lished data show evidence of an imbalance in the plasmin

regulation system in this acute early phase of myocarditis

by significant induced mRNA abundance of uPA with

simultaneously reduced levels of PAI mRNA abundance

(Fig. 3). As described above, a restored interstitial matrix

with an undilated chamber could be demonstrated in a uPA

knock-out model of chronic volume overload [89], suggest-

ing that the above demonstrated imbalance in the matrix

degradation system was mainly responsible for the devel-

opment of left ventricular dysfunction. Increased levels of

MMPs, decreased levels of TIMPs and the activated

plasmin system in the acute phase of myocarditis may lead

to an imbalance in the matrix degradation system in favour

of matrix protein degradation. This ultimately reduces the

matrix integrity and disrupts the three dimensional collagen

network by cleaving the cross-links between the collagen

molecules, which then leads to left ventricular dysfunction

and dilatation.

Fig. 3. Differential mRNA abundances of myocardial MMP-3, TIMP-1, PAI and

Dominance of matrix degrading components with loss of their controlling agents

6.2. ECM in dilated cardiomyopathy

As described above, previous investigations suggested an

association between myocarditis and inflammatory cardio-

myopathy caused by viral persistence. Signs are dystrophin

degradation, myocardial inflammation with cytotoxic T-

lymphocyte-mediated myocytolysis, B-lymphocyte-mediat-

ed generation of autoantibodies and induction of the MMP-

system with pathologic collagen degradation and left

ventricular dilatation. The results of our recent analysis of

endomyocardial biopsies emphasize the importance of

persistent inflammation in dilated cardiomyopathy regarding

ECM alterations and the development of left ventricular

dysfunction. The myocardial mRNA abundance of MMP-3

and TIMP-1 was analyzed in endomyocardial biopsies of

patients with dilated cardiomyopathy with or without

inflammation and in biopsies of patients with normal left

ventricular function without histological signs of inflamma-

tion. We could demonstrate a significantly induced expres-

sion of myocardial MMP-3 in inflammatory cardiomyopathy

accompanied by a reduced expression of TIMP-4 [107] in

dilated cardiomyopathy without inflammation. This is in line

with the results of Schwartzkopff et al. who have shown

elevated serum markers of collagen degradation accompa-

nied by increased levels of MMP-1 in patients with DCM

[108]. Furthermore there was a negative correlation between

the MMP/TIMP ratio and the degree of LV-dilatation,

uPA and gelatinase activity in acute myocarditis on 10th day postinfection.

. Tp <0.05 were considered as significant.

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underlining the importance of collagen degradation in the

development of left ventricular dysfunction. Moreover, we

could detect a co-localization of CD-3 and MMP-3,

measured by immune histochemistry, which further empha-

sizes the importance of inflammation in this pathogenesis.

The increased production of collagen in the later stage of

myocarditis seems to be a response to collagen degradation

caused by increased MMP-activity. Since matrikines en-

hance the synthesis of procollagen it might be possible that

after the initial importance of degradation, fibrosis takes

over in the later phase of myocarditis [58]. This was also

verified by Pauschinger et al. in patients with DCM, who

had an increase in the myocardial collagen content

measured by picrosirius red staining [8]. McCormick et al.

speculated that there was a defect in collagen cross-linking

pathways, leading to an increase in collagen concentration

and collagenase activity with ventricular dilatation since in

patients with idiopathic dilated cardiomyopathy, collagen

deposition was doubled but hydroxyproline concentration

was reduced [109,110]. Furthermore a prospective study on

serum markers of collagen metabolism in idiopathic DCM

showed that patients with increased serum markers had an

increased risk for transplantation, impaired left ventricular

function, or advanced clinical stage of heart failure, and

death suggesting that increased collagen synthesis and

degradation act as a factor in risk stratification [111].

During the fibrotic process, the collagen accumulation

was also accompanied by a change in the ratio of Collagen I

and III, suggesting increased myocardial stiffness with

impaired systolic and diastolic function [8].

Kuhl et al. have demonstrated an improved left

ventricular function by eliminating viral persistence (Ade-

novirus and Enterovirus) through therapy with Interferon-h[112]. In this study the viral elimination led to significantly

reduced inflammation, which furthermore reflects the

pivotal role of viral persistence and chronic induced

inflammation. Kuhl et al. also suggest that active viral

replication interferes with inflammatory cytokine release as

well as with matrix integrity. This may be partially

reversible after viral elimination and could explain im-

proved cardiac function after viral elimination. Further

analysis will show whether the possibly reduced patholog-

ical alterations of the MMP/TIMP system in response to

myocardial collagen deposition play a role in the develop-

ment of improved left ventricular dysfunction after viral

elimination through h-interferon.

6.3. ECM-remodeling in acute myocarditis with

b-adrenergic-blockage

In order to explore the influence of induced sympathic

activity and oxidative stress on cardiac inflammatory

reaction we investigated the effect of a h-adrenergic-blockage on a possible improvement of myocardial injury

and imbalance in the MMP/TIMP-system [29]. The effects

of carvedilol and metoprolol on myocardial inflammation,

ECM remodeling and left ventricular function were

examined in hearts of Coxsackievirus B3 infected Balb/c

mice on the 10th day after infection. Carvedilol could

improve left ventricular dysfunction with a significant

enhancement of LVESP, dP / dtmax and dP / dtmin [113].

This improvement was accompanied by a reduced inflam-

matory reaction as shown by the reduced release of

proinflammatory cytokines such as IL-1h, TNF-a and

TGF-h. The importance of proinflammatory cytokines in

the development of left ventricular function was demon-

strated by a significant correlation between the myocardial

enlargement caused by proinflammatory cytokines and

cardiac hemodynamic parameters. We could furthermore

show an improved balance of the MMP/TIMP-system with

reduced levels of myocardial mRNA abundance of MMPs,

especially MMP-8, reflecting a reduced myocardial cell

infiltration by the cell specific expression of neutrophils

underlined by its significant correlation to the regulation of

IL-1h, TNF-a. This emphasizes the complex interaction of

ECM remodeling, neurohumoral activation, reactive oxygen

species, myocardial cell infiltration and release of proin-

flammatory cytokines. A comparison between carvedilol

and metoprolol showed that carvedilol exerts a better effect

in the improvement of left ventricular function. This might

be due to the absent effect of the selective h-adrenergicblocker metoprolol on the release of myocardial proin-

flammatory cytokines and MMPs. Nishio et al. demonstrat-

ed that the actions of epinephrine could be blocked by

carvedilol and propanolol, but not by metoprolol, suggest-

ing maintenance of epinephrine effects over h2-adrenergic

receptor stimulation [114]. Besides antioxidative properties

[115], carvedilol has also been proven to inhibit the

generation of free oxygen radicals by neutrophils [116]

and to reduce the production of oxidized low density

lipoproteins [117]. This might partially explain its expanded

effects on the MMP/TIMP-system which could explain the

improved cardiac function.

7. Conclusion

The myocardial ECM is a complex network which

balance determines the structural integrity of the heart.

Alteration in the matrix degradation system caused by

inflammatory mediators, oxygen species and neurohumoral

reaction leads to an impairment of left ventricular function

as seen in myocarditis and inflammatory cardiomyopathy.

The imbalance of the matrix degrading system with induced

expression of MMPs and plasminogen activators as well as

the reduced expression of TIMPs, leads to a pathologic

collagen turnover, with the loss of structural integrity of the

heart and an impairment of LV function. Therefore, the

regulation of the MMP/TIMP system is an important

therapeutic target in the prevention of the progression of

inflammatory heart failure. Further investigations are

needed to determine the best target for intervention in order

S. Rutschow et al. / Cardiovascular Research 69 (2006) 646–656 653

to influence this complex system leading to a dynamic

balance between collagen accumulation and degradation.

Acknowledgement

This research was supported by a grant of the Deutsche

Forschungsgemeinschaft (DFG Transregio 19).

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