Warm blood cardioplegic arrest induces mitochondrial-mediated cardiomyocyte apoptosis associated with increased urocortin expression in viable cells

Objectives This study assesses the mechanisms of apoptosis in patients after on-pump coronary artery bypass graft surgery and the potential involvement of the endogenous cardiac peptide urocortin as a cardiomyocyte salvage mechanism. We have previously described the mechanisms of apoptosis after ischemia-reperfusion injury in the rat heart and shown that endogenous urocortin is cardioprotective. Here we extend these findings to the human heart exposed to ischemic-reperfusion injury. Methods Two sequential biopsy specimens were obtained from the right atriums of 24 patients undergoing coronary artery bypass grafting at the start of grafting and 10 minutes after release of the aortic clamp. Apoptosis was identified by means of immunocytochemical colocalization between terminal deoxynucleotidyl transferase-mediated nick end-labeling positivity and active caspase-3. Immunostaining for active caspase-9 and caspase-8 was performed to identify the pathways of apoptosis induction. Urocortin and adenosine triphosphate-dependent potassium channel expression was also assessed by means of immunocytochemistry. Results Myocyte apoptosis (<0.1% before coronary artery bypass grafting) was increased after coronary artery bypass grafting and reperfusion and was greater in patients with longer periods of cardioplegic arrest (3.3% ± 0.5% with <55 minutes and 5.1% ± 0.9% with 85-100 minutes, P < .001). Processing of caspase-9 was always more pronounced than that of caspase-8 (P < .05). Cardioplegic arrest was also associated with increased urocortin expression (up to 29% ± 3.5% vs <3% in samples obtained before coronary artery bypass grafting, P < .001) but only in nonapoptotic myocytes. These and surrounding viable myocytes also showed increased Kir6.1 adenosine triphosphate-dependent potassium channel expression. Conclusions Cardioplegic arrest and subsequent reperfusion result in cardiomyocyte apoptosis, largely through mitochondrial injury, as well as exclusive urocortin expression in viable cells. This finding might suggest a cardioprotective role for endogenous urocortin in human subjects.