Cardiovascular Research Advance Access originally published online on November 20, 2007
Cardiovascular Research 2008 77(3):448-451; doi:10.1093/cvr/cvm074
An alternative view of apoptosis in heart development and disease

Cell Signaling and Apoptosis Group, Biomedical Research Institute of Lleida (IRBLLEIDA), Av. Rovira Roure, 80, 25198 Lleida Spain
* Corresponding author. Tel: +34 973702215; fax: +34 973702213. E-mail address: daniel.sanchis{at}cmb.udl.cat
Although the involvement of caspases in cardiomyocyte death is widely accepted [reviewed in1], increasing experimental evidence suggests that caspase activation is not relevant for post-mitotic cardiomyocyte cell death.2–7 Controversy also exists as to the mechanisms conferring cardioprotection by caspase inhibitors, which could be unrelated to apoptosis or target non-myocardial cells.8–11 In addition, the genes controlling the caspase-dependent death pathway are silenced during early post-natal development.7,12 Finally, the major role of death receptors and the Bcl-2-related proteins in the myocardium is probably to control differentiation, adaptation to stress and mitochondrial integrity. In light of these findings, we propose here an alternative explanation of the role of canonical apoptosis regulators in the control of cardiomyocyte life and death.
| 1. Caspase-dependent signalling is important during heart morphogenesis and is later silenced in post-mitotic cardiomyocytes |
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Cell death implying apoptotic-like DNA damage occurs during embryonic heart development.13–15 Experiments using caspase inhibitors suggest that caspase-dependent cell death occurs in the cardiac regions submitted to important morphological changes, such as the ventriculoarterial connections, the atrioventricular cushions, and the conduction tissue.16–18 Therefore, caspase activation is likely assuring the proper formation of the cardiac cavities and the correct docking of the arteries to the ventricles during development. Later, the caspase-dependent death machinery is repressed during cardiomyocyte terminal differentiation,7,12 as it has been described in retinal neurons.19
| 2. Mitochondrial damage implicated in post-mitotic cardiomyocyte death is not associated with caspase activation |
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Many reports have demonstrated that mitochondrial damage precedes post-mitotic cardiomyocyte cell death and have suggested the involvement of caspases20 yet the engagement of these proteases downstream of mitochondrial damage is still debated [e.g. 4 vs. 21]. The Bcl-2 family controls mitochondrial events leading to caspase activation by regulating outer mitochondrial membrane permeabilization. However, mitochondrial damage also hinders aerobic metabolism and alters cellular Ca2+ homeostasis. Thus, Bcl-2 and Bcl-XL-dependent cardioprotection could be achieved by maintaining mitochondrial physiology through preservation of mitochondrial membrane integrity.22–25 Further, supporting a role of mitochondrial damage unrelated to caspases yet involving Bcl-2-related proteins, Bnip3 induces caspase-independent mitochondrial permeabilization during cardiac ischaemia.5 In this setting, myocyte DNA degradation is independent of caspases.5,7 In addition, high expression of Bcl-2 is suggested to limit autophagy in the heart.26 Because of its relevance in cardiomyocyte homeostasis,3,27–29 autophagy is a process controlled by the Bcl-2 family that could affect cardiomyocyte viability.
Another event involved in mitochondrial damage is the destabilization of the inner mitochondrial membrane integrity (mitochondrial permeability transition, MPT). MPT dissipates the electrochemical gradient, affecting aerobic energy production, and triggering the release of mitochondrial proteins to the cytosol.30 In cardiomyocytes, MPT is implied in cell death in a caspase-independent and Bcl-2-independent manner during ischaemia and reperfusion.31 In addition, caspase-independent calpain activation ensuing from mitochondrial damage could also impair Na+/K+ exchanger function, and hence Ca2+ homeostasis, exacerbating cardiac cell death during reperfusion.4,32 Moreover, an increase in the cytosolic Ca2+ pool could aggravate mitochondrial damage by increasing the cyclophilin-D-dependent MPT.31 Finally, the antiapoptotic protein ARC (Apoptotic Repressor with CARD domain)33,34 that has been shown to safeguard the heart34 and to block caspase activation in cell lines35,36 can also protect from caspase-independent death,37,38 suggesting that ARC-dependent protection could be caspase-independent in post-mitotic cardiomyocytes.
The above evidences suggest that mitochondrial damage is an important event leading to cardiomyocyte death without downstream activation of caspases. Our results show that the disruption between cytochrome c release and caspase activity is due to the silencing of key pro-apoptotic genes including Apaf-1 and executioner caspases during cardiac development [6,7, see Figure 1]. This could be an evolutionary selection to prevent death of long-lived cardiomyocytes after release of cytochrome c in order to sustain viability in case of mitochondrial rupture.
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| 3. Death receptor-dependent apoptosis is involved in non-myocyte cell death in experimental models of heart disease |
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Fas-dependent signalling has been implicated in cardiomyocyte death during graft rejection and ischaemia/reoxygenation, as suggested by experiments comparing cardiomyocyte death in wild type mice and mice carrying loss-of-function mutations of either Fas or Fas ligand (FasL) genes (lpr and gld mice, respectively).39–41 However, it has been demonstrated that cardiac graft salvage in lpr and gld mice is due to a general impairment of the host immune response, which normally would attack the graft, and not to a specific role of cardiac Fas signalling.42 During ischaemia/reoxygenation-induced cardiomyocyte death, Fas and FasL have been shown recently to promote granulation tissue death but not cardiomyocyte loss.43,44 These results agree with the finding that the main role of caspase inhibitors given during experimental myocardial infarction is to protect non-myocardial cells.11 Tumor necrosis factor-
(TNF-
) was reported to induce DNA damage in cultured adult cardiomyocytes, although the involvement of caspases was not checked.45 However, recent reports using biochemical and genetic approaches have discarded a direct role of this cytokine in cardiomyocyte death.46–51 TNF-
genetic deficiency reduced cardiac inflammation and fibrosis, suggesting a role of TNF-
in granulation tissue signalling.51 Interestingly, TNF-
also induces caspase activation in vascular endothelial cells,52 which dye by apoptosis during congestive heart failure.53 Therefore, the extrinsic pathway likely induces granulation tissue and endothelial cell death but not cardiomyocyte death during heart disease. | 4. Death receptors play a relevant role in cardiomyocyte differentiation and growth |
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Against expectation, null mutation of some components of the death receptor pathway, such as Fas-associated death domain (FADD), caspase-8 and cFLIP, a caspase-8-like protein that lacks the protease motif, induce ventricular cell hypoplasia and non compaction of the ventricular wall in the embryo.54–56 Interestingly, the role of these proteins in heart development seems to be independent of cell death because deficiency in the pro-apoptotic factors FADD and caspase-8, as well as lack of anti-apoptotic cFLIP, result in the same cardiac phenotype. On the contrary, experimental overexpression of Fas or FasL induces hypertrophy in cardiomyocytes.57–59 Cardiac hypertrophy ensues also from TNF-
stimulation in vitro46,47 and in vivo.48–49 In addition, mice lacking TNF receptors 1 and 2 have larger infarct areas than wild-type animals,50 and TNF-
genetic deficiency decreases the hypertrophic growth of the myocardium after aortic banding.51 These data suggest that cardiac death receptor activation triggers hypertrophy. Therefore, genetic and biochemical evidences suggest that the extrinsic pathway regulates cardiomyocyte differentiation and cardiac response to stress through cell death-independent mechanisms that remain to be explored. | 5. Concluding remarks |
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In our opinion, there is solid evidence suggesting that although caspase-dependent cell death is involved in heart morphogenesis, post-mitotic cardiomyocyte death is a caspase-independent event. This shift could come after the repression of pro-apoptotic genes in cardiomyocytes during differentiation (see Figure 1). Caspase activation would affect indirectly post-mitotic myocyte cell survival and heart performance because it induces death of endothelial cells and granulation tissue. On the contrary, post-mitotic cardiomyocyte death would ensue from mitochondrial damage, which hampers aerobic respiration and alters calcium homeostasis in the absence of caspases. In addition, death receptors and the Bcl-2 family regulate events that are essential for cardiac function, such as cell differentiation and mitochondrial integrity, and modulate the response to stress by inducing hypertrophy and controlling autophagy. The full comprehension of these events will have great therapeutic potential.
Conflict of interest: none declared.
| Funding |
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Ministry of Education and Science of Spain (SAF2005-02197 to D.S.).
Comissionat per a Universitats i Recerca-Government of Catalonia (Suport als Grups de Recerca de Catalunya conjoint grant to J.X.C., D.S. and M.L.).
Ministry of Education and Science of Spain (Ramón y Cajal contract to D.S. and M.L.).
| Notes |
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The opinions expressed in this article are not necessarily those of the Editors of Cardiovascular Research or of the European Society of Cardiology.
Present address. Universitat Autònoma de Barcelona (UAB), Edifici M Campus Bellaterra, 08193 Bellaterra, Spain. ![]()
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