Mechanical forces pattern endocardial Notch activation via mTORC2-PKC pathway

Joint Public Review:

The overall goal of this manuscript is to understand how Notch signaling is activated in specific regions of the endocardium, including the OFT and AVC, that undergo EMT to form the endocardial cushions. Using dofetilide to transiently block circulation in E9.5 mice, the authors show that Notch receptor cleavage still occurs in the valve-forming regions due to mechanical sheer stress as Notch ligand expression and oxygen levels are unaffected. The authors go on to show that changes in lipid membrane structure activate mTOR signaling, which causes phosphorylation of PKC and Notch receptor cleavage.

The strengths of the manuscript include the dual pharmacological and genetic approaches to block blood flow in the mouse, the inclusion of many controls including those for hypoxia, the quality of the imaging, and the clarity of the text. However, several weaknesses were noted surrounding the main claims where the supporting data are incomplete.

PKC - Notch1 activation:

(1) Does deletion of Prkce and Prkch affect blood flow, and if so, might that be suppressing Notch1 activation indirectly?

(2) It would be helpful to visualize the expression of prkce and prkch by in situ hybridization in E9.5 embryos.

(3) PMA experiments: Line 223-224: A major concern is related to the conclusion that "blood flow activates Notch in the cushion endocardium via the mTORC2-PKC signaling pathway". To make that claim, the authors show that a pharmacological activation with a potent PKC activator, PMA, rescues NICD levels in the AVC in dofetilide-treated embryos. This claim would also need proof that a lack of blood flow alters the activity of mTORC2 to phosphorylate the targets of PKC phosphorylation. Also, this observation does not explain the link between PKC activity and Notch activation.

(4) In addition, the authors hypothesise that shear stress lies upstream of PKC and Notch activation, and that because shear stress is highest at the valve-forming regions, PKC and Notch activity is localised to the valve-forming regions. Since PMA treatment affects the entire endocardium which expresses Notch1, NICD should be seen in areas outside of the AVC in the PMA+dofetilide condition. Please clarify.

Lipid Membrane:

(1) It is not clear how the authors think that the addition of cholesterol changes the lipid membrane structure or alters Cav-1 distribution. Can this be addressed? Does adding cholesterol make the membrane more stiff? Does increased stiffness result from higher shear stress?

(2) The loss of blood flow apparently affects Cav1 membrane localization and causes a redistribution from the luminal compartment to lateral cell adhesion sites. Cholesterol treatment of dofetilide-treated hearts (lacking blood flow) rescued Cav1 localization to luminal membrane microdomains and rescued NICD expression. It remains unclear how the general addition of cholesterol would result in a rescue of regionalized membrane distribution within the AVC and in high-shear stress areas.

(3) The authors do not show the entire heart in that rescue treatment condition (cholesterol in dofetilide-treated hearts). Also, there is no quantification of that rescue in Figure 4B. Currently, only overview images of the heart are shown but high-resolution images on a subcellular scale (such as electron microscopy) are needed to resolve and show membrane microdomains of caveolae with Cav1 distribution. This is important because Cav-1could have functions independent of caveolae (eg. Lolo et al., https://doi.org/10.1038/s41556-022-01034-3).

Figure Legends, missing data, and clarity:

(1) The number of embryos used in each experiment is not clear in the text or figure legends. In general, figure legends are incomplete (for instance in Figure 1).

(2) Line 204: The authors refer to unpublished endocardial RNAseq data from E9.5 embryos. These data must be provided with this manuscript if it is referred to in any way in the text.

(3) Figure 1 shows Dll4 transcript levels, which do not necessarily correlate with protein levels. It would be important to show quantifications of these patterns as Notch/Dll4 levels are cycling and may vary with time and between different hearts.

(4) Line 212-214: The authors describe cardiac cushion defects due to the loss of blood flow and refer to some quantifications that are not completely shown in Figure 3. For instance, quantifications for cushion cellularity and cardiac defects at three hours (after the start of treatment?) are missing.

(5) Related to Figure 5. The work would be strengthened by quantification of the effects of dofetilide and verapamil on heartbeat at the doses applied. Is the verapamil dosage used here similar to the dose used in the clinic?

Overstated Claims:

(1) The authors claim that the lipid microstructure/mTORC2/PKC/Notch pathway is responsive to shear stress, rather than other mechanical forces or myocardial function. Their conclusions seem to be extrapolated from various in vitro studies using non-endocardial cells. To solidify this claim, the authors would need additional biomechanical data, which could be obtained via theoretical modelling or using mouse heart valve explants. This issue could also be addressed by the authors simply softening their conclusions.

(2) Line 263-264: In the discussion, the authors conclude that "Strong fluid shear stress in the AVC and OFT promotes the formation of caveolae on the luminal surface of the endocardial cells, which enhances PKCε phosphorylation by mTORC2." This link was shown rather indirectly, rather than by direct evidence, and therefore the conclusion should be softened. For example, the authors could state that their data are consistent with this model.

(3) In the Discussion, it says: "Mammalian embryonic endocardium undergoes extensive EMT to form valve primordia while zebrafish valves are primarily the product of endocardial infolding (Duchemin et al., 2019)." In the paper cited, Duchemin and colleagues described the formation of the zebrafish outflow tract valve. The zebrafish atrioventricular valve primordia is formed via partial EMT through Dll-Notch signaling (Paolini et al. Cell Reports 2021) and the collective cell migration of endocardial cells into the cardiac jelly. Then, a small subset of cells that have migrated into the cardiac jelly give rise to the valve interstitial cells, while the remainder undergo mesenchymal-to-endothelial transition and become endothelial cells that line the sinus of the atrioventricular valve (Chow et al., doi: 10.1371/journal.pbio.3001505). The authors should modify this part of the Discussion and cite the relevant zebrafish literature.