Pharmacologically inducing regenerative cardiac cells by small molecule drugs

Reviewer #1 (Public Review):

Summary:

This manuscript reports that a combination of two small molecules, 2C (CHIR99027 and A-485) enabled to induce the dedifferentiation of hESC-derived cardiomyocytes (CMs) into regenerative cardiac cells (RCC). These RCCs had disassembled sarcomeric structures and elevated expression of embryonic cardiogenic genes such as ISL1, which exhibited proliferative potential and were able to differentiate into cardiomyocytes, endothelial cells, and smooth muscle cells. Lineage tracing further suggested that RCCs originated from TNNT2+ cells, not pre-existing ISL1+ cells. Furthermore, 2C treatment increased the numbers of RCC cells in neonatal rat and adult mouse hearts and improved cardiac function post-MI in adult mice. Mechanistically, bulk RNA-seq analysis revealed that 2C led to elevated expression of embryonic cardiogenic genes while down-regulation of CM-specific genes. Single-cell RNA-seq data showed that 2C promoted cardiomyocyte transition into an intermediate state that is marked with ACTA2 and COL1A1, which subsequently transformed into RCCs. Finally, ChIP-seq analysis demonstrated that CHIR99027 enhanced H3K9Ac and H3K27Ac modifications in embryonic cardiac genes, while A-485 inhibited these modifications in cardiac-specific genes. These combined alterations effectively induced the dedifferentiation of cardiomyocytes into RCCs.

Strengths:

Overall, this work is quite comprehensive and is logically and rigorously designed. The phenotypic and functional data on 2C are strong.

Weaknesses:

The mechanistic insights of 2C are primarily derived from transcriptomic and genomic datasets without experimental verification.

Reviewer #2 (Public Review):

Summary:

The ability of cardiac cells to regenerate has been the object of intense (and sometimes controversial) research in biology. While lower organisms can robustly undergo cardiac regeneration by reactivation of the embryonic cardiogenic pathway, this ability is strongly reduced in mice, both temporally and qualitatively. Finding a way to derive precursor cells with regenerative ability from differentiated cells in mammals has been challenging.

Zhou, He, and colleagues hypothesized that ISL-1-positive cells would show regenerative capacity and developed a small molecules screen to dedifferentiate cardiomyocytes (CM) to ISL1-positive precursor cells. Using hESC-derived CM, the authors found that the combination of both, WNT activation (CHIR99021) and p300 acetyltransferase inhibition (A-485) (named 2C protocol) induces CM dedifferentiation to regenerative cardiac cells (RCCs). RCCs are proliferative and re-express embryonic cardiogenic genes while decreasing the expression of more mature cardiac genes, bringing them towards a more precursor-like state. RCCs were able to differentiate into CM, smooth muscle cells, and endothelial cells, highlighting their multipotent property. In vivo, administration of 2C in rats and mice had protective effects on myocardial infarction.

Mechanistically, the authors report that the 2C protocol drives CM-specific transcriptional and epigenetic changes.

Strengths:

The authors made a great effort to validate their data using orthogonal ways, and several hESC lines. The use of lineage tracing convincingly showed a dedifferentiation from CM. They translate their findings into an in vivo model of myocardial injury, and show functional cardiac regeneration post-injury. They also showed that 2C could surprisingly be used as a preventive treatment. Together their data may suggest a regenerative effect of 2C both in vitro and in vivo settings. If confirmed, this study might unlock therapeutic strategy for cardiac regeneration.

Weaknesses:

Several points remain puzzling to me and some aspects of this study need to be clarified and extended:

General comments:

* Experimental design & Interpretation*

1. The main hypothesis (line 50) that Isl1 cells have regenerative properties is not extremely novel (10.1172/jci.insight.80920, doi.org/10.1038/nature03215,10.1016/s1534-5807(03)00363-0).

2. Based on Table S1, concentration of A-485 used in the screen is 10uM but used throughout this study at 0.5um. Could the authors provide a rationale for this 20x reduction of concentration? It would be useful to get a titration of this compound for the effects tested.

3. It is confusing to clearly understand what proportion of CMs dedifferentiate to become RCCs. The lineage tracing data suggests only 0.6%-1.5% of cells undergo this transition. It is difficult to understand how such a small fraction can have wide effects in their different experimental settings. This is specifically true when the author quantified nuclear and cytosolic area on brightfield pictures - would the same effect on nuclear/cytosolic area be observed in Isl1 KO cells?

4. The authors totally disregard the effect of i-BET-762 that gives a very similar percentage of Isl1-positive cells when combined to 2C (Supp. 1E). What is the effect of CHIR + I-BET-762 alone?

5. It is really hard to understand the contradictory effects of A-485 on acetylation status. The authors mentioned that A-485 only has an effect on H3K27Ac and not on H3K9Ac (line 221) to later (line 226) contradict themselves by saying it also has an effect on H3K9Ac. To explain this discrepancy, the authors vaguely mentioned "further analyses" without giving any other details. It would be transparent to explain what led to this radical change in interpretation.

6. The difference in the ChIP peak height is rather minimal for the H3K9Ac data. Were the peaks normalized to the sequencing depth? What does the y-axis represent on these ChIP traces (number of counts?)

7. Would it be possible to test this 2C protocol on mESC and see if similar changes occur? How transcriptionally different would these mouse RCCs be to Isl1+ progenitors isolated from neonatal mice (P1-P5)?

Statistics & Data acquisition

1. The authors mentioned experiments were done at least 3 times and each dot plotted on a graph is an average of technical repeat for one biological repeat. My understanding would be that if I see 9 dots, it means the experiment has been done 9 times - What would be the rationale for such a high number of repeats? It is an "artificial" way to increase the power of a test and might lead to misinterpretation of the data. This becomes relevant for some figures where biological difference is minimal and they still show statistical differences (e.g. Supp 2E, Supp 3A, Supp 9C,...). This is also true for in vivo section (Fig. 4G).

It would help to have a precise clarification between technical and biological repeats in the figure legends (e.g. n=3 biological repeat (aka 3 dots on a graph) obtained from averaging XX technical repeats), as well as the specific test stated the legend in addition to the general paragraph in the methods. Providing raw numerical data so readers can re-test them independently would also be a transparent way to do it.

1. Does the author test for normality before applying a specific test? Please clarify and justify either way.

2. If each dot represents a biological repeat as stated in the method section, why do some datasets have different numbers of repeats between NC and 2C if obtained in parallel? Have repeats been excluded?

Reviewer #3 (Public Review):

Summary:

The manuscript by Zhou and colleagues describes the potential of a two-compound combination (2C), CHIR99021 and A-485, which can generate regenerative cardiac cells (RCCs) from human embryonic stem cell-derived TNNT2+ cardiomyocytes. The authors have also demonstrated this phenomenon in neonatal rats CMs in vitro. Further, the administration of 2C can generate RCCs in adult mouse hearts and significantly improve survival and cardiac function in mice subjected to myocardial infarction. Interestingly, 2C treatment induces global changes in transcription and epigenetic modifications.

Strengths of the study:

1. This study describes the potential of 2C in improving the regeneration of the heart post-MI. The findings may have a translation potential. The idea of promoting the regenerative capacity of the heart by reprogramming CMs into RCCs is interesting.

2. The authors have validated the effect of 2C independently in hESCs, rat CMs, and a model of MI.

3. The authors explored the mechanism by Single-cell RNA-seq and Chip-Seq, which points to the transcriptional and epigenetic activation of genes essential for RCC.

Weaknesses of the study:

1. The mechanism involved in the 2C-mediated generation of RCCs is still unclear. The leads found in the RNA-seq and ChIP-seq were not validated experimentally.

2. Considering the very low number of RCCs (0.6%-1.5% of cells) generated, I cannot comprehend how the heart is protected from MI. Did the author believe 2C would affect the survival or metabolism of existing CM under hypoxia? What percentage of cells were regenerated by 2C treatment post-MI?

3. I would like to know about administering 2C in mice, which could have generated RCCs- dedifferentiated CMs in the heart. Does 2C affect the cardiac functions in mice under basal conditions? Also, does 2C administration affect any physiology in mice? The cardiac structural and functional parameters are required post-2C administration.

4. It is also not tested whether 2C would affect other cell types of the heart, including fibroblasts and endothelial cells, in vitro and in vivo. Assuming the level of protection by 2C in mice, it would affect other cell types.

5. It is still being determined how the authors chose the dose of 2C for in vivo and in vitro studies, although the concentration used for screening is different. Assessing the effect of 2C in a dose-dependent manner is essential.

6. A-485 affects H3K27Ac but not H3K9Ac. However, data show that both H3K27Ac and H3K9Ac are affected. An explanation is required.

7. The authors use "regeneration" even at the screening stage. I am wondering if regeneration could be assessed by the experimental approach they adopted.

Reviewer #4 (Public Review):

Overview:

The present manuscript by Zhou and colleagues investigates the impact of a new combination of compounds termed CHIR99021 and A-485 on stimulating cardiac cell regeneration. This manuscript fits the journal and addresses an important contribution to scientific knowledge. However, the following major revisions need to be addressed as stated below.

Major comments:

-The authors should include more information that clarifies and justifies their hypothesis.
-The story line is not well developed and thus not convincing since the results from different sections are not well connected.
-The main text needs to be improved, and authors should explain their purpose in choosing to study ISL1-CMs. Also, to well argument why they conducted this study and its significance.
-Page 3, row 57-58: Please add the references.
-Page 3-4, row 67-68, authors stated "When CMs resumed contraction, they were treated with individual small molecules from a collection of over 4,000 compounds for 3 days (SI Appendix, Fig. S1C and Table S1), and then fixed and immunostained with ISL1". Please explain better, and show the results of the selected screening compounds.
-Authors must make an effort to discuss their findings in a bold way in order to provide a comprehensive and articulate explanation of their results to the readers. There is much information missing from this section. This should also propose new research avenues and foresee the challenges in future investigations.
-Authors must include a conclusion and future perspectives of this study.
- Page 4, row 73, the authors stated that the unique compound combination 'CHIR99021 and A-485' was found to be the most efficient in promoting ISL1 expression with a healthy cell state. However, the authors should prove that by showing at least the cell viability of these compound combinations at different concentrations and timings as a supplementary figure.
-There is some missing information in the methods part, for example, "Images were captured using a confocal Zeiss LSM710 and Olympus IX83 inverted microscope"; authors should include the objective used and the image size, and should include which method they used to analyze the acquired images.
-Figure S3A shows that the TNNT2 mRNA expression was completely absent after 60 hours of 2C administration. Authors should explain this further.
-Figure 3J, there is high variability in the graph of mCherry cells (%). Please choose a better graph, or increase the independent experiment.
-Authors did not explain/discuss their results of the DNA-binding motif analysis of ISL1 in the cells treated with A-485 or 2C (Figure 7K).
-Figure S1B and D: the image's labeling is not clear. In the exact same figure S1B, how can the authors explain the reduction of ISL cells? Do the authors make the treatment with the compound CHIR99021 as shown in figure S1A? If so, the authors should clarify the ISL reduction in Figure S1B.
-Figure 1H: please improve the immunoblot, the level of B-actin does not match among the different conditions, or provide a relative quantification of the proteins.
-Please indicate further information in the methodology part about the compounds used in this study.
-Figures are not well justified and figure legends are not sufficient enough to explain the figures.
-Please improve the figure legends by including more further information; for example, in Figure 2SH it is highlighted only the "DAPI (4′,6-diamidino-2- phenylindole) staining labeled nuclei as blue" but how about the other markers?
-Figure 2F: the graph shows some high variations in "ns" between NC at 2C and in 60h+3d. I would recommend increasing the independent experiments. Similar observation goes also for figure 2E.
-Authors should provide limitations of this study.