The present study is the first to investigate the effect of VNS started just prior to and continued during early reperfusion on both infarct size and extent of no-reflow in a large animal model of STEMI, using a clinically translational protocol. The main findings were that (1) VNS significantly limited infarct size and extent of no-reflow; (2) these effects were accompanied by reductions in regional infiltration of neutrophils and macrophages; (3) Inhibition of NO-synthase prevented the cardioprotection by VNS against necrosis, no-reflow and leukocyte influx.
Infarct size
Several studies, though not all [
3,
4], indicate that VNS limits infarct size, when started prior to [
8,
21,
54], at [
22,
25,
40] or halfway through [
39,
48] the onset of myocardial ischemia (Table
4). The majority of these studies have been performed in rodents or rabbits, which are sympathetically dominant, and are therefore likely to have a different sympathico-vagal balance than larger mammalian species such as pigs and humans. Although it could be argued that this may enhance the effects of VNS in smaller animal species with low baseline vagal activity, recent studies observed that VNS produced similar reductions in infarct size in swine [
39,
40], suggesting that its cardioprotective effects do not critically depend on basal vagal activity.
Table 4
Studies on the cardioprotective effects of vagal nerve stimulation
Pre/onset
ischemia
|
| Rat | 30 min/2 h | 5 min pre-ischemia | 35 min | Sham | 85 ± 3 | – |
VNS | 34 ± 2* |
| Rat | 30 min/24 h | 5 min pre-ischemia | 40 min | Sham | 53 ± 5 | – |
VNS | 7 ± 1* |
| Rat | 60 min/2 h | 15 min pre-ischemia | 75 min | Sham | 47 ± 4 | – |
VNS | 27 ± 3* |
| Rat | 4 h/0 h | Onset ischemia | 240 min | Sham | 52 ± 2 | – |
VNS | 28 ± 2* |
| Mouse | 3 h/0 h | Onset ischemia | 180 min | Sham | 56 ± 1 | – |
VNS | 24 ± 2* |
| Rabbit | 30 min/3 h | 10–15 min pre-ischemia | 10 min | Sham | 52 ± 4 | – |
VNS | 71 ± 4* |
| Rabbit | 45 min/4 h | 10 min pre-ischemia | 10 min | Sham | 45 ± 2 | – |
VNS | 63 ± 3* |
I-VNS | 30 ± 3* |
Shinlapawittayatorn et al. [ 40] | Swine | 60 min/2 h | Onset ischemia | 180 min | Sham | 46 ± 5 | – |
VNS | 19 ± 4* |
I-VNS | 5 ± 2* |
Early/mid-ischemia
|
Shinlapawittayatorn et al. [ 39] | Swine | 60 min/2 h | 30 min into ischemia | 150 min | Sham | 46 ± 3 | – |
I-VNS | 19 ± 3* |
| Rat | 30 min/2 h | 15 min into ischemia | 30 min | Sham | 72 ± 2 | – |
VNS | 47 ± 3* |
Pre/onset
reperfusion
|
Shinlapawittayatorn et al. [ 39] | Swine | 60 min/2 h | Onset reperfusion | 120 min | Sham | 46 ± 3 | – |
I-VNS | 44 ± 3 |
Uitterdijk et al. | Swine | 45 min/2 h | 5 min pre-reperfusion | 20 min | Sham | 67 ± 2 | 54 ± 6 |
VNS | 54 ± 5* | 32 ± 6* |
From the studies in Table
4, it is difficult to determine whether the protective effect of VNS occurred during ischemia or whether a reduction in lethal reperfusion injury contributed as well. Two studies in which no reperfusion was allowed [
22,
25] suggest that at least part of the protective effect is targeted against ischemic cell death. Furthermore, a recent study reported that an intermittent VNS protocol failed to attenuate infarct size when started at the very onset of reperfusion [
39], questioning whether VNS can protect against reperfusion injury. In view of the critical importance of the presence of an intervention during the golden first minute(s) of reperfusion [
42], we hypothesized that continuous VNS started just prior to reperfusion might be effective against reperfusion injury. Indeed, we found that VNS, started a few minutes prior to reperfusion, was able to reduce myocardial infarct size, showing its cardioprotective potential against lethal reperfusion injury. The discordance between our findings and the study of Shinlapawittayatorn et al. [
39] may well be due to the difference in VNS algorithm, i.e., intermittent VNS starting at the very onset of reperfusion [
39] versus continuous VNS starting 5 min prior to reperfusion (Table
4), and may thus reflect the importance of full VNS during the golden first minute(s) of reperfusion [
42].
The mechanism by which VNS limits infarct size is presently incompletely understood, but could involve indirect hemodynamic effects. Thus, the decrease in heart rate and the rate–pressure product could lower metabolic demand and modify reactive hyperemia during early reperfusion, thereby generating favorable (gentle) reperfusion conditions [
32]. However, most evidence suggests that VNS-induced cardioprotection is independent of the reduction in heart rate. Thus, Calvillo et al. [
8] showed that restoring the heart rate to baseline levels by atrial pacing did not affect cardioprotection by VNS, while several studies have shown a lack of correlation between the reduction in heart rate and the reduction in infarct size by VNS [
8,
21,
40]. Those findings are supported by the lack of a significant correlation between the rate–pressure product and infarct size in the present study (Fig.
6). Moreover, coronary reactive hyperemia was not attenuated during VNS (Supplemental Figure S1), which may have been due to the opposing effects of the bradycardia-associated blunted metabolic stimulus for reactive hyperemia and the bradycardia-associated increase in diastolic perfusion time. Taken together, these findings suggest that the VNS-mediated cholinergic activation [
8] and muscarinic receptor stimulation [
40] protect against necrosis principally via a direct myocardial mechanism. Consequently, we studied the involvement of the reperfusion injury signaling kinase pathway, distal to the muscarinic receptor, by investigating the role of NO-synthase [
9]. NO-synthase inhibition abolished VNS-mediated cardioprotection, at a time when the hemodynamic effects of VNS were unperturbed, indicating that cardiac NO-synthase activity was critical for VNS-mediated infarct-size and no-reflow reductions. These observations are in line with studies from our laboratory [
28,
29] showing an important role for nitric oxide in cardioprotection against reperfusion injury, likely by limiting opening of the mitochondrial permeability transition pore [
36,
39,
40]. Future studies are needed to further investigate the molecular underpinnings of VNS-mediated cardioprotection.
No-reflow
Reperfusion following a prolonged period of myocardial ischemia is associated with microvascular obstruction, termed no-reflow [
38]. No-reflow is the result of endothelial cell damage, deterioration of the glycocalyx, increased neutrophil plugging, micro-embolization, microvessel rupture and edema [
15,
38]. No-reflow has been shown to be a strong clinical prognosticator for long-term outcome [
33,
38], which is, at least in part, due to its close correlation with infarct size [
18,
31,
45]. However, recent studies suggest that not only infarct size [
30,
51], but also the extent of no-reflow [
17,
33,
38] is an independent predictor of clinical outcome, which is supported by experimental studies reporting reductions in no-reflow by hypothermia [
17] or pharmacological intervention [
27], independent of a decrease in myocardial infarct size. These recent insights clearly suggest that novel strategies to limit no-reflow have significant therapeutic potential.
The present study is to our knowledge the first to investigate the effects of VNS on the extent of no-reflow. VNS markedly reduced no-reflow, which was accompanied by a reduction in recruitment of macrophages and neutrophils to the infarct area. These findings suggest that VNS modulates the regional immune response and are consistent with the activation of the cholinergic anti-inflammatory pathway by VNS [
8,
20,
48]. VNS-induced reduction of no-reflow in the infarct area was prevented by NO-synthase inhibition in parallel with the abolition of infarct-size limitation, indicating that NO signaling is critical for the cardioprotective effects of VNS against both cardiomyocyte necrosis and microvascular obstruction.
Methodological considerations
An intriguing observation in the present study was that the values for no-reflow of sham animals were considerably higher in the first (Fig.
2) than in the second (Table
3) series of experiments. The second series of experiments was performed approximately 1–2 years after completing the first series. Plotting all sham–control animals that underwent 45 min of ischemia and 120 min of reperfusion in the first series (2011 + 2012) and in the second series (2013 + 2014) demonstrates that the no-reflow area (and to a lesser extent infarct size) was significantly smaller in the latter period (Supplemental Figure S2). Although an explanation is not readily found (same supplier, same swine breed, same laboratory, same investigators), it should be noted that the first series was principally performed in the period of February–July, whereas the second series was performed in the period of August–January, suggesting that seasonal influences could be involved [
24]. Although the present study does not allow identification of the exact mechanisms underlying these differences, the observations do emphasize the importance of time-matched sham–control experiments, as performed in the present study.
We also observed that while the occurrence of VF was high in both control + sham and LNNA-treated swine, there was a trend toward an increase in intractable VF from 27 % (3 out of 11) in sham animals to 53 % (9 out of 17) in LNNA-treated animals (
p = 0.19). These findings are not readily explained, but there is evidence that loss of NO bioavailability increases the susceptibility to VF during ischemia–reperfusion [
2,
6,
23]. Importantly, intractable VF invariably occurred prior to randomization to sham or VNS treatment in both control + sham and LNNA-treated animals and hence did not affect the study results.
A potential limitation of the present study is that we studied only the very early effects of VNS on infarct size and no-reflow in swine with acute myocardial infarction, with a follow-up limited to 2-h post-reperfusion. This time point was chosen in view of the demonstrated lack of development of infarct size and no-reflow over time between 2 and 5 h of reperfusion [
16], so that we do not expect that infarct size and no-reflow would have evolved much further beyond the 2-h point. However, the 2-h reperfusion time was clearly insufficient to allow the VNS-mediated infarct-size reduction to translate into significant improvements in regional and global LV function. Future studies are required to investigate the long-term effects of infarct-size and no-reflow reductions by VNS on LV remodeling and function.
Another methodological consideration is the use of pentobarbital anesthesia. Pentobarbital is known to possess vagolytic properties, although this effect appears negligible in swine, as heart rates under pentobarbital anesthesia ([
7]; present study) are not different from the heart rates we typically observe in awake resting swine [
14]. Importantly, even if vagal tone is reduced, the ability to stimulate the vagal nerve and induce bradycardia remains principally intact [
5], suggesting that pentobarbital’s vagolytic effects are centrally mediated and do not interfere with efferent vagal nerve stimulation.
In the present study, a custom-made coil to perform VNS was used, which may have contributed to a higher mA than what has been typically used (1–4 mA) in clinical studies [
10,
35,
53] and in a previous study (1–4 mA; 30 Hz, pulse width 0.2 ms) from our laboratory in swine [
7]. The latter was associated with reductions in heart rate of up to ~30 %. Those settings, which are similar to the settings used in VNS for the treatment of epilepsy and are well tolerated [
37,
46], were similar in frequency and pulse duration as used in the present study (25 Hz, 0.3 ms), but the intensity used in the present study (10 mA) was significantly higher. The fact that we produced slightly smaller reductions in heart rate at higher VNS intensities may reflect the custom coil versus the clinical grade coil that we previously had access to. It is important to note that this was a proof-of-concept study that did not test a clinically approved device, but investigated the efficacy of VNS started just prior to reperfusion and continued for only 15 min into reperfusion, in which we were able to demonstrate cardioprotection, despite a modest 20 % reduction in heart rate.
Another limitation of the present study is that only a single VNS protocol was studied and hence it is likely that other VNS algorithms may afford greater cardioprotection [
25]. Optimization of the VNS protocol may include changes in stimulation frequency [
1] and extending the duration of stimulation beyond 15 min of reperfusion.