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Purpose: Neonatal brachial plexus injury (NBPI) causes disabling and incurable muscle contractures, arising from impaired longitudinal growth of denervated muscles. This growth impairment is caused by dysregulation of muscle proteostasis characterized by increased proteasome-mediated protein degradation. Myostatin (MSTN), a secreted growth differentiation factor and prominent muscle-specific negative regulator of proteostasis, drives muscle protein degradation. MSTN signaling is thus a possible pathway through which denervation impairs muscle growth and a potential muscle-specific molecular target for preventing contractures. This study uses pharmacologic inhibition of MSTN signaling in a mouse model of NBPI to test the hypothesis that NBPI induces contractures through MSTN-dependent impairment of longitudinal muscle growth. Methods: Unilateral NBPI was generated in postnatal day (P)5 mice. Mice were treated weekly with Dulbecco’s phosphate-buffered saline (DPBS) or ACVR2B-Fc, a soluble inhibitory decoy receptor for MSTN, starting at P4. Mice were sacrificed at P33, whereupon elbow and shoulder range of motion were measured to assess contractures. Brachialis muscles were prepared for microCT assessment of cross-sectional area (CSA) and volume, then processed for sarcomere length measurement as a readout of longitudinal muscle growth. Total protein content in biceps was assessed via Bradford assay. Protein degradation in triceps was quantified via 20S proteasome β1 subunit activity assay. Results: In female mice, myostatin inhibition with ACVR2B-Fc enhanced muscle weight and total protein content of denervated biceps (Figure 1), increased cross-sectional and volumetric growth of denervated brachialis (Figure 2), preserved longitudinal growth in denervated brachialis (Figure 3), and reduced elbow and shoulder contracture severity in the denervated limbs (Figure 4). Analysis of protein dynamics demonstrates the improvements in female denervated muscles were associated with a reduction in proteasome β1 subunit activity (Figure 5). However, no such improvements in denervated muscles occurred in male mice with ACVR2B-Fc. Conversely, myostatin inhibition increased muscle weight, CSA, volume, and total protein content of the normally innervated, contralateral control muscles in both male and female mice (Figures 1 and 2). Conclusion: Our findings reveal MSTN as a driver of impaired muscle growth and contracture formation in female but not male mice. This sex dimorphism lies in the pathophysiology of denervation-induced contractures rather than drug pharmacodynamics, given the sex-independent effects of MSTN inhibition on normally innervated muscle. Future studies must rigorously interrogate the contributions of sex in contracture pathophysiology. Significance: Our discovery identifies MSTN as a signaling target for modulating contractures in females and highlights the overlooked role of sex in the pathophysiology of acquired neuromuscular disorders. Level of Evidence: Not Applicable FDA: The FDA has not cleared the following pharmaceuticals and/or medical devices for the use described in this presentation.

Neonatal brachial plexus injury (NBPI) causes disabling and incurable muscle contractures that are driven by impaired growth of denervated muscles. A rare form of NBPI, which maintains afferent muscle innervation despite motor denervation, does not cause contractures. As afferent innervation regulates various aspects of skeletal muscle homeostasis through NRG/ErbB signaling, our current study investigated the role of this pathway in modulating contracture development. Through pharmacologic modification with an ErbB antagonist and NRG1 isoforms, we discovered that NRG/ErbB signaling does not modulate the development of contractures in neonatal mice. Instead, ErbB inhibition impeded growth in nondenervated skeletal muscles, whereas increased ErbB activation exacerbated denervation-induced skeletal muscle atrophy. This potential regulatory effect of NRG/ErbB signaling on neonatal muscle growth warrants deeper investigation.

Rationale: Compromised protein quality control can result in proteotoxic intracellular protein aggregates in the heart, leading to cardiac disease and heart failure. Defining the participants and understanding the underlying mechanisms of cardiac protein aggregation is critical for seeking therapeutic targets. We identified Ube2v1 (ubiquitin-conjugating enzyme E2 variant 1) in a genome-wide screen designed to identify novel effectors of the aggregation process. However, its role in the cardiomyocyte is undefined. Objective: To assess whether Ube2v1 regulates the protein aggregation caused by cardiomyocyte expression of a mutant αB crystallin (CryAB R120G ) and identify how Ube2v1 exerts its effect. Methods and Results: Neonatal rat ventricular cardiomyocytes were infected with adenoviruses expressing either wild-type CryAB (CryAB WT ) or CryAB R120G . Subsequently, loss- and gain-of-function experiments were performed. Ube2v1 knockdown decreased aggregate accumulation caused by CryAB R120G expression. Overexpressing Ube2v1 promoted aggregate formation in CryAB WT and CryAB R120G -expressing neonatal rat ventricular cardiomyocytes. Ubiquitin proteasome system performance was analyzed using a ubiquitin proteasome system reporter protein. Ube2v1 knockdown improved ubiquitin proteasome system performance and promoted the degradation of insoluble ubiquitinated proteins in CryAB R120G cardiomyocytes but did not alter autophagic flux. Lys (K) 63-linked ubiquitination modulated by Ube2v1 expression enhanced protein aggregation and contributed to Ube2v1’s function in regulating protein aggregate formation. Knocking out Ube2v1 exclusively in cardiomyocytes by using AAV9 (adeno-associated virus 9) to deliver multiplexed single guide RNAs against Ube2v1 in cardiac-specific Cas9 mice alleviated CryAB R120G -induced protein aggregation, improved cardiac function, and prolonged lifespan in vivo. Conclusions: Ube2v1 plays an important role in protein aggregate formation, partially by enhancing K63 ubiquitination during a proteotoxic stimulus. Inhibition of Ube2v1 decreases CryAB R120G -induced aggregate formation through enhanced ubiquitin proteasome system performance rather than autophagy and may provide a novel therapeutic target to treat cardiac proteinopathies.

Background: Neonatal brachial plexus injury (NBPI) causes disabling and incurable contractures, or limb stiffness, which result from proteasome-mediated protein degradation impairing the longitudinal growth of neonatally denervated muscles. We recently showed in a mouse model that the 20S proteasome inhibitor, bortezomib, prevents contractures after NBPI. Given that contractures uniquely follow neonatal denervation, the current study tests the hypothesis that proteasome inhibition during a finite window of neonatal development can prevent long-term contracture development. Methods: We used a mouse model of NBPI in which neonatal forelimb denervation at P5 causes shoulder and elbow contractures 4 weeks post-denervation. We first outlined the minimum period for proteasome inhibition to prevent contractures 4 weeks post-NBPI by treating mice with saline or bortezomib for varying durations between P8 and P32. We then compared the ability of varying durations of longer-term proteasome inhibition to prevent contractures at 8 and 12 weeks post-NBPI. Elbow and shoulder contractures, elbow flexor muscle length, and proteasome catalytic subunit activity were assessed. Findings: Proteasome inhibition can be delayed 3-4 days after denervation but is required throughout skeletal growth to prevent contractures long-term. Proteasome inhibition becomes less effective in preventing contractures beyond the neonatal period. The therapeutic effect of bortezomib is associated with attenuation of 20S proteasome β1 subunit activity. Interpretation: Temporary neonatal proteasome inhibition does not prevent contractures long-term. Instead, neonatal denervation causes a permanent longitudinal growth deficiency that must be continuously ameliorated during skeletal growth. Additional mechanisms must be explored to reduce the risk of toxicity from long-term proteasome inhibition. Funding Statement: This work was supported by grants to RC from the National Institutes of Health (NIH) (R01HD098280-01) and Pediatric Orthopaedic Society of North America (POSNA), as well as funding from the Cincinnati Children’s Hospital Division of Orthopaedic Surgery and Junior Cooperative Society. Declaration of Interests: The authors have declared that no conflict of interest exists. Ethics Approval Statement: This study was performed in strict accordance with the recommendations in the Guide for the Care and Use of Laboratory Animals of the National Institutes of Health. All mice were handled according to approved institutional animal care and use committee (IACUC) protocols (#2017-0084) of the Cincinnati Children’s Hospital Medical Center. All surgeries were performed under isoflurane anesthesia, and every effort was made to minimize suffering.

The early events that signal renal dysfunction in presymptomatic heart failure are unclear. We tested the hypothesis that functional and mechanistic changes occur in the kidney that precede the development of symptomatic heart failure. We employed a transgenic mouse model with cardiomyocyte-specific overexpression of mutant α-B-crystallin that develops slowly progressive cardiomyopathy. Presymptomatic transgenic mice displayed an increase in serum creatinine (1.17 ± 0.34 vs. wild type 0.65 ± 0.16 mg/dl, P < 0.05) and in urinary neutrophil gelatinase-associated lipocalin (NGAL; 278.92 ± 176.24 vs. wild type 49.11 ± 22.79 ng/ml, P < 0.05) but no renal fibrosis. Presymptomatic transgenic mouse kidneys exhibited a twofold upregulation of the Ren1 gene, marked overexpression of renin protein in the tubules, and a worsened response to ischemia-reperfusion injury based on serum creatinine (2.77 ± 0.66 in transgenic mice vs. 2.01 ± 0.58 mg/dl in wild type, P < 0.05), urine NGAL (9,198.79 ± 3,799.52 in transgenic mice vs. 3,252.94 ± 2,420.36 ng/ml in wild type, P < 0.05), tubule dilation score (3.4 ± 0.5 in transgenic mice vs. 2.6 ± 0.5 in wild type, P < 0.05), tubule cast score (3.2 ± 0.4 in transgenic mice vs. 2.5 ± 0.5 in wild type, P < 0.05), and TdT-mediated dUTP nick-end labeling (TUNEL)-positive nuclei (10.1 ± 2.1 in the transgenic group vs. 5.7 ± 1.6 per 100 cells counted in wild type, P < 0.01). Our findings indicate functional renal impairment, urinary biomarker elevations, and induction of renin gene and protein expression in the kidney that occur in early presymptomatic heart failure, which increase the susceptibility to subsequent acute kidney injury.

Rationale: Hypertrophic cardiomyopathy occurs with a frequency of about 1 in 500 people. Approximately 30% of those affected carry mutations within the gene encoding cMyBP-C (cardiac myosin binding protein C). Cardiac stress, as well as cMyBP-C mutations, can trigger production of a 40kDa truncated fragment derived from the amino terminus of cMyBP-C (Mybpc3 40kDa ). Expression of the 40kDa fragment in mouse cardiomyocytes leads to hypertrophy, fibrosis, and heart failure. Here we use genetic approaches to establish a causal role for excessive myofibroblast activation in a slow, progressive genetic cardiomyopathy—one that is driven by a cardiomyocyte-intrinsic genetic perturbation that models an important human disease. Objective: TGFβ (transforming growth factor-β) signaling is implicated in a variety of fibrotic processes, and the goal of this study was to define the role of myofibroblast TGFβ signaling during chronic Mybpc3 40kDa expression. Methods and Results: To specifically block TGFβ signaling only in the activated myofibroblasts in Mybpc3 40kDa transgenic mice and quadruple compound mutant mice were generated, in which the TGFβ receptor II (TβRII) alleles ( Tgfbr2 ) were ablated using the periostin ( Postn ) allele, myofibroblast-specific, tamoxifen-inducible Cre ( Postnmcm ) gene-targeted line. Tgfbr2 was ablated either early or late during pathological fibrosis. Early myofibroblast-specific Tgfbr2 ablation during the fibrotic response reduced cardiac fibrosis, alleviated cardiac hypertrophy, preserved cardiac function, and increased lifespan of the Mybpc3 40kDa transgenic mice. Tgfbr2 ablation late in the pathological process reduced cardiac fibrosis, preserved cardiac function, and prolonged Mybpc3 40kDa mouse survival but failed to reverse cardiac hypertrophy. Conclusions: Fibrosis and cardiac dysfunction induced by cardiomyocyte-specific expression of Mybpc3 40kDa were significantly decreased by Tgfbr2 ablation in the myofibroblast. Surprisingly, preexisting fibrosis was partially reversed if the gene was ablated subsequent to fibrotic deposition, suggesting that continued TGFβ signaling through the myofibroblasts was needed to maintain the heart fibrotic response to a chronic, disease-causing cardiomyocyte-only stimulus.

Introduction: Impairment of protein quality control leads to the accumulation of intracellular misfolded protein aggregates, contributing to cardiac disease and heart failure. Essential protein quality control pathways, including proteasomal degradation and autophagy, are involved in maintaining cellular homeostasis and cardiac function during proteotoxic insult. In a prior study, we undertook an unbiased, total genomewide screen for RNA transcripts and their protein products that affect aggregate accumulations in the cardiomyocytes. Forkhead box F1 (Foxf1) gene was one of the hits from our high throughput screening. In this study, we have performed further validation of Foxf1, a transcription factor and previously unknown player in proteotoxic processes. Aims and Methods: The objective of this study was to validate Foxf1 as a contributor to protein quality control and understand its role in contributing to protein aggregate formation during proteotoxic-induced cardiac disease. We knocked down Foxf1 expression using siRNA mediated transfection in neonatal rat ventricular cardiomyocytes that expressed the protein aggregate inducing mutation of the chaperone α B crystallin (CryABR120G). Proteasomal function and relative activity in cells was analyzed using a degron-destablized green fluorescent protein (GFPu) based reporter protein. Similarly, autophagy activity was determined by autophagic flux assay using bafilomycin treatment. Results: CryABR120G expression leads to aggregate formation and decreased proteasomal function in cardiomyocytes. Knockdown of Foxf1 gene expression in CryABR120G-transfected cardiomyocytes reduced the proteotoxic sequelae, decreasing aggregate concentration. Knockdown of Foxf1 significantly increased proteasomal function in the model without altering autophagy activity. Conclusion: Decreased Foxf1 expression reduced CryABR120G induced aggregate protein accumulation and decreased proteotoxic stress in cardiomyocytes, likely through the maintenance of clearance of the misfolded protein via the proteasomal pathway.

Background: Mutations in cardiac myosin binding protein C ( MYBPC3 ) account for more than one third of identified hypertrophic cardiomyopathy (HCM). Data from both human patients and mouse models suggest that cardiac fibrosis preceeds hypertrophy and cardiac dysfunction, implying that fibrosis related signaling may be one of the initial signs of developing cardiac disease. We wished to determine if cardiomyocyte-autonomous TGFβ signaling is sufficient to initiate pathogenic fibrosis in the heart in the context of a cMyBP-C-induced disease. Methods and Results: Neonatal rat ventricular cardiomyocytes (NRVMs) expressing either wild-type or Mybpc3 mutations were mediated by adenovirus for 48 hours. Both cells and culture medium (conditional medium) were harvested. The fibrotic effects of the conditional medium on neonatal rat ventricular fibroblasts (NRVFs) were determined using “fibrotic” gene promoters driving luciferase (luc) expression ( αSMA-luc , postn-luc and col1a1-luc ). TGFβ levels in the conditional medium were determined using ELISA assays. Expression of cMybpc3 mutations activated TGFβ promoter activity ( Tgfb1-luc , Tgfb2-luc and Tgfb3-luc ) in a TGFβ receptor(s) (TβRs) dependent manner. Upregulation of TGFβ was also confirmed in transgenic mice expressing a fragment of cMyBP-C (cMyBP-C 40kDa ) whose expression results in significant fibrosis and cardiac disease. To establish causality, we genetically ablated TGFβ receptors ( Tgfbr1 and Tgfbr2 ) in the cardiomyocytes of the cMybpc3 40kDa mice. TGFβ receptors ablation blocked the induction of TGFβ expression, alleviating cardiac fibrosis and decreasing cardiac hypertrophy. Cardiac function was significantly improved and survival of the cMyBP-C 40kDa mice was increased. Conclusions: Cardiomyocytes are a critical source of TGFβ in cMyBP-C 40kDa hearts during the initial stages of pathogenesis. Thus, TβRs ablation at the early stage completely prevent the progression of the pathological process in vivo .

Background Cardiac stress can trigger production of a 40‐kDa peptide fragment derived from the amino terminus of the cardiac myosin‐binding protein C. Cardiac stress, as well as cMyBP ‐C mutations, can trigger production of 1 such truncated protein fragment, a 40‐kDa peptide fragment derived from the amino terminus of cMyBP ‐C. Genetic expression of this 40‐kDa fragment in mouse cardiomyocytes ( cMyBP ‐C 40k ) leads to cardiac disease, fibrosis, and death within the first year. Fibrosis can occur in many cardiovascular diseases, and mitogen‐activated protein kinase––activated protein kinase‐2 signaling has been implicated in a variety of fibrotic processes. Recent studies demonstrated that mitogen‐activated protein kinase––activated protein kinase‐2 inhibition using the cell‐permeant peptide inhibitor MMI ‐0100 is protective in the setting of acute myocardial infarction. We hypothesized that MMI ‐0100 might also be protective in a chronic model of fibrosis, produced as a result of cMyBP ‐C 40k cardiomyocyte expression. Methods and Results Nontransgenic and cMyBP ‐C 40k inducible transgenic mice were given MMI ‐0100 or PBS daily for 30 weeks. In control groups, long‐term MMI ‐0100 was benign, with no measurable effects on cardiac anatomy, function, cell viability, hypertrophy, or probability of survival. In the inducible transgenic group, MMI ‐0100 treatment reduced cardiac fibrosis, decreased cardiac hypertrophy, and prolonged survival. Conclusions Pharmaceutical inhibition of mitogen‐activated protein kinase––activated protein kinase‐2 signaling via MMI ‐0100 treatment is beneficial in the context of fibrotic cMyBPC 40k disease.

Introduction: Transforming Growth Factor beta (TGFβ) is an important cytokine in mediating cardiac fibrosis. Cardiomyocyte-specific expression of a mutant αB-crystallin (CryAB R120G ) that is responsible for human Desmin Related Myopathy results in significant cardiac fibrosis and cardiac remodeling leading to heart failure. Onset of fibrosis is initiated by the activation of a quiescent fibroblast population to an active, “myofibroblast” state and TGFβ binding is thought to mediate an essential signaling pathway underlying this process. Our central hypothesis is that myofibroblast-based TGFβ signaling can result in significant cardiac fibrosis. Here, we have partially ablated TGFβ signaling in cardiac myofibroblasts to observe if cardiac fibrosis is altered. Objective: To understand the contributions of myofibroblast-based TGFβ signaling to the development of cardiac fibrosis. Methods and Results: To test the hypothesis we partially ablated myofibroblast specific TGFβ signaling by crossing CryAB R120G mice with mice containing a floxed allele of TGFβ’s receptor 1 (TGFβr1). The double transgenic animals were further crossed with activated myofibroblast specific Cre mice in which Cre expression was driven off the periostin promoter so that TGFβr1 would be ablated subsequent to myofibroblast conversion as the periostin promoter became active. Echocardiography, Masson’s Trichome staining, the hydroxyproline assay, PCR arrays, immunohistochemistry and western blots were used to characterize fibrosis and cardiac function in mice lacking TGFβr1 in the myofibroblasts were used to characterize the resultant animals. Conclusion: Myofibroblast-targeted knockdown of Tgfβr1 signaling resulted in reduced fibrosis and improved cardiac function.

Background: Hypertrophic cardiomyopathy is considered one of the most common genetic heart disorders, occurring with a frequency of about 1 in 200, with approximately 30% of those affected showing mutations within the cardiac myosin-binding protein C (cMyBP-C) gene ( MYBPC3 ). Cardiac stress, as well as cMyBP-C mutations, can trigger production of a 40kDa truncated fragment derived from the amino terminus of cMyBP-C. Genetic expression of this 40kDa fragment in mouse cardiomyocytes (MyBP-C 40k ) leads to hypertrophic cardiomyopathy), fibrosis and heart failure. Fibrosis can occur in many cardiovascular diseases and the p38-MK2 signaling pathway has been implicated in a variety of fibrotic processes. Recent studies demonstrated that MK2 inhibition using the cell-permeant peptide inhibitor MMI-0100 is protective in the setting of acute myocardial infarction. We hypothesized that MMI-0100 might also be protective in a chronic model of fibrosis, produced as a result of cMyBP-C 40k cardiomyocyte expression. Methods and Results: Non-transgenic and MyBP-C 40k transgenic (Dtg) mice were given MMI-0100 or PBS daily for 30 weeks. In control groups, long term MMI-0100 was benign, with no measurable effects on cardiac anatomy, function, cell viability, hypertrophy or probability of survival. In the Dtg group, MMI-0100 treatment reduced cardiac fibrosis, decreased cardiac hypertrophy and prolonged survival. Conclusions: Pharmaceutical inhibition of p38-MK2 signaling via MMI-0100 treatment is beneficial in the context of fibrotic MyBPC 40k disease.

Introduction: Transforming Growth Factor Beta (TGFβ) is an important cytokine in mediating the fibrogenic response and, in particular, cardiac fibrosis. Extensive fibrosis accompanies the cardiac remodeling that occurs during development of the protein conformation-based disease caused by cardiomyocyte-specific expression of a mutant, small, heat shock-like protein and chaperone, aB crystallin (CryABR120G). During the onset of fibrosis, fibroblasts are activated to the so-called “myofibroblast” state and TGFβ binding is thought to mediate an essential signaling pathway underlying this process. Our central hypothesis is that TGFβ signaling processes that result in significant cardiac fibrosis in a mouse model of proteotoxic heart disease are mediated by cardiac fibroblasts, rather than cardiomyocytes. Here, we have partially ablated TGFβ signaling only in cardiac myofibroblasts to observe if cardiac fibrosis is reduced. Aims and Methods: The objective of this study was to understand the contributions of fibroblast-derived TGFβ signaling to the development of cardiac fibrosis in a proteotoxic mouse model that results in significant cardiac fibrosis. To test the hypothesis we partially deleted the myofibroblast specific canonical and non-canonical signaling by crossing CryAB R120G mice with Tgfbr1 or Tgfbr2 floxed mice. The double transgene containing mice were further crossed with activated myofibroblast specific Cre mice in which Cre expression was driven off the periostin promoter. Echocardiography, Masson’s Trichome staining, PCR arrays, IHC and western blots were performed to characterize the fibrotic progression in CryAB R120G transgenic mice. Results: We observed that myofibroblast-targeted partial knockdown of Tgf βr1 signaling prolonged survival, modestly reducing fibrosis and improving cardiac function . Similarly, Tgf βr2 partial knockdown prolonged survival, modestly reducing fibrosis without improving cardiac function during fibrosis development in CryAB R120G mice. Conclusion: These findings suggest that, in a model of proteotoxic heart disease, myofibroblast based TGFβ signaling in the heart may contribute to cardiac hypertrophy/dysfunction but cannot account entirely for the fibrotic response.