Protection of Myocardial Ischemia–Reperfusion by Therapeutic Hypercapnia: a Mechanism Involving Improvements in Mitochondrial Biogenesis and Function

  • Laiting Chi
  • Nan Wang
  • Wanchao Yang
  • Qi Wang
  • Dengming Zhao
  • Tian Sun
  • Wenzhi LiEmail author
Original Article


Previous studies proposed that acidic reperfusion may be a protective strategy for myocardial ischemia–reperfusion therapy with potential of clinical transformation. In this study, we investigated whether therapeutic hypercapnia could mimic acidosis postconditioning in isolated hearts with a 30-min left coronary artery ligation–reperfusion model in rats. Therapeutic hypercapnia (inhalation 20% CO2 for 10 min) is cardioprotective with a strict therapeutic time window and acidity: it reduced the infarct ratio and serum myocardial enzyme and increased the myocardial ATP content. Furthermore, mitochondrial morphology damage, the loss of mitochondrial membrane potential, and the formation of mitochondrial permeability transition pore were effectively inhibited, indicating the improvements in mitochondrial function. The expression of the mitochondrial biogenesis regulators was upregulated simultaneously. These findings indicated therapeutic hypercapnia in animals can mimic ex vivo acidosis postconditioning to alleviate myocardial ischemia–reperfusion injury. The effect is related to improvement in mitochondrial function and regulation of the mitochondrial biogenesis pathway.


Myocardial ischemia–reperfusion Hypercapnia Mitochondrial biogenesis Acidosis Postconditioning 



AMP-activated protein kinase


Cardiac troponin I




Mean arterial pressure


Mitochondrial permeability transition pores


Na+–bicarbonate cotransporter


Na+–Ca2+ exchanger


Na+–H+ exchanger


Nuclear magnetic resonance


Percutaneous coronary intervention


Peroxisome proliferator–activated receptor γ coactivator-1α


Intracellular pH


Phosphatidylinositol 3 kinase


Protein kinase C


Transmission electron microscopy


Mitochondrial transcription factor A


2,3,5-triphenyltetrazolium chloride


Reactive oxygen species


Mitochondrial membrane potential



The authors greatly appreciate the technical assistance of the Department of Pathology of Harbin Medical University (Harbin, Heilongjiang Province, China) in transmission electron microscope evaluation, Harbin, Heilongjiang Province, China.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All institutional ethical guidelines and national guidelines for the care and use of laboratory animals were followed and approved by the Animal Care Committee of Harbin Medical University, China. No human studies were carried out for this article.


  1. 1.
    Yellon, D. M., & Hausenloy, D. J. (2007). Myocardial reperfusion injury. The New England Journal of Medicine, 357(11), 1121–1135. Scholar
  2. 2.
    Cohen, M. V., Yang, X. M., & Downey, J. M. (2007). The pH hypothesis of postconditioning: staccato reperfusion reintroduces oxygen and perpetuates myocardial acidosis. Circulation, 115(14), 1895–1903. Scholar
  3. 3.
    Inserte, J., Barba, I., Hernando, V., Abellan, A., Ruiz-Meana, M., Rodriguez-Sinovas, A., & Garcia-Dorado, D. (2007). Effect of acidic reperfusion on prolongation of intracellular acidosis and myocardial salvage. Cardiovascular Research, 77(4), 782–790. Scholar
  4. 4.
    Baines, C. P. (2009). The mitochondrial permeability transition pore and ischemia-reperfusion injury. Basic Research in Cardiology, 104(2), 181–188. Scholar
  5. 5.
    Ong, S. B., Samangouei, P., Kalkhoran, S. B., & Hausenloy, D. J. (2015). The mitochondrial permeability transition pore and its role in myocardial ischemia reperfusion injury. Journal of Molecular and Cellular Cardiology, 78, 23–34. Scholar
  6. 6.
    Shanmugam, K., Ravindran, S., Kurian, G. A., & Rajesh, M. (2018). Fisetin confers cardioprotection against myocardial ischemia reperfusion injury by suppressing mitochondrial oxidative stress and mitochondrial dysfunction and inhibiting glycogen synthase kinase 3beta activity. Oxidative Medicine and Cellular Longevity, 2018, 9173436. Scholar
  7. 7.
    Sun, L., Zhao, M., Yu, X. J., Wang, H., He, X., Liu, J. K., & Zang, W. J. (2013). Cardioprotection by acetylcholine: a novel mechanism via mitochondrial biogenesis and function involving the PGC-1alpha pathway. Journal of Cellular Physiology, 228(6), 1238–1248. Scholar
  8. 8.
    Pohjoismaki, J. L., & Goffart, S. (2017). The role of mitochondria in cardiac development and protection. Free Radical Biology & Medicine, 106, 345–354. Scholar
  9. 9.
    Vega, R. B., & Kelly, D. P. (2017). Cardiac nuclear receptors: architects of mitochondrial structure and function. The Journal of Clinical Investigation, 127(4), 1155–1164. Scholar
  10. 10.
    Rasbach, K. A., & Schnellmann, R. G. (2007). PGC-1alpha over-expression promotes recovery from mitochondrial dysfunction and cell injury. Biochemical and Biophysical Research Communications, 355(3), 734–739. Scholar
  11. 11.
    Zhang, Q., Wu, Y., Zhang, P., Sha, H., Jia, J., Hu, Y., & Zhu, J. (2012). Exercise induces mitochondrial biogenesis after brain ischemia in rats. Neuroscience, 205, 10–17. Scholar
  12. 12.
    Jager, S., Handschin, C., St-Pierre, J., & Spiegelman, B. M. (2007). AMP-activated protein kinase (AMPK) action in skeletal muscle via direct phosphorylation of PGC-1alpha. Proceedings of the National Academy of Sciences of the United States of America, 104(29), 12017–12022. Scholar
  13. 13.
    Fernandez-Marcos, P. J., & Auwerx, J. (2011). Regulation of PGC-1alpha, a nodal regulator of mitochondrial biogenesis. The American Journal of Clinical Nutrition, 93(4), 884S–890S. Scholar
  14. 14.
    Tan, J., Liu, Y., Jiang, T., Wang, L., Zhao, C., Shen, D., & Cui, X. (2018). Effects of hypercapnia on acute cellular rejection after lung transplantation in rats. Anesthesiology, 128(1), 130–139. Scholar
  15. 15.
    Gao, W., Liu, D. D., Li, D., & Cui, G. X. (2015). Effect of therapeutic hypercapnia on inflammatory responses to one-lung ventilation in lobectomy patients. Anesthesiology, 122(6), 1235–1252. Scholar
  16. 16.
    Tao, T., Liu, Y., Zhang, J., Xu, Y., Li, W., & Zhao, M. (2013). Therapeutic hypercapnia improves functional recovery and attenuates injury via antiapoptotic mechanisms in a rat focal cerebral ischemia/reperfusion model. Brain Research, 1533, 52–62. Scholar
  17. 17.
    Zhou, Q., Cao, B., Niu, L., Cui, X., Yu, H., Liu, J., Li, H., & Li, W. (2010). Effects of permissive hypercapnia on transient global cerebral ischemia-reperfusion injury in rats. Anesthesiology, 112(2), 288–297. Scholar
  18. 18.
    Li, A. M., Quan, Y., Guo, Y. P., Li, W. Z., & Cui, X. G. (2010). Effects of therapeutic hypercapnia on inflammation and apoptosis after hepatic ischemia-reperfusion injury in rats. Chinese Medical Journal, 123(16), 2254–2258 Accessed 11 January 2010
  19. 19.
    Haerter, F., Simons, J. C., Foerster, U., Moreno Duarte, I., Diaz-Gil, D., Ganapati, S., Eikermann-Haerter, K., Ayata, C., Zhang, B., Blobner, M., et al. (2015). Comparative effectiveness of calabadion and sugammadex to reverse non-depolarizing neuromuscular-blocking agents. Anesthesiology, 123(6), 1337–1349. Scholar
  20. 20.
    Yu, L., Sun, Y., Cheng, L., Jin, Z., Yang, Y., Zhai, M., Pei, H., Wang, X., Zhang, H., Meng, Q., et al. (2014). Melatonin receptor-mediated protection against myocardial ischemia/reperfusion injury: role of SIRT1. Journal of Pineal Research, 57(2), 228–238. Scholar
  21. 21.
    Flameng, W., Borgers, M., Daenen, W., & Stalpaert, G. (1980). Ultrastructural and cytochemical correlates of myocardial protection by cardiac hypothermia in man. The Journal of Thoracic and Cardiovascular Surgery, 79(3), 413–424.Google Scholar
  22. 22.
    Poole-Wilson, P. A., & Cameron, I. R. (1975). Intracellular pH and K+ of cardiac and skeletal muscle in acidosis and alkalosis. American Journal of Physics, 229(5), 1305–1310. Scholar
  23. 23.
    Steinberg, J. J., & Harken, A. H. (1981). The central venous catheter in the assay of acid base status. Surgery, Gynecology & Obstetrics, 152(2), 221–222 Scholar
  24. 24.
    Middleton, P., Kelly, A. M., Brown, J., & Robertson, M. (2006). Agreement between arterial and central venous values for pH, bicarbonate, base excess, and lactate. Emergency Medicine Journal, 23(8), 622–624. Scholar
  25. 25.
    Walkey, A. J., Farber, H. W., O'Donnell, C., Cabral, H., Eagan, J. S., & Philippides, G. J. (2010). The accuracy of the central venous blood gas for acid-base monitoring. Journal of Intensive Care Medicine, 25(2), 104–110. Scholar
  26. 26.
    Allen, D. G., & Xiao, X. H. (2003). Role of the cardiac Na+/H+ exchanger during ischemia and reperfusion. Cardiovascular Research, 57(4), 934–941 Accessed 16 July 2002
  27. 27.
    Griffiths, E. J., & Halestrap, A. P. (1995). Mitochondrial non-specific pores remain closed during cardiac ischaemia, but open upon reperfusion. The Biochemical Journal, 307(Pt 1), 93–98 Accessed 30 September 1994
  28. 28.
    Inserte, J., Barba, I., Hernando, V., & Garcia-Dorado, D. (2009). Delayed recovery of intracellular acidosis during reperfusion prevents calpain activation and determines protection in postconditioned myocardium. Cardiovascular Research, 81(1), 116–122. Scholar
  29. 29.
    Qiao, X., Xu, J., Yang, Q. J., Du, Y., Lei, S., Liu, Z. H., Liu, X., & Liu, H. (2013). Transient acidosis during early reperfusion attenuates myocardium ischemia reperfusion injury via PI3k-Akt-eNOS signaling pathway. Oxidative Medicine and Cellular Longevity, 2013, 126083. Scholar
  30. 30.
    Cohen, M. V., Yang, X. M., & Downey, J. M. (2008). Acidosis, oxygen, and interference with mitochondrial permeability transition pore formation in the early minutes of reperfusion are critical to postconditioning’s success. Basic Research in Cardiology, 103(5), 464–471. Scholar
  31. 31.
    Inserte, J., Garcia-Dorado, D., Ruiz-Meana, M., Padilla, F., Barrabes, J. A., Pina, P., Agullo, L., Piper, H. M., & Soler-Soler, J. (2002). Effect of inhibition of Na(+)/Ca(2+) exchanger at the time of myocardial reperfusion on hypercontracture and cell death. Cardiovascular Research, 55(4), 739–748 Accessed 8 October 2001
  32. 32.
    Orchard, C. H., & Kentish, J. C. (1990). Effects of changes of pH on the contractile function of cardiac muscle. The American Journal of Physiology, 258(6 Pt 1), C967–C981. Scholar
  33. 33.
    Inserte, J., Ruiz-Meana, M., Rodriguez-Sinovas, A., Barba, I., & Garcia-Dorado, D. (2011). Contribution of delayed intracellular pH recovery to ischemic postconditioning protection. Antioxidants & Redox Signaling, 14(5), 923–939. Scholar
  34. 34.
    Zhu, L., Wang, Q., Zhang, L., Fang, Z., Zhao, F., Lv, Z., Gu, Z., Zhang, J., Wang, J., Zen, K., et al. (2010). Hypoxia induces PGC-1alpha expression and mitochondrial biogenesis in the myocardium of TOF patients. Cell Research, 20(6), 676–687. Scholar
  35. 35.
    Chang, X., Zhang, K., Zhou, R., Luo, F., Zhu, L., Gao, J., He, H., Wei, T., Yan, T., & Ma, C. (2016). Cardioprotective effects of salidroside on myocardial ischemia-reperfusion injury in coronary artery occlusion-induced rats and Langendorff-perfused rat hearts. International Journal of Cardiology, 215, 532–544. Scholar
  36. 36.
    Li, X., Liu, Y., Ma, H., Guan, Y., Cao, Y., Tian, Y., & Zhang, Y. (2016). Enhancement of glucose metabolism via PGC-1alpha participates in the cardioprotection of chronic intermittent hypobaric hypoxia. Frontiers in Physiology, 7, 219. Scholar
  37. 37.
    Tao, L., Bei, Y., Lin, S., Zhang, H., Zhou, Y., Jiang, J., Chen, P., Shen, S., Xiao, J., & Li, X. (2015). Exercise training protects against acute myocardial infarction via improving myocardial energy metabolism and mitochondrial biogenesis. Cellular Physiology and Biochemistry, 37(1), 162–175. Scholar
  38. 38.
    Zaha, V. G., Qi, D., Su, K. N., Palmeri, M., Lee, H. Y., Hu, X., Wu, X., Shulman, G. I., Rabinovitch, P. S., Russell, R. R., 3rd, et al. (2016). AMPK is critical for mitochondrial function during reperfusion after myocardial ischemia. Journal of Molecular and Cellular Cardiology, 91, 104–113. Scholar
  39. 39.
    Laffey, J. G., Engelberts, D., & Kavanagh, B. P. (2000). Buffering hypercapnic acidosis worsens acute lung injury. American Journal of Respiratory and Critical Care Medicine, 161(1), 141–146. Scholar
  40. 40.
    Horie, S., Ansari, B., Masterson, C., Devaney, J., Scully, M., O'Toole, D., & Laffey, J. G. (2016). Hypercapnic acidosis attenuates pulmonary epithelial stretch-induced injury via inhibition of the canonical NF-kappaB pathway. Intensive Care Medicine Experimental, 4(1), 8. Scholar
  41. 41.
    Laffey, J. G., Jankov, R. P., Engelberts, D., Tanswell, A. K., Post, M., Lindsay, T., Mullen, J. B., Romaschin, A., Stephens, D., McKerlie, C., et al. (2003). Effects of therapeutic hypercapnia on mesenteric ischemia-reperfusion injury. American Journal of Respiratory and Critical Care Medicine, 168(11), 1383–1390. Scholar
  42. 42.
    Crimi, E., Taccone, F. S., Infante, T., Scolletta, S., Crudele, V., & Napoli, C. (2012). Effects of intracellular acidosis on endothelial function: an overview. Journal of Critical Care, 27(2), 108–118. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Laiting Chi
    • 1
  • Nan Wang
    • 1
  • Wanchao Yang
    • 1
  • Qi Wang
    • 1
  • Dengming Zhao
    • 1
  • Tian Sun
    • 1
  • Wenzhi Li
    • 1
    Email author
  1. 1.Department of Anesthesiology, The Heilongjiang Province Key Lab of Research on Anesthesiology and Critical Care MedicineSecond Affiliated Hospital of Harbin Medical UniversityHarbinChina

Personalised recommendations