Human induced pluripotent stem cell-derived cardiomyocytes to study inflammation-induced diastolic dysfunction

Reviewer #1 (Public Review):

Summary:

This is an original manuscript submission by Tatekoshi et al entitled, "Human induced pluripotent stem cell-derived cardiomyocytes to study inflammation-induced diastolic dysfunction." Based on the premise that treated HIV individuals commonly have heart failure with preserved ejection fraction, yet robust animal models have not been established, the team developed iPS-CM models to study HFpEF with this angle in mind. The group established iPS-CMs using standard methods and studied TNFa and IFNy effects on calcium transients. They observed that both cytokines increased calcium transient decay and downstroke times, which could be reversed by mitoTempo treatment in the case of TNFa. To determine how mitochondrial dysfunction may impact the cytokine-induced calcium transient changes, the team measured OCR treatment changes. They observed that NAC and TNFa co-treated cells demonstrated reduced OCR. The team went on to test the effects of antiretroviral therapies including tenofovir, relategravir, elvitegravir, and darunavir at 3-10 uM levels in iPS-CMs. The team noted that ART treatments reversed the diastolic dysfunction associated with TNFa treatment suggesting that ART therapies may improve diastolic dysfunction that is associated with TNFa signaling directly in cardiomyocytes. Following up on this treatment effect, the team screened several other candidates across drug classes and identified that dapagliflozin (SGLT2i) reversed diastolic dysfunction induced by TNFa. Finally, the team collected human serum from patients with HIV+ patients from two hospitals - Northwestern with diastolic dysfunction by cMRI, and UCSF with normal diastolic function by echo. Both cohort serum samples did not change calcium transients in iPS-CMs. However, due to numerous and significant major methodological concerns, and the potential low impact of the study results, this manuscript is expected to be of very low impact to the field in its current form.

Strengths:

1. From a significance standpoint, understanding the mechanisms of HFpEF, particularly in conditions such as HIV would be very impactful.

2. Collecting HIV patient serum and identifying a plasma factor that impacts cardiac function could be very significant if successful.

Weaknesses:

(1) I am not convinced how this study relates to HIV individual HFpEF, and the study design does not seem to be well thought out.

(2) The connectivity of the study experiments is loose, and data analysis and conclusions are broadly overstated and misinterpreted.

(3) For example the study lacks any measure of diastolic contractile function, and even if performed, the relevance of TNFa treatments to cells in vitro in these immature cell contexts would remain unclear. There is surprisingly no reported molecular analyses of potential mechanisms of the calcium transient changes. The study falls short in molecular detail and instead relies on drug treatments and responses that are hard to interpret with dosages that are not well justified and treatments that are numerous. Unclear what changes in calcium transients mean functionally without a comprehensive assessment of CM biomechanical contraction and relaxation measurements, and this would also require parallel molecular investigations of potential targets of any phenotypes observed.

(4) Calcium transient data need to be better illustrated such as with representative peak tracings. The data overall is with too few samples, particularly given the inherent heterogeneity of iPS-CM studies. The iPS-CM system as a model for diastolic dysfunction remains unestablished.

(5) There are unclear dose choices for the various ART drugs tested, as well as the other drugs tested such as SGLT2i. Besides the observation that SLC5A2 (SGLT2 target) is not established to be expressed in adult mammalian cardiomyocytes.

(6) HIV plasma samples were not tested for cytokine levels, but this could be done to assess the validity of the final experiments. It is unclear what is being tested with these experiments.

(7) The choice of serum controls from a second institution (UCSF) opens up concerns over batch effects unrelated to differences in diastolic dysfunction. However, there were no differences with the Northwestern samples. It is unclear why this data is included as it does not add to the impact of the study.

(8) There are concerns about the quality of the iPS-CMs since there is no cell imaging or molecular analyses. Figure 5 Supplement 1 images are of low quality and low resolution to assess cell quality. Overall the iPS-CM QC data is extremely sparse

Reviewer #2 (Public Review):

The authors investigated the role of inflammatory molecules in diastolic dysfunction and screened antiviral and cardioprotective pharmacological agents for their potential to reverse inflammation-mediated diastolic dysfunction. This study focuses on heart failure with preserved ejection fraction (HFpEF) in people living with HIV (PLWH), a condition often challenging to study due to the lack of suitable animal models. Using human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs), researchers simulated HFpEF in vitro. They observed that inflammatory cytokines impaired cardiomyocyte relaxation, mimicking HFpEF, while SGLT2 inhibitors and mitochondrial antioxidants reversed this effect. Exposure to serum from HIV patients did not induce dysfunction in hiPSC-CMs. These findings suggest hiPSC-CMs as a promising model for understanding HFpEF mechanisms and testing potential treatments.

Comments to improve the study:

The manuscript is well-written, and the results are well-illustrated. However, there are some topics that are not well-connected, and the rationale and hypothesis are not clearly defined beforehand, such as mitochondrial membrane potential, mitochondrial ROS, and angiogenic potential.

As the hiPSC cardiomyocytes are treated with various reagents to measure diastolic dysfunction, it is important to confirm whether the treatment time and dose used were sufficient to exert a functional effect. Dose and time-dependent experiments are essential, or at least sufficient citations should be provided for selecting the dose for IFN and TNF.

After IFN and TNF treatment, determining the expression levels of molecular markers of DD/HFpEF is crucial. Again, if sufficient evidence is available, it can be cited.

The Methods section describes TMRE colocalization and immunofluorescence, but no images are provided.

The concentration of TNF and IFN in patients is critical, which was acknowledged and discussed as a limitation of the study by the authors. Authors should consider this aspect, and if not feasible, clinical reports should be cited to provide a rough estimation of their concentration.