Background
Pulmonary hypertension (PH) is a progressive disease with poor prognosis, which affects approximately 1% people worldwide according to recent epidemiological data [
1,
2]. In PH, the increased pulmonary vascular resistance results in chronic pressure overload to right ventricular (RV) and leads to right heart failure (RHF). The survival rate for pulmonary arterial hypertension (PAH) patients with stable RV function is much higher than patients with devastating RV function, independent of pulmonary vascular resistance, and RHF is the major cause of mortality and morbidity among PH patients [
3]. Because of the irregular size of RV, it is technically difficult to evaluate RHF precisely.
In the presence of pressure overload, RV cardiac fibroblasts activate and subsequently remodel the myocardium via pathological alterations of collagen network that surrounds cardiomyocytes and interstitium, which leads to myocardial fibrosis and reduced compliance of the RV [
4]. Currently, myocardial fibrosis is assessed by magnetic resonance imaging (MRI) and endomyocardial biopsy [
5]. However, cardiac fibrosis cannot be detected by MRI at the early stage of heart failure [
6], and endomyocardial biopsy is invasive. Fibroblast activation protein (FAP) is robustly expressed in activated fibroblast, and could be detected by FAP inhibitor-42 (FAPI-42) via positron emission tomography (PET)/computed tomography (CT) imaging [
7]. Currently, FAPI PET/CT has been used to identify fibroblast activation in the process of lung and liver fibrosis [
8,
9], and a recent image study reported higher uptake of FAPI in the RV of a PH patient with PET/CT imaging [
10,
11]. However, the effects of [
18 F] ‑FAPI-42 PET/CT for evaluating the progress of RHF, especially the early stage of RHF, have not been reported.
In addition to myocardial fibrosis, the other pathological changes of RV failure include hypertrophy, inflammation and capillary rarefaction; while molecular changes include alteration in the expression of genes related to extracellular matrix, inflammation, angiogenesis, mitochondrial biogenesis and reactive oxygen species production [
12]. Despite of these understandings, there is a lack of approaches for early diagnosis of RHF, and there is no medical treatment that directly targets RV failure so far [
13]. In an attempt to explore novel mechanisms that may lead to early diagnosis and precise evaluation of RHF, this study is aimed to demonstrate the process of RV failure development and progression in response to pressure overload. Here, using surgical pulmonary artery banding (PAB) to establish an RV pressure overload rat model, we sought to demonstrate the longitudinal echocardiographic, hemodynamic, histological, and molecular changes of RVF, and determine the dynamic changes of [
18 F] -FAPI-42 uptake via PET/CT at a series of time points.
Discussion
This study demonstrated that RV myocardial hypertrophy, RV fibrosis and capillary rarefaction emerged early after PAB and gradually progressed with the duration of pressure overload, which suggest that pressure overload-induced RV dysfunction is progressive. Using RNA-seq as an unbiased tool, we identified that genes related to fibrosis is the most critical process of RHF. Inspired by these findings, we investigated the changes of FAP which has been developed as an imaging maker of fibrosis, and found that the uptake of [18 F]-FAPI-42 was gradually increased via PET/CT imaging with the duration of pressure overload; in addition, the uptake of [18 F]-FAPI-42 is RV is associated with cardiac fibrosis detected by tissue staining. To best of our knowledge, this is the first study that applied [18 F]-FAPI-42-PET/CT as a noninvasive tool for precise evaluation of RHF development and progression.
In response to pressure overload, the changes of RV structure include cardiomyocyte hypertrophy, fibrosis and capillary rarefaction, which termed as RV remodeling. In our study, we found that RV hypertrophy appears earlier than fibrotic and vascular myocardial remodeling in rat PAB model, which is consistent with the results from other RV pressure overload models which are mainly PH animal models [
25]. Compared with the RV pressure load study in PH animal models induced by monocrotaline, hypoxia or SU5416 + hypoxia, the RV remodeling in PAB models is purely dependent of pressure overload, as drugs or hypoxia may lead to direct damage on RV function [
26]. Interestingly, we found that the RVEDP began to increase at day 3 and peaked at week 2 after PAB, then gradually decreased at 4 and 8 weeks. This result is consistent with a previous report which shows that RVEDP peaked at week 2, and gradually decreased at week 5 and 12 post-PAB in rats [
27]. The following reasons may contribute to the decline in RVEDP after 2 weeks: first, the rats used in our study were 6-week-old, which is still growing at the beginning of the experiment, and the growth of body and heart at the later time points may affect RVEDP; second, the degree of anesthesia could be lower in the later time points in our experiment, which may reduce RVEDP. These speculations were supported by the fact that the rats in the sham group also showed lower RVEDP at week 4 and 8 than those at week 2.
Using an unbiased RNA sequencing analysis, we found that the most enriched GO terms of the key upregulated genes in the RV from PAB models are associated to collagen fiber deposition, which is an important process of tissue fibrosis. RV fibrosis is important for PH prognosis, PAH patients with systemic sclerosis which is characterized by excessive fibrosis in the body including RV have a shorter survival duration [
28]; in the contrary, PAH patients with Eisenmenger syndrome show less RV fibrosis and have a longer survival duration, when compared to idiopathic PAH [
29]. These may suggest that excessive myocardial fibrosis in RV implicates worse prognosis in RHF. Pathophysiologically, myocardial fibrosis leads to RV stiffness [
25], and diminished diastolic and systolic function of RV, which may eventually result in decompensated RHF. Cardiomyocytes have been found as the cell type that immediately respond to pressure overload in RV, which has been considered as compensative because hypertrophic RV could overcome the increased pulmonary vascular resistance to maintain sufficient cardiac output. As the pressure overload persists, RV hypertrophy transits to RHF, and RV fibrosis is a remarkable feature in decompensated RHF [
30]. In a PAB model with gradual reduction of the afterload burden through absorption of pulmonary artery bands, normalization of cardiomyocyte hypertrophy was observed at earlier time point compared to the reversal of myocardial fibrosis [
31]. These may suggest that if myocardial fibrosis appears in RV, it may take longer duration for PH patients to recover with afterload reduction. Thus, it is important to determine RV fibrosis in PH patients, which may help the PH specialists to evaluate the prognosis of the disease.
Currently, there is no ideal technique for assessing RV fibrosis effectively in RHF patients. Myocardial fibrosis is mainly assessed by magnetic resonance imaging (MRI) and endomyocardial biopsy [
5]. Nevertheless, myocardial fibrosis cannot be detected by MRI at the early stage of heart failure, and endomyocardial biopsy is invasive. Several case reports revealed that the right heart uptake of
68Ga-FAPI was observed in patients with idiopathic PAH and chronic thromboembolic pulmonary hypertension (CTEPH) [
11,
32]. However, it remains unknown whether FAPI-PET/CT can be used to estimate the severity of RV fibrosis or detect RV fibrosis as early as tissue biopsy. Compared to
68Ga (t
1/2=67.8 min), which is typically produced in limited quantities and has a short half-life,
18 F (t
1/2=109.7 min) offers greater convenience in terms of transportation and availability from cyclotrons, and its lower positron energy (
18 F 0.25 MeV vs.
68Ga 0.83 MeV) provides higher spatial resolution in PET/CT imaging. The
18 F-labeled FAPI targeted radioligand,
18 F-FAPI-42, has been reported following to exhibit comparable uptake in FAP-positive cells and tumors as
68Ga-FAPI-04 [
33], with numerous studies demonstrating its diagnostic efficacy in various cancers and fibrotic diseases [
34‐
36]. In our study, using a noninvasive [
18 F] -FAPI-42-PET/CT imaging, we could identify obvious RV fibrosis 2 weeks after PAB, and this time point is consistent with our pathological finding of myocardial fibrosis from RV specimen. Moreover, correlation analysis shows that RV uptake of [
18 F] -FAPI-42 in PET/CT is positively associated with collagen deposition detected by Masson’s Trichrome staining of RV specimen with the progression of RHF. These may suggest that [
18 F] -FAPI-42-PET/CT is as accurate as tissue biopsy in evaluating RV fibrosis induced by pressure overload, even at the early phase of RHF. Pulmonary arterial adventitial fibroblast (PAAF) plays an essential role in pulmonary artery remodeling during the progression of PH. PAAF activation deteriorates PH through reduction of pulmonary artery compliance and induction of perivascular inflammation [
37,
38]. Using
68 Ga-FAPI-04 PET/CT in thirteen patients with CTEPH, nine (69%) patients showed enhanced
68 Ga-FAPI-04 uptake in the main pulmonary artery (PA) and PA branches, and
68 Ga-FAPI-04 activity in PA is positively correlated with pulmonary diastolic pressure [
39]. Together with our findings in RV, these suggest that FAPI-PET/CT has the potential to assess fibroblast activation in both RV and PA, as RV-PA coupling is vital to the prognosis of PH patients [
40], measurement of fibrotic remodeling in both RV and PA may provide a new perspective for the evaluation of PH.
Current RHF therapies rely on load amelioration, and there is no approved therapy that directly improve RV function. As fibrosis is the most prominent molecular changes and positively correlated with the progression of RHF; thus, inhibition of myocardial fibrosis remodeling is a potential strategy to preserve RV function. In this study, we found that FAP is significantly increased after PAB and correlates with myocardial fibrosis detected by RV pathological staining. Indeed, FAP is not only a marker of tissue fibrosis, but also participates in fibrogenesis. In mice myocardial infarction model, inhibition of FAP reduces ventricular fibrosis, improves cardiac function and promotes angiogenesis via stabilizing BNP [
41]. And pharmacological FAP inhibition alleviates liver fibrosis in chronic liver injury via attenuating macrophage infiltration and activation [
42], macrophage-derived inflammation contributes to the development of RHF [
43]. The above may suggest that targeting FAP may change the prognosis of RHF, which is worth to be investigated in the future. In addition, GO analysis shows that transforming growth factor-β (TGF-β) cascade was enriched among the upregulated genes in the RV tissue from PAB rats (Fig. 3E). As activation of TGF-β pathway has been reported to exacerbate left ventricular fibrosis under pressure overload [
44], these may suggest that TGF-β pathway contributes to RHF development. Recent clinical trials indicated that sotatercept, a drug that targets TGF-β pathway, reduces pulmonary vascular resistance among PH patients [
45]. Thus, this drug may benefit PH patients in both pulmonary vascular resistance amelioration and RV function preservation via inhibiting TGF-β pathway.
Several limitations should be considered in this study. First, only male rats were used to induced PAB models; we choose the male in this study because female rats show better adaptation to RV afterload burden [
46]. Second, we only observed the RV changes in 8 weeks after PAB because there is a high mortality rate after 8 weeks due to severe RHF. Third, the results in this study should be considered as a proof-of-principle study, more mechanistic studies are warranted to demonstrate the mechanism of fibrosis and FAP changes in RV under pressure overload.
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