2021 12 17 21267825v1 Full

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1 Matrix metalloproteinase 2 and 9 enzymatic activities are selectively increased in
2 the myocardium of Chronic Chagas Disease cardiomyopathy patients: role of
3 TIMPs
5 Running title: Metalloproteinases 2 and 9 in Chagas disease
7 Monique Andrade Baron1,2,3,¶, Ludmila Rodrigues Pinto Ferreira1,2,3,4, ¶, Priscila Camillo
8 Teixeira1,2,3,¶,#a, Ana Iochabel Soares Moretti5, Ronaldo Honorato Barros Santos6,
9 Amanda Farage Frade1,2,3,#b, Andréia Kuramoto1,3, Victor Debbas4, Luiz Alberto
10 Benvenuti6, Fabio Antônio Gaiotto5, Fernando Bacal5, Pablo Pomerantzeff5, Christophe
11 Chevillard7,*, Jorge Kalil2,3, Edecio Cunha-Neto1,2,3,*.
12
1
13 Laboratory of Immunology, Heart Institute (InCor), University of São Paulo, School of
14 Medicine, 05403-900, São Paulo, Brazil.

2
15 Division of Clinical Immunology and Allergy, University of São Paulo, School of
16 Medicine, 01246100, São Paulo, Brazil.

3
17 Institute for Investigation in Immunology (iii), INCT, 05403-001, São Paulo, Brazil.
4
18 Universidade Santo Amaro (UNISA), São Paulo, Brazil.
5
19 Vascular Biology Laboratory, Heart Institute (InCor), University of São Paulo, School
20 of Medicine, 05403-900, São Paulo, Brazil.

6
21 Division of Transplantation, Heart Institute (InCor), University of São Paulo, School of
22 Medicine, 05403-900, São Paulo, Brazil

7
23 INSERM, UMR_1090, Aix Marseille Université, TAGC Theories and Approaches of
24 Genomic Complexity, Institut MarMaRa, Marseille, France
25
NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.
1
medRxiv preprint doi: https://doi.org/10.1101/2021.12.17.21267825; this version posted December 17, 2021. The copyright holder for this
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26
27 ¶ These authors contributed equally to this work
28 Present addresses:
#a
29 Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124
30 Building 93 / Room 6.20 CH 4070 Basel, Switzerland.

#b
31 Bioengineering Program, Instituto Tecnológico, Universidade Brasil, rua Carolina da
32 Fonseca, 235, Itaquera, São Paulo, SP, Brazil.
33
*
34 Addresses for correspondence:
35 Edecio Cunha-Neto, Laboratory of Immunology, Heart Institute (Incor), Avenida Dr.
36 Enéas de Carvalho Aguiar, 44 – Bloco II, 9o. Andar. São Paulo, Brazil. 05403-900. E-
37 mail: edecunha@gmail.com
38 Dr. Christophe Chevillard, Theories and Approaches of Genomic Complexity (TAGC),
39 INSERM/AMU UMR_1090, Parc Scientifique de Luminy, case 928, 163, avenue de
40 Luminy, 13288 Marseille France Phone: 33491828736, E-mail:
41 christophe.chevillard@univ-amu.fr
42
43 Conflict of interest statement :
44 Authors have no financial and personal relationships that might bias their work. The
45 authors have declared that no competing interests exist.
46
47
48 Word count for the main text: 3500 words
49
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50 Abstract (150 words)
51 Chronic Chagas disease (CCC) is an inflammatory dilated cardiomyopathy with a worse
52 prognosis compared to other cardiomyopathies. We show the expression and activity of
53 Matrix Metalloproteinases (MMP) and of their inhibitors TIMP (tissue inhibitor of
54 metalloproteinases) in myocardial samples of end stage CCC, idiopathic dilated
55 cardiomyopathy (DCM) patients, and from organ donors. Our results showed
56 significantly increased mRNA expression of several MMPs, several TIMPs and
57 EMMPRIN in CCC and DCM samples. MMP-2 and TIMP-2 protein levels were
58 significantly elevated in both sample groups, while MMP-9 protein level was exclusively
59 increased in CCC. MMPs 2 and 9 activities were also exclusively increased in CCC.
60 Results suggest that the balance between proteins that inhibit the MMP-2 and 9 is shifted
61 toward their activation. Inflammation-induced increases in MMP-2 and 9 activity and
62 expression associated with imbalanced TIMP regulation could be related to a more
63 extensive heart remodeling and poorer prognosis in CCC patients.
64 Keywords: Chagas disease, metalloproteinases, heart failure; cardiac remodeling, MMPs
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65 Introduction
66 Chronic Chagas cardiomyopathy (CCC) is the most important chronic clinical
67 manifestation of Chagas disease, a zoonosis caused by the protozoan parasite,
68 Trypanosoma cruzi (T. cruzi) naturally transmitted through haematophagous reduviid
69 bugs, but also by blood transfusions, organ transplants or congenitally [1]. The World
70 Health Organization estimates that approximately 7-8 million people are infected with T.
71 cruzi in Central and South America [2], with an estimated 300.000 cases in the United
72 States and 120.000 cases in Europe alone due to migration of people from endemic areas.
73 The acute phase of Chagas disease usually lasts 6-8 weeks, and most frequently is oligo-
74 or asymptomatic [3]. About 30% of the asymptomatic patients will develop CCC, a
75 progressive, fibrotic disease in which myocardial inflammation plays a fundamental role
76 causing tissue damage and also dysregulation of heart extracellular matrix (ECM) leading
77 to a maladaptive cardiac remodeling that constitutes the basic step to a progressive heart
78 failure [4-8].
79 The term cardiac remodeling describes a response mechanism in response to injury and
80 differs from the physiological cardiac hypertrophy observed during gestation and
81 intensive exercising [9, 10]. Different cardiovascular disorders, like myocardial
82 infarction, ischemia, reperfusion injury and viral myocarditis displays an intense cardiac
83 remodeling that involves cardiac fibroblasts, the main cell type responsible for ECM
84 regulation and homeostasis [6, 11]. Cardiac fibroblasts perform important functions by
85 synthetizing ECM molecules as well as regulating the ECM turnover by secreting matrix
86 metalloproteinases (MMPs) [6, 12]. MMPs are zinc-dependent endopeptidases
87 responsible for degradation and remodeling of ECM components including collagens,
88 proteoglycans, fibronectin and laminin within the injury zone [12]. Because MMPs have
89 a dual role functioning in both physiological and pathological processes, their functions
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90 should be tightly regulated. MMPs are synthesized and secreted, in most cases, as inactive
91 proenzymes (pro-MMPs) that are activated by other proteinases [13, 14]. MMPs also
92 regulate the activities of effector proteins involved in inflammation and fibrosis [15]. The
93 homeostasis in a normal healthy heart is dependent on the balance between activation of
94 pro-MMPs to active degradative MMPs, a process controlled by complex formation with
95 their endogenous inhibitors: tissue inhibitors of MMPs (TIMPs) [13, 16]. MMPs
96 expression and activity were shown to be dysregulated in different cardiovascular
97 diseases and in failing hearts of various etiologies like acute myocardial infarction, DCM
98 and heart failure [17]. Two important members of MMPs, MMP-2 and MMP-9, are from
99 the group of gelatinases and have been indicated as key enzymes responsible for profound
100 cardiac remodeling [18, 19]. Right after an acute injury, like a myocardial infarction, the
101 pre-existing pro-MMP-2 and 9 within the myocardium are activated and disrupt the
102 fibrillar collagen network to allow inflammatory cells to infiltrate into the infarct zone to
103 remove the necrotic cells [20]. Myocytes, fibroblasts and activated macrophages as well
104 as neutrophils are thought to be the main cellular sources for the increased MMP-2 and
105 MMP-9 levels [21]. Previous studies have shown higher serum and plasma levels of
106 MMP-2 and MMP-9 in CCC [22, 23]. Other MMPs, such as MMP-3, MMP-8, MMP-13
107 and MMP-12 also have as substrate collagen type I and III, main components of heart
108 extracellular matrix [24, 25]; Extracellular matrix metalloproteinase Inducer EMMPRIN,
109 an inducer of MMP2 and MMP9 [26, 27]. Here, we show for the first time, gene and
110 protein expression, as well as enzymatic activity of MMP-2, MMP-9 and gene and protein
111 expression of their specific inhibitors TIMP 1, 2, 3 and 4 and EMMPRIN in myocardial
112 tissue samples from CCC patients compared to DCM and from heart transplant donors
113 (control samples). Our results suggest an important role of MMP-2 and MMP-9 in
114 myocardial remodeling and in cardiac dysfunction observed in patients with CCC.
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115 Materials and Methods
116 Ethics Statement
117 The protocol was approved by the Institutional Review Board of the School of Medicine,
118 University of São Paulo (Protocol number 492/682) and written informed consent was
119 obtained from the patients. In the case of samples from heart donors, written informed
120 consent was obtained from their families.
121
122 Samples of human myocardium
123 Myocardial samples were obtained from left ventricular-free wall heart tissue from end-
124 stage heart failure patients at the moment of heart transplantation. The patients belonged
125 to three diagnostic groups: CCC (at least 2 positive results in 3 independent anti-T. cruzi
126 serology tests – ELISA immunoassay, indirect immunofluorescence assay and indirect
127 hemagglutination test), DCM (idiopathic dilated cardiomyopathy) and controls, left
128 ventricular free wall samples obtained from healthy hearts of organ donors, which were
129 not used for transplantation due to size mismatch with available recipients (Table 1). All
130 Chagas disease patients underwent standard electrocardiography and echocardiography.
131 Echocardiography was performed in the hospital setting using an Acuson Sequoia model
132 512 echocardiographer (Siemens, Germany) with a broad-band transducer. The left
133 ventricular dimensions and regional and global function evaluations were performed
134 using a 2 dimensions and M mode approach, in accordance with the recommendations of
135 the American Society of Echocardiography. Patients with CCC presented with abnormal
136 electrocardiography findings that ranged from typical conduction abnormalities (right
137 bundle branch block and/or left anterior division hemiblock) to severe arrhythmia [28,
138 29]. A group of patients also presented varying degrees of ventricular dysfunction
139 classified on the basis of left ventricular ejection fraction with all other causes of
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140 ventricular dysfunction/heart failure excluded. Characteristics of patients and normal
141 donors whose samples were used in this study are described in Table 1 and Supplemental
142 Table 2.
143
144 Table 1. Clinical characteristics of the study subjects.
145
CLINICAL PARAMETERS GROUPS
CCC DCM CONTROL
Age 47.8 ±14,2 40,6±17,1 28,3 ± 11,0
Male, n (%) 6 (35%) 9 (75%) 6 (100%)
Sample size, n 17 12 6
Body Surface (m2) 1.6 ± 0.3 1.7 ± 0.1 N.D.
Ejection Fraction- EF (%) 23.59 ± 8.5 21.6 ± 7.9 N.D.
Fractional shortening (%) 11.94 ± 7.3 12.2 ± 3.7 N.D.
Left ventricular end diastolic

62.12 ± 98 70.6 ± 19.8 N.D.
diameter LVEDD (mm)
Left ventricular end systolic

48.82 ± 15.6 62.7 ± 20.1 N.D.
diameter LVESD (mm)
Ventricular Septum (mm) 8.53 ± 1.7 8.3 ± 1.4 N.D.
Posterior wall of left ventricle

8.5 ± 1.8 8.6 ± 1.4 N.D.
(mm)
Left atrial diameter (mm) 49.18 ± 5.5 52.1 ± 7.4 N.D.
Aortic sinus (mm) 29.53 ± 3.1 31.8 ± 5.3 N.D.
Myocardial mass index (g/m2) 187.88 ± 69.3 233.8 ± 76.6 N.D.
Relative wall thickness (mm) 0.68 ± 0.5 0.60 ± 0.1 N.D.
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Diastolic volume (ml) 288.41 ± 136.6 349.9 ± 131.8 N.D.
Systolic volume (ml) 194.06 ± 131.8 267.5 ± 127.4 N.D.
146 N.D.: not done.
147 Control: Heart donors; DCM: Idiopathic dilated cardiomyopathy; CCC: Chronic Chagas
148 cardiomyopathy.
149 Datas were expressed as mean ± SD.
150 Reference values: EF: Ejection Fraction (>55%); Ejection Fraction - EF (25-43%); Left
151 ventricular end diastolic diameter - LVESD (mm): (42-59mm); Left ventricular end
152 systolic diameter – LVESD (mm): (25-39mm); Ventricular Septum (mm): (6-10mm);
153 Posterior wall of the left ventricule (mm): (6-10mm); Left atrial diameter (mm): (30-
154 40mm); Aortic sinus (mm): (31-47mm); Myocardial mass index (g/m2): (49-115 g/m2);
155 Relative wall thickness (mm): (<0.42).
156
157 Samples preparation
158 All samples were cleared from pericardium and fat and 100mg pieces of left ventricle
159 heart wall were quickly frozen in liquid nitrogen and stored at −80°C and another set was
160 fixed in a solution of 10% neutral buffered formalin, embedded in paraffin and sectioned
161 at thickness of individual 5 µm sections. The slides were stained with Hematoxylin-Eosin
162 (H&E) for evaluation of the intensity and location of the inflammatory infiltrate and
163 PicroSirius Red (Abcam, UK) staining to visualize the degree of fibrosis. Stained sections
164 were acquired with a 20x objective lens by Leica DM2500 microscope (Leica Cambridge,
165 Ltd, UK) and true color digital images were captured. Slides were scored for the intensity
166 of myocarditis and for the presence or absence of hypertrophy (Supplemental Table 2).
167
168 Morphometric analysis for myocardial collagen area
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169 A total of 15 images were captured per myocardium tissue sample under 10X
170 magnification; we studied 5 samples of each patient group (CCC, DCM, and control). For
171 quantitative evaluation of fibrosis, collagen area was calculated using Leica Qwin Plus
172 3.5 image analysis software, as percentage of fibrosis area per total area of heart tissue
173 sections.
174
175 Isolation of total RNA
176 Total RNA was isolated from 100mg of tissue from each heart sample (CCC N=17, DCM
177 N=12, Control N=6) by mechanical disruption with the Precellys 24-bead-based
178 homogenizer (Bertin Technologies, France) using 3 cycles of 15 seconds with pause of
179 20 seconds each at 6.000 rpm. Samples were homogenized in 1ml of Trizol reagent (Life
180 Technologies, USA) following the manufacturer's protocol. All sample had an OD
181 260/280 ration ≥1.9. The RNA integrity was analyzed on a Bioanalyzer 2100 (Agilent,
182 USA). Only samples with RIN (RNA Integrity Number) value > 6.5 were used in our
183 analysis.
184
185 Analysis of mRNA expression by quantitative real time polymerase chain reaction
186 (Real Time – qPCR)
187 RNA from each sample was treated with Rnase-free DNAse I (United States Biological,
188 Ohio, USA) cDNA was obtained from 5 µg total RNA using Super-script II reverse
189 transcriptase (Invitrogen, USA) and mRNA expression was analyzed by real-time qPCR
190 with SYBR Green I PCR Master Mix (Applied Biosystems, USA) with 250nM of sense
191 and anti-sense specific primers using the ABI Prism 7500 Real Time PCR System. The
192 following primers were designed using Primer Express software version 3.0 (Applied
193 Biosystems, USA; Supplemental table 1). All the samples were processed in triplicate
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194 for the target and for the endogenous reference gene, RPLP0. A set of “no RT” and "non
195 template controls" controls were included in each experiment. Ct values were averaged
196 for the replicates and expression was calculated as the mean ± interquartile ranges per
197 group for each individual data point using the relative expression equation (fold change
198 over control samples) by the 2-DDCT method.
199
200 Protein extraction from heart tissue samples
201 Protein was isolated from each heart sample with RIPA buffer containing 150 mM sodium
202 chloride, 1% sodium deoxycholate, 0.1% sodium dodecyl sulfate, 100 mMl/Tris-HCL pH
203 7.5, and proteolytic enzyme inhibitors (1mM phenymethylsulfonylfluoride, PMSF and
204 1% aprotinin) (Sigma-Aldrich, USA) by mechanical disruption with the Precellys 24-
205 bead-based homogenizer using 3 cycles of 15 seconds with pause of 20 seconds each at
206 6,000 rpm at 4˚C. The homogenate was sonicated for 3 cycles of 10 seconds each of 10
207 Watts (60 Dismembrator Sonic, Fischer Scientific, USA), centrifuged at 12.000g for 30
208 minutes at 4˚C. Supernatants were collected and protein quantification was performed
209 using the Bradford method (Bio-Rad Laboratories, USA).
210
211 Protein expression analysis by Western blotting
212 About 70µg of isolated protein from each myocardial sample (5 samples per group: CCC,
213 DCM and Control) were heated for 5 minutes at 95˚C, and subjected to one dimensional
214 electrophoresis (SDS-PAGE) using 12.5% polyacrylamide using the vertical
215 electrophoresis System Ruby SE600 (GE Healthcare, USA). After electrophoresis,
216 proteins were transferred from gel to a nitrocellulose membrane using the TE Semi-Dry
217 Transfer Unit (GE Healthcare, USA). The nitrocellulose membranes (Bio-Rad,
218 Laboratories, USA) were blocked for nonspecific binding with 5% non-fat dry milk in
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219 Tris-buffered saline and 0.1% Tween 20% (TBST) for 2h at room temperature. Blots were
220 washed in TBST twice over 30 minutes and the ECL Plus Western Blotting Detection
221 Reagents, were used for detection. Images were capture using the ImageQuant LAS 4000
222 equipment (GE Healthcare, USA) and membranes were imaged using a LI-Cor Odyssey
223 scanner (LI-COR Biotechnology - UK Ltd). Analysis of densitometry was performed
224 using the program ImageQuant TL, and the data was normalized to beta-actin.
225
226 Zymography assay analysis of MMP-2 and MMP-9 activity
227 Activities of MMP-2 and MMP-9 in myocardium tissue sample from CCC, DCM and
228 Control (5 samples/each group) were examined by gelatin zymography. About 70µg
229 protein isolated from each heart tissue sample were applied to 1D electrophoresis using
230 10% polyacrylamide gel copolymerized with 1% gelatin type A from porcine skin
231 (Sigma, USA) as a substrate for gelatinolytic proteases. After electrophoresis, the gels
232 were washed twice in 2.5% Triton X-100 (Amersham Biosciences, UK) in water for 30
233 minutes. The gels were then incubated overnight at 37˚C in reaction buffer (5mM CaCl2,
234 2mM NaN3 and 50mM Tris-HCL buffer pH 7.4). After incubation, the gels were stained
235 for 3h in 45% methanol,10% glacial acetic acid containing 1% Coomassie Blue R-250
236 (Amersham Biosciences/GE Healthcare, USA) and were subsequently partially destained
237 with the same solution without dye. The gelatinolytic activity of each MMP was
238 qualitatively evaluated as a clear band of digested gelatin against a blue background. To
239 confirm that the visualized bands of lysis were due to MMP activity, selected duplicate
240 gels was incubated with MMP inhibitors (5mM EDTA or 10mM 1,10-phenanthroline).
241 Proteolytic signals of active MMP-2 and MMP-9 were quantified based on the peak area,
242 using the software ImageQuant TL [30].
243
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244 Statistical analysis
245 Difference between groups was determined by one-way Analysis of Variance (ANOVA)
246 followed by a non-parametrical test (Mann-Whitney Rank Sum Test). All statistical
247 analyses were performed with GraphPad Prism 6.0 software (GraphPad Prism Software,
248 Inc., USA). Results were expressed as mean ± SEM. P-values were considered significant
249 if  0.05 (marked with a * symbol).
250
251
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252 Results
253 Cardiomyocyte hypertrophy and collagen deposit in heart of CCC and DCM
254 patients.
255 The histopathological analysis revealed that both groups CCC and DCM present
256 cardiomyocyte hypertrophy with nuclear enlargement (Figure 1A). As expected,
257 myocarditis associated with a predominant lymphocytic infiltration was observed only in
258 heart samples of CCC patients, evidenced by H&E staining (Supplemental Table 2,
259 Figure 1A). To evaluate ECM fibrosis distribution, heart tissue sections were stained
260 with Picro Sirius Red to detect collagen deposition. Both CCC and DCM displayed a
261 significantly higher percentage of fibrosis area as compared to Controls (Figure 1B).
262 Collagen area was also significantly higher in the heart tissue sections from CCC
263 compared to DCM group. There were no significant differences in the analyzed clinical
264 parameters such as ejection fraction (E.F), left ventricle diastolic diameter (LVDD) and
265 left ventricle systolic diameter (LVSD) between DCM and CCC groups (Table 1).
266
267 MMPs are significantly altered in heart from CCC and DCM patients
268 We evaluated gene and protein expression of different classes of MMPs (MMP-2, MMP-
269 3, MMP-8, MMP-9, MMP-12, MMP-13) and EMMPRIN in heart samples from DCM,
270 CCC and CONT patients. We observed a significant upregulation in gene expression of
271 MMP-2, MMP-9 (Figure 2A), MMP-12, MMP-13 and EMMPRIN in both DCM and
272 CCC heart samples compared to Control (Supplemental figure 1). MMP-3 and MMP-8
273 mRNA expression were undetectable in all samples tested. Western blotting analysis
274 showed that MMP-2 protein is increased in both DCM and CCC heart samples and MMP-
275 9 protein is exclusively increased in CCC compared to Control group (Figure 2B). There
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276 were no significant differences in protein expression of MMP-3, MMP-8, MMP-12,
277 MMP-13 and EMMPRIN between CCC, DCM and control samples (Figure 6D).
278 Gelatin zymography was carried out on DCM, CCC and control patient heart samples (5
279 samples per group) to assess MMP-2 and MMP-9 enzymatic activity. Figure 2C shows
280 the detection of gelatinolytic bands for MMP-2 (62kDa) and MMP-9 (88kDa) on SDS-
281 PAGE gel. Densitometry analysis (Figure 2D) shows that both enzymes MMP-2 and
282 MMP-9 are significantly more active in CCC heart tissue samples as compared to both
283 control and/or DCM samples. MMP-2 and MMP-9 activities in the DCM group were not
284 significantly different from control tissue.
285
286 Gene and Protein expression of Tissue inhibitors of MMPs (TIMPs) in heart from
287 CCC and DCM patients
288 We assessed gene and protein expression of TIMPs 1, 2, 3 and 4 in heart tissue from CCC,
289 DCM and control samples. A significant upregulation in gene expression was found for
290 all TIMPs analyzed in CCC and DCM heart tissue samples (Figure 3A) compared to the
291 control group (P 0.05). TIMP-2 was the only inhibitor with significantly increased
292 protein levels, both in DCM and CCC heart tissue samples as compared to Control
293 samples (Figure 3B).
294
295 Balance between MMP-2 and MMP-9 and their tissue inhibitors (TIMPs) is shifted
296 towards activation in CCC and DCM heart tissue
297 We observed that the MMP-2/TIMP-1, MMP-2/TIMP-2, MMP-2/TIMP-3 and MMP-
298 2/TIMP-4 ratios were increased in CCC heart tissue compared to DCM or control group
299 samples (P 0.05) (Figures 4A to 4D). As shown in Figures 5A to 5C, MMP-9/TIMP-1
300 and MMP-9/TIMP-3 ratios were also increased in CCC heart tissue in comparison to
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301 DCM or control group (P 0.05); MMP9/TIMP2 and MMP-9/TIMP-4 ratio did not show
302 any significant changes between the analyzed groups (Figure 5D).
303
304 Expression of MMP-3, MMP-8, MMP-12, MMP-13 and EMMPRIN
305 We evaluated gene and protein expression of the other classes of MMPs and EMMPRIN
306 in myocardial samples from the CCC, DCM and control. Figures 6A to 6C shows that
307 gene expression levels of MMP-12, MMP-13 and EMMPRIN were significantly higher
308 in CCC and DCM myocardial tissue in comparison to samples from control group (P
309 0.05). The gene expression of MMP-3 and MMP-8 were undetectable in all samples
310 tested. There were no significant differences in protein expression of MMP-3, MMP-8,
311 MMP-12, MMP-13 and EMMPRIN between CCC, DCM and control samples (Figure
312 6D).
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313 Discussion
314 Here, we report for the first time that the myocardium from CCC and DCM patients have
315 alterations in MMP-2, MMP-9 and their TIMPs. We found that collagen area, MMP-2
316 and TIMP-2 protein levels and mRNA expression of the MMPs -2, -9, -12, -13, the TIMPs
317 -1, -2, -3, -4 and MMP inducer EMMPRIN were increased in both CCC and DCM
318 samples as compared to controls. Importantly, MMP-9 protein levels and MMP-2 and
319 MMP-9 enzymatic activity were increased only in CCC. Moreover, MMP Enzymatic
320 activity/TIMP protein ratios MMP-2/TIMP-1, MMP-2/TIMP-3, MMP-9/TIMP-1 and
321 MMP-9/TIMP-3 were increased in CCC as compared with DCM and control, and MMP-
322 2/TIMP-2 and MMP-2/TIMP-4 ratios were higher among CCC than DCM.
323 Our findings on MMP-2 and MMP-9 corroborate the important involvement of MMPs in
324 physiological and pathological myocardial remodeling [31-33]. Gutierrez et al. described
325 an increase in MMP-2 and MMP-9 expression in hearts of mice acutely infected with T.
326 cruzi, and TIMP treatment reduced myocarditis and increased survival [34]. Polyakova
327 et al. demonstrated that increased expression of MMP-2 and MMP-9 is associated with
328 collagen maturation in heart failure, showing an important role of these enzymes in
329 fibrosis through collagen configuration, activation and deposition with cardiomyocyte
330 hypertrophy and fibrosis contributing with remodeling and cardiac dysfunction [24].
331 Myocardial TNF-α was correlated with MMP-9 activity in a mouse model of myocardial
332 infarction [35]. These authors demonstrated that TNF-α blockade decreased left
333 ventricular dilation, which was associated with a decrease in the production and activity
334 of MMP-9. Activation of TNF-α receptors can induce the synthesis of MMP-9 by
335 activating the transcription factors, AP-1 (activator protein-1) and NF-kB (Nuclear factor
336 kappa B), both capable of binding to MMP-9 promoter regions [36, 37]. Inflammatory
337 cells present in the CCC myocardium produce high levels of TNF-α and other pro-
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338 inflammatory cytokines, like IFN-γ and IL-6 [38]. Human macrophages infected with T.
339 cruzi produced increased levels of MMP-9, which was related to the production of
340 cytokines such as IL-1β, TNF-α and IL-6 [39]. Medeiros et al. reported that neutrophils
341 and monocytes from indeterminate and cardiac Chagas disease patients had higher
342 intracellular levels of MMP-2 and MMP-9 than those found in non-infected individuals
343 [40]. Together with our data showing increased protein levels of MMP-9 in CCC
344 myocardium, this suggests that MMP-9 – possibly coming from inflammatory cells-
345 might be the main MMP with activity induced by locally produced inflammatory
346 cytokines. Our results that MMP-2 and MMP-9 activities are predominantly increased in
347 CCC myocardium are consistent with the hypothesis that local inflammation induces
348 metalloproteinase activity, exacerbating extracellular matrix remodeling with progressive
349 fibrosis.
350 An imbalance in the proportions of MMPs and their endogenous TIMP inhibitors may
351 lead to excessive degradation of ECM and disease [41]. The finding of increased ratios
352 of MMP-2 and MMP-9 activity/TIMP protein levels suggest an overall dominance of
353 MMP-2 and MMP-9 activity over TIMPs inhibition in myocardium samples from CCC
354 but not DCM patients. The finding that only TIMP 1 and 3 showed significantly increased
355 MMP/TIMP ratios in CCC vs both DCM and control might suggest TIMP-1 and TIMP-
356 3 imbalance was key to the increased activity of both MMP-2 and -9 in CCC myocardium.
357 Although all TIMPs have affinity for MMP-9, TIMP-1 was described to be the major
358 endogenous inhibitor of MMP-9 [42]. Conversely, our data showing that TIMP-2 and
359 TIMP-4 ratios were increased in CCC vs DCM in MMP-2 but not MMP-9 are consistent
360 with TIMP-2 and TIMP-4 having an effect on MMP-2, but not on MMP-9. TIMP-2 is the
361 most universal MMP inhibitor [24, 31], binding with high affinity to both the active and
362 pro-form of MMP-2 [31]. Transcriptional regulation of MMP and TIMPs is partially
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363 overlapping; MMP-2 and TIMP-2 share the same transcription factor, AP-2 (activator
364 protein) [31], which might explain the increased mRNA and protein expression of TIMP-
365 2 and MMP-2 in myocardium samples from CCC and DCM patients.
366 Previous studies showed that patients with Chagas disease have higher circulating MMP-
367 2 and MMP-9 protein and activity compared to patients with asymptomatic form of the
368 disease [23, 43]. Sherbuck et al. showed that in patients with severe chagasic
369 cardiomyopathy MMP-2 could be a predictive marker of mortality [44]. Fares et al.
370 showed that CCC patients have a higher plasma levels and activity of MMP-2 and MMP-
371 9 compared to patients with asymptomatic form of the disease, and they hypothesized that
372 the increased activity of MMP-9 favors the development of the cardiac form of Chagas
373 disease. Authors also noted that MMP-9 expression was positively correlated with the
374 production of pro-inflammatory cytokines, like TNF-α and IL-1β [23]. It is likely that the
375 increased tissue activities of MMP-2 and -9 are the proximal cause of the increased
376 circulating levels of the same MMPs. Regarding the other MMP studied, the finding of
377 increased mRNA of collagen I -degrading MMP-12, MMP-13 and MMP inducer
378 EMMPRIN in CCC and DCM myocardial tissue in the absence of a corresponding
379 increase in protein expression may be simply a response to similar transcriptional signals.
380 Our study had limitations. The sample size was reduced and the ages and sex were not
381 matched between the control and patient samples. This is linked to the fact that organ
382 donors are almost always younger than the recipient cohort. However, in one of our
383 previous studies [45], we had shown that these two covariates had a limited impact on the
384 whole transcriptomic pattern.
385 Taken together, results suggest that myocardial remodeling and MMP-2 and MMP-9
386 activity are increased in CCC as compared with DCM, possibly by means of differential
387 TIMP regulation of MMP activity. These findings may suggest a possible mechanism for
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388 the increased fibrosis, myocardial remodeling and cardiac dysfunction observed in
389 patients with CCC as compared to other forms of cardiomyopathy. Pharmacological
390 modulation of endogenous agents linked to fibrosis in CCC, like Galectin-3 [46] and
391 microRNA-21 [47], or treatment with spironolactone [48], colchicine [49] or bone
392 marrow cells [50] promoted a significant reduction in cardiac fibrosis in rodent models
393 of Chagas disease, showing that pathological remodeling is a promising therapeutic target
394 in CCC.
395
396 Financial Disclosure statement
397 The funders had no role in study design, data collection and analysis, decision to publish,
398 or preparation of the manuscript.
399
400
19
perpetuity.
401 Acknowledgments :
402 We thank all the patients and their relatives.
403
404 Funding sources :
405 This work was supported by the Brazilian Council for Scientific and Technological
406 Development – CNPq, from the São Paulo State Research Funding Agency - FAPESP
407 (2013/50302-3, and 2014/50890-5) and from the National Institutes of Health/USA (grant
408 numbers: 2 P50 AI098461–02 and 2U19AI098461–06). ECN and JK are recipients of
409 productivity awards by CNPq. AFF, MB, PCT and LRPF held fellowships from the
410 FAPESP. ECN and JK are recipients of a productivity award from CNPq. This work was
411 also supported by the Institut National de la Santé et de la Recherche Médicale
412 (INSERM); the Aix-Marseille University (AMIDEX “International_2018”
413 MITOMUTCHAGAS), the French Agency for Research (Agence Nationale de la
414 Recherche-ANR (“Br-Fr-Chagas” and “landscardio”). This project has received funding
415 from the Excellence Initiative of Aix-Marseille University (A*Midex) a French
416 “Investissements d’Avenir programme”- Institute MarMaRa AMX-19-IET-007. The
417 funders had no role in study design, data collection and analysis, decision to publish, or
418 preparation of the manuscript.
419
420 Author contributions :
421 Development of methodology and experimental work: MAB, LRPF, PCT, AISM, AFF,
422 AK.
423 Histological analysis: RHBS, VD, LAB, FAG, FB, PP, FB.
424 Statistical analysis: MAB, PCT, ECN.
425 Writing, review, and/or revision of the manuscript: CC, JK, ECN.
20
perpetuity.
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555
556
557
558 Figure Legends
559 Figure 1. Histopathological features of myocardial samples. (A) Slides of hematoxylin-
560 eosin (H&E) and picrosirius red stained myocardial sections of representative patients with
561 CCC, DCM and individuals without cardiomyopathies (Controls). Representative heart
562 sections were shown with magnification: 20X. Myocardial hypertrophy characterized by fiber
563 and nuclear enlargement is evident in the CCC and DCM groups. Lymphocytic myocarditis
564 is present only in the CCC group. Interstitial fibrosis stained in red with picrosirius red is
565 present in the CCC and DCM groups. (B) The severity of fibrosis was quantified by collagen
566 area fraction (%) in DCM and CCC group exhibit a significant increase in the deposition of
567 collagen. Groups were compared by a non-parametrical test (Mann-Whitney Rank Sum Test)
568 with GraphPad Prism software (version 6.0; GraphPad). Results were expressed as
569 mean±SEM. * P-values were considered significant if p value (0.05) corrected for multiple
570 comparisons by Bonferroni’s method (corrected p value=0.05/3=0.0166).
26
perpetuity.
571
572 Figure 2. MMP-2 and MMP-9 mRNA and protein expression and activity in
573 myocardium tissue from control, DCM and CCC samples.
574 Myocardial expression of MMP-2 and MMP-9 mRNA. Real-time PCR analysis of mRNA
575 expression in control (n=6), DCM (n=12) and CCC (n=17) myocardium. The expression was
576 calculated as the mean ± SEM for each group as individual data points using the relative
577 expression (fold change over control) by the 2–ΔΔCt method, normalized with the endogenous
578 gene RPL0, as described in Methods section. (A) Relative expression of MMP-2 mRNA and
579 MMP-9 mRNA. (B) Western blotting image showing protein of MMP-2 and MMP-9 in
580 extracts from myocardium samples from the control, DCM and CCC (n= 5 in each group).
581 The densitometric values of each protein for each sample were normalized by the values of
582 Beta actin, as described in methods section. Densitometry analysis of the MMP-2.
583 Densitometry analysis of the MMP-9. (C) Zimography image showing activity of MMP-2 and
584 MMP-9 in extracts from myocardium samples from control, DCM and CCC (n= 5 in each
585 group). (D) Densitometry analysis of the activated MMP-2 (66 kD band) and activated MMP-
586 9 (88kD band) results. Groups were compared by a non-parametrical test (Mann-Whitney
587 Rank Sum Test) with GraphPad Prism software (version 6.0; GraphPad). Results were
588 expressed as mean±SEM. * P-values were considered significant if p value (0.05) corrected
589 for multiple comparisons by Bonferroni’s method (corrected p value=0.05/3=0.0166).
590 Primary antibodies (with their respective dilution) against the following proteins were used:
591 MMP-2 (mouse monoclonal, 1:1000, Abcam, UK); MMP-3 (rabbit polyclonal, 1: 500,
592 Abcam, UK); MMP-8 (rabbit polyclonal, 1:500, UK); MMP-9 (rabbit polyclonal, 1:1000,
593 UK); MMP-12 (rabbit polyclonal, 1:1000, UK); MMP-13 (rabbit polyclonal, 1:1000, UK);
594 EMMPRIN (mouse monoclonal, 1:500, Santa Cruz, Biotechnology, USA); TIMP-1 (1:1000);
595 TIMP-2 (1:1000); TIMP-3 (goat plyclonal,1:500, Santa Cruz Biotechnology, USA); TIMP-4
27
perpetuity.
596 (goat plyclonal,1:500, Santa Cruz Biotechnology, USA); Reck (mouse polyclonal,1:1000,
597 Abcam, UK). Anti- beta-actin antibody (mouse monoclonal, 1:2000, Sigma, USA), was used
598 to detect beta-actin, used as protein loading control. All antibodies were diluted in TBST and
599 incubated at 4˚C overnight. After washing twice over 30 minutes with TBST, each membrane
600 was incubated with compatible secondary antibodies horseradish peroxidase conjugate (goat
601 anti-rabbit, rabbit anti-goat or goat anti-mouse, 1:10000, Calbiochem, USA) for 2h at room
602 temperature.
603
604 Figure 3. Tissue inhibitors of MMPs (TIMPs) mRNA expression and protein expression
605 in heart tissue from CCC and DCM samples
606 Real-time PCR analysis of mRNA expression in control (n=6), DCM (n=12) and CCC (n=17)
607 myocardium. The expression was calculated as the mean ± SEM for each group as individual
608 data points using the relative expression (fold change over control) by the 2–ΔΔCt method,
609 normalized with the endogenous gene RPL0, as described in Methods section. (A) Relative
610 expression of TIMP-1 mRNA; TIMP-2 mRNA; TIMP-3 mRNA; TIMP-4 mRNA. (B)
611 Western blotting image showing protein of the 21 kDa TIMP-2 bands in extracts from
612 myocardium samples from the control, DCM and CCC (n= 5 in each group). The
613 densitometric values of TIMP-2 protein for each sample were normalized by the values of 42
614 kD Beta actin band, as described in methods section. Groups were compared by a non-
615 parametrical test (Mann-Whitney Rank Sum Test) with GraphPad Prism software (version
616 6.0; GraphPad). Results were expressed as mean±SEM. * P-values were considered
617 significant if p value (0.05) corrected for multiple comparisons by Bonferroni’s method
618 (corrected p value=0.05/3=0.0166).
619
620 Figure 4. Ratios of MMP2/TIMP in heart tissue from CCC and DCM samples
28
perpetuity.
621 Activity of MMP-2 / expression protein TIMP stoichiometric ratios were calculated for
622 samples CCC, DCM and control. (A) MMP-2/TIMP-1. (B) MMP-2/TIMP-2. (C) MMP-
623 2/TIMP-3. (D) MMP-2/TIMP-4. * P-values were considered significant if p value (0.05)
624 corrected for multiple comparisons by Bonferroni’s method (corrected p
625 value=0.05/3=0.0166).
626
627
630 samples CCC, DCM and control (A) MMP-9/TIMP-1. (B) MMP-9/TIMP-2. (C) MMP-
631 9/TIMP-3. (D) MMP-9/TIMP-4. Groups were compared by a non-parametrical test (Mann-
632 Whitney Rank Sum Test) with GraphPad Prism software (version 6.0; GraphPad). Results
633 were expressed as mean±SEM and arbitrary units. * P-values were considered significant if p
634 value (0.05) corrected for multiple comparisons by Bonferroni’s method (corrected p
635 value=0.05/3=0.0166).
636
637 Figure 6. Expression of MMP-3, MMP-8, MMP-12, MMP-13 and EMMPRIN in heart
638 tissue from CCC and DCM samples
639 Myocardial expression of MMP-12, MMP-13 and EMMPRIN mRNA. Real-time PCR
640 analysis of mRNA expression in control (n=6), DCM (n=12) and CCC (n=17) myocardium.
641 The expression was calculated as the mean ± SEM for each group as individual data points
642 using the relative expression (fold change over control) by 2–ΔΔCt method, normalized with the
643 endogenous gene RPL0, as described in methods section. (A) Relative expression of MMP-
644 12 mRNA. (B) Relative expression of MMP-13 mRNA. (C) Relative expression of
645 EMMPRIN mRNA. The expression of mRNA of MMP-3 and MMP-8 was undetectable in all
29
perpetuity.
646 samples tested (data no show). (D) Densitometry analysis of the MMP-3, MMP-8, MMP-12,
647 MMP-13 and EMMPRIN.
648 Groups were compared by a non-parametrical test (Mann-Whitney Rank Sum Test) with
649 GraphPad Prism software (version 6.0; GraphPad). Results were expressed as mean±SEM. *
650 P-values were considered significant if p value (0.05) corrected for multiple comparisons by
651 Bonferroni’s method (corrected p value=0.05/3=0.0166).
652
30
perpetuity.
653 Figure legends
654 Figure 1. Histopathological features of myocardial samples.
655 (A) Slides of hematoxylin-eosin (H&E) and picrosirius red stained myocardial sections of
656 representative patients with CCC, DCM and individuals without cardiomyopathies (Controls).
657 Representative heart sections were shown with magnification: 20X. Myocardial hypertrophy
658 characterized by fiber and nuclear enlargement is evident in the CCC and DCM groups.
659 Lymphocytic myocarditis is present only in the CCC group. Interstitial fibrosis stained in red
660 with picrosirius red is present in the CCC and DCM groups. (B) The severity of fibrosis was
661 quantified by collagen area fraction (%) in DCM and CCC group exhibit a significant increase
662 in the deposition of collagen. Groups were compared by a non-parametrical test (Mann-
664 were expressed as mean±SEM. * P-values were considered significant if p value (0.05)
666 value=0.05/3=0.0166).
667
668 Figure 2. MMP-2 and MMP-9 mRNA and protein expression and activity in
669 myocardium tissue from control, DCM and CCC samples.
670 Myocardial expression of MMP-2 and MMP-9 mRNA. Real-time PCR analysis of mRNA
671 expression in control (n=6), DCM (n=12) and CCC (n=17) myocardium. The expression was
672 calculated as the mean ± SEM for each group as individual data points using the relative
673 expression (fold change over control) by the 2–ΔΔCt method, normalized with the
674 endogenous gene RPL0, as described in Methods section. (A) Relative expression of MMP-
675 2 mRNA and MMP-9 mRNA. (B) Western blotting image showing protein of MMP-2 and
676 MMP-9 in extracts from myocardium samples from the control, DCM and CCC (n= 5 in each
677 group). The densitometric values of each protein for each sample were normalized by the
31
perpetuity.
678 values of Beta actin, as described in methods section. Densitometry analysis of the MMP-2.
679 Densitometry analysis of the MMP-9. (C) Zimography image showing activity of MMP-2 and
680 MMP-9 in extracts from myocardium samples from control, DCM and CCC (n= 5 in each
681 group). (D) Densitometry analysis of the activated MMP-2 (66 kD band) and activated MMP-
682 9 (88kD band) results. Groups were compared by a non-parametrical test (Mann-Whitney
683 Rank Sum Test) with GraphPad Prism software (version 6.0; GraphPad). Results were
684 expressed as mean±SEM. * P-values were considered significant if p value (0.05) corrected
685 for multiple comparisons by Bonferroni’s method (corrected p value=0.05/3=0.0166).
686 Primary antibodies (with their respective dilution) against the following proteins were used:
687 MMP-2 (mouse monoclonal, 1:1000, Abcam, UK); MMP-3 (rabbit polyclonal, 1: 500,
688 Abcam, UK); MMP-8 (rabbit polyclonal, 1:500, UK); MMP-9 (rabbit polyclonal, 1:1000,
689 UK); MMP-12 (rabbit polyclonal, 1:1000, UK); MMP-13 (rabbit polyclonal, 1:1000, UK);
690 EMMPRIN (mouse monoclonal, 1:500, Santa Cruz, Biotechnology, USA); TIMP-1 (1:1000);
691 TIMP-2 (1:1000); TIMP-3 (goat plyclonal,1:500, Santa Cruz Biotechnology, USA); TIMP-4
692 (goat plyclonal,1:500, Santa Cruz Biotechnology, USA); Reck (mouse polyclonal,1:1000,
693 Abcam, UK). Anti- beta-actin antibody (mouse monoclonal, 1:2000, Sigma, USA), was used
694 to detect beta-actin, used as protein loading control. All antibodies were diluted in TBST and
695 incubated at 4˚C overnight. After washing twice over 30 minutes with TBST, each membrane
696 was incubated with compatible secondary antibodies horseradish peroxidase conjugate (goat
697 anti-rabbit, rabbit anti-goat or goat anti-mouse, 1:10000, Calbiochem, USA) for 2h at room
698 temperature.
699
700 Figure 3. Tissue inhibitors of MMPs (TIMPs) mRNA expression and protein expression
701 in heart tissue from CCC and DCM samples
32
perpetuity.
702 Real-time PCR analysis of mRNA expression in control (n=6), DCM (n=12) and CCC (n=17)
703 myocardium. The expression was calculated as the mean ± SEM for each group as individual
704 data points using the relative expression (fold change over control) by the 2–ΔΔCt method,
705 normalized with the endogenous gene RPL0, as described in Methods section. (A) Relative
706 expression of TIMP-1 mRNA; TIMP-2 mRNA; TIMP-3 mRNA; TIMP-4 mRNA. (B)
707 Western blotting image showing protein of the 21 kDa TIMP-2 bands in extracts from
708 myocardium samples from the control, DCM and CCC (n= 5 in each group). The
709 densitometric values of TIMP-2 protein for each sample were normalized by the values of 42
710 kD Beta actin band, as described in methods section. Groups were compared by a non-
711 parametrical test (Mann-Whitney Rank Sum Test) with GraphPad Prism software (version
712 6.0; GraphPad). Results were expressed as mean±SEM. * P-values were considered
713 significant if p value (0.05) corrected for multiple comparisons by Bonferroni’s method
714 (corrected p value=0.05/3=0.0166).
715
718 samples CCC, DCM and control. (A) MMP-2/TIMP-1. (B) MMP-2/TIMP-2. (C) MMP-
719 2/TIMP-3. (D) MMP-2/TIMP-4. * P-values were considered significant if p value (0.05)
721 value=0.05/3=0.0166).
722
725 samples CCC, DCM and control (A) MMP-9/TIMP-1. (B) MMP-9/TIMP-2. (C) MMP-
726 9/TIMP-3. (D) MMP-9/TIMP-4. Groups were compared by a non-parametrical test (Mann-
33
perpetuity.
728 were expressed as mean±SEM and arbitrary units. * P-values were considered significant if p
729 value (0.05) corrected for multiple comparisons by Bonferroni’s method (corrected p
730 value=0.05/3=0.0166).
731
732 Figure 6. Expression of MMP-3, MMP-8, MMP-12, MMP-13 and EMMPRIN in heart
733 tissue from CCC and DCM samples
734 Myocardial expression of MMP-12, MMP-13 and EMMPRIN mRNA. Real-time PCR
735 analysis of mRNA expression in control (n=6), DCM (n=12) and CCC (n=17) myocardium.
736 The expression was calculated as the mean ± SEM for each group as individual data points
737 using the relative expression (fold change over control) by 2–ΔΔCt method, normalized with
738 the endogenous gene RPL0, as described in methods section. (A) Relative expression of
739 MMP-12 mRNA. (B) Relative expression of MMP-13 mRNA. (C) Relative expression of
740 EMMPRIN mRNA. The expression of mRNA of MMP-3 and MMP-8 was undetectable in all
741 samples tested (data no show). (D) Densitometry analysis of the MMP-3, MMP-8, MMP-12,
742 MMP-13 and EMMPRIN.
743 Groups were compared by a non-parametrical test (Mann-Whitney Rank Sum Test) with
744 GraphPad Prism software (version 6.0; GraphPad). Results were expressed as mean±SEM. *
745 P-values were considered significant if p value (0.05) corrected for multiple comparisons by
746 Bonferroni’s method (corrected p value=0.05/3=0.0166).
747
748
749
750
751
34
perpetuity.
752
753 Supplemental materials.
754 Supplemental Figure 1. Western blots showing MMP-3 (54 kD), -8 (65 kD), -12 (54 kD), -
755 13 and EMMPRIN/CD147 (60 kD) protein bands. Protein bands stained with specific
756 antibodies and developed as in Methods are depicted, together with the densitometric
757 measurements using beta actin as a loading control.
758
759 Supplemental Table 1. Oligonucleotide primers used in gene expression analysis.
760 Supplemental Table 2. Histopathological features of the samples

761
35
Table 1. Clinical characteristics of the study subjects.
CLINICAL PARAMETERS GROUPS
CCC DCM CONTROL
Age 47.8 ±14,2 40,6±17,1 28,3 ± 11,0
Male, n (%) 6 (35%) 9 (75%) 6 (100%)
Sample size, n 17 12 6
Body Surface (m2) 1.6 ± 0.3 1.7 ± 0.1 N.D.
Ejection Fraction- EF (%) 23.59 ± 8.5 21.6 ± 7.9 N.D.
Fractional shortening (%) 11.94 ± 7.3 12.2 ± 3.7 N.D.
Left ventricular end diastolic

62.12 ± 98 70.6 ± 19.8 N.D.
diameter LVEDD (mm)
Left ventricular end systolic

48.82 ± 15.6 62.7 ± 20.1 N.D.
diameter LVESD (mm)
Ventricular Septum (mm) 8.53 ± 1.7 8.3 ± 1.4 N.D.
Posterior wall of left ventricle

8.5 ± 1.8 8.6 ± 1.4 N.D.
(mm)
Left atrial diameter (mm) 49.18 ± 5.5 52.1 ± 7.4 N.D.
Aortic sinus (mm) 29.53 ± 3.1 31.8 ± 5.3 N.D.
Myocardial mass index (g/m2) 187.88 ± 69.3 233.8 ± 76.6 N.D.

Relative wall thickness (mm) 0.68 ± 0.5 0.60 ± 0.1 N.D.
Diastolic volume (ml) 288.41 ± 136.6 349.9 ± 131.8 N.D.
Systolic volume (ml) 194.06 ± 131.8 267.5 ± 127.4 N.D.
N.D.: not done.
Control: Heart donors; DCM: Idiopathic dilated cardiomyopathy; CCC: Chronic Chagas
cardiomyopathy.
Datas were expressed as mean ± SD.
Reference values: EF: Ejection Fraction (>55%); Ejection Fraction - EF (25-43%); Left
ventricular end diastolic diameter - LVESD (mm): (42-59mm); Left ventricular end systolic
diameter – LVESD (mm): (25-39mm); Ventricular Septum (mm): (6-10mm); Posterior wall
of the left ventricule (mm): (6-10mm); Left atrial diameter (mm): (30-40mm); Aortic sinus
(mm): (31-47mm); Myocardial mass index (g/m2): (49-115 g/m2); Relative wall thickness
(mm): (<0.42).

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medRxiv preprint doi: https://doi.org/10.1101/2021.12.17.21267825; this version posted December 17, 2021.

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1 Matrix metalloproteinase 2 and 9 enzymatic activities are selectively increased in

2 the myocardium of Chronic Chagas Disease cardiomyopathy patients: role of

5 Running title: Metalloproteinases 2 and 9 in Chagas disease

7 Monique Andrade Baron1,2,3,¶, Ludmila Rodrigues Pinto Ferreira1,2,3,4, ¶, Priscila Camillo

8 Teixeira1,2,3,¶,#a, Ana Iochabel Soares Moretti5, Ronaldo Honorato Barros Santos6,

9 Amanda Farage Frade1,2,3,#b, Andréia Kuramoto1,3, Victor Debbas4, Luiz Alberto

10 Benvenuti6, Fabio Antônio Gaiotto5, Fernando Bacal5, Pablo Pomerantzeff5, Christophe

11 Chevillard7,*, Jorge Kalil2,3, Edecio Cunha-Neto1,2,3,*.

14 Medicine, 05403-900, São Paulo, Brazil.

16 Medicine, 01246100, São Paulo, Brazil.

20 of Medicine, 05403-900, São Paulo, Brazil.

22 Medicine, 05403-900, São Paulo, Brazil

24 Genomic Complexity, Institut MarMaRa, Marseille, France

27 ¶ These authors contributed equally to this work

30 Building 93 / Room 6.20 CH 4070 Basel, Switzerland.

32 Fonseca, 235, Itaquera, São Paulo, SP, Brazil.

35 Edecio Cunha-Neto, Laboratory of Immunology, Heart Institute (Incor), Avenida Dr.

38 Dr. Christophe Chevillard, Theories and Approaches of Genomic Complexity (TAGC),

39 INSERM/AMU UMR_1090, Parc Scientifique de Luminy, case 928, 163, avenue de

40 Luminy, 13288 Marseille France Phone: 33491828736, E-mail:

43 Conflict of interest statement :

45 authors have declared that no competing interests exist.

48 Word count for the main text: 3500 words

50 Abstract (150 words)

51 Chronic Chagas disease (CCC) is an inflammatory dilated cardiomyopathy with a worse

52 prognosis compared to other cardiomyopathies. We show the expression and activity of

53 Matrix Metalloproteinases (MMP) and of their inhibitors TIMP (tissue inhibitor of

54 metalloproteinases) in myocardial samples of end stage CCC, idiopathic dilated

56 significantly increased mRNA expression of several MMPs, several TIMPs and

61 toward their activation. Inflammation-induced increases in MMP-2 and 9 activity and

62 expression associated with imbalanced TIMP regulation could be related to a more

63 extensive heart remodeling and poorer prognosis in CCC patients.

64 Keywords: Chagas disease, metalloproteinases, heart failure; cardiac remodeling, MMPs

66 Chronic Chagas cardiomyopathy (CCC) is the most important chronic clinical

67 manifestation of Chagas disease, a zoonosis caused by the protozoan parasite,

68 Trypanosoma cruzi (T. cruzi) naturally transmitted through haematophagous reduviid

75 progressive, fibrotic disease in which myocardial inflammation plays a fundamental role

81 intensive exercising [9, 10]. Different cardiovascular disorders, like myocardial

86 metalloproteinases (MMPs) [6, 12]. MMPs are zinc-dependent endopeptidases

87 responsible for degradation and remodeling of ECM components including collagens,

93 homeostasis in a normal healthy heart is dependent on the balance between activation of

94 pro-MMPs to active degradative MMPs, a process controlled by complex formation with

96 expression and activity were shown to be dysregulated in different cardiovascular

115 Materials and Methods

116 Ethics Statement

120 consent was obtained from their families.

122 Samples of human myocardium

130 Chagas disease patients underwent standard electrocardiography and echocardiography.

140 ventricular dysfunction/heart failure excluded. Characteristics of patients and normal

144 Table 1. Clinical characteristics of the study subjects.

CCC DCM CONTROL

Age 47.8 ±14,2 40,6±17,1 28,3 ± 11,0

Male, n (%) 6 (35%) 9 (75%) 6 (100%)

Body Surface (m2) 1.6 ± 0.3 1.7 ± 0.1 N.D.

Ejection Fraction- EF (%) 23.59 ± 8.5 21.6 ± 7.9 N.D.

Fractional shortening (%) 11.94 ± 7.3 12.2 ± 3.7 N.D.

Left ventricular end diastolic

Left ventricular end systolic

Ventricular Septum (mm) 8.53 ± 1.7 8.3 ± 1.4 N.D.

Posterior wall of left ventricle

Left atrial diameter (mm) 49.18 ± 5.5 52.1 ± 7.4 N.D.

11 Chevillard7,, Jorge Kalil2,3, Edecio Cunha-Neto1,2,3,.