Congenital Left to Right Shunts

HEALTHY HEART

Typically, post-natal systemic and pulmonary circulation run in parallel and maintain separation between low and high oxygen blood. When separation is incomplete, low and high oxygen blood mix, which produces systemic blood with insufficient oxygen concentrations.

The Great Vessels

  • The aorta carries blood with a high oxygen concentration to the body tissues.
  • The pulmonary trunk carries blood with a low oxygen concentration to the lungs.
  • Ductus arteriosus
    • Allows blood to flow from pulmonary trunk to aorta, bypassing the lungs.
    • The ligamentum arteriosus is the adult remnant of the ductus arteriosus.

Left to right shunts
In conditions with left to right blood shunting, oxygenated blood recirculates through the lungs rather reaching the body tissues.

Ventricular septal defects

Characterized by an incomplete ventricular septum, which allows oxygenated blood to pass from the left ventricle to the right, which then returns it to the lungs.

Atrial septal defects

Allow oxygenated blood from the left atrium to pass into the right heart and, ultimately, back through the pulmonary circulation.

Patent ductus arteriosus

Typically, the ductus arteriosus regresses after birth and becomes the ligamentum arteriosus; however, in some cases, the channel persists.

  • Low pulmonary vascular pressure allows oxygenated blood to “backflow” from the aorta into the pulmonary trunk, which then recirculates it through the lungs.

Eisenmenger syndrome

Occurs when an uncorrected congenital left to right shunt induces anatomical changes that reverse the shunt.

  • A congenital left to right shunt increases pulmonary blood flow.
  • Increased pulmonary blood flow work induces hypertrophy of the right ventricle.
  • Hypertrophic right ventricle becomes so powerful that it eventually overwhelms the pressure from the left ventricle and sends deoxygenated blood directly into the left ventricle, causing hypoxemia.

Congenital Right to Left Shunts

Healthy Heart
Typically, post-natal systemic and pulmonary circulation run in parallel and maintain separation between low and high oxygen blood. When separation is incomplete, low and high oxygen blood mix, which produces systemic blood with insufficient oxygen concentrations.

Review fetal circulation & adult circulation

Right to Left Shunts

  • Diagnosed prenatally or soon after birth.
  • Are characterized by early cyanosis.
    • So-called “blue babies” have hypoxemia because systemic blood bypasses the lungs.

The Great Vessels

  • The aorta carries blood with a high oxygen concentration to the body tissues.
  • The pulmonary trunk carries blood with a low oxygen concentration to the lungs.
  • Ductus arteriosus
    • Allows blood to flow from pulmonary trunk to aorta, bypassing the lungs.
    • The ligamentum arteriosus is the adult remnant of the ductus arteriosus.

Persistent Truncus Arteriosus

  • Caused by a malformed or absent aortico-pulmonary septum that fails to form separate outflow tracts for systemic and pulmonary circulations.
  • Thus, blood from each ventricle enters the common vessel, largely bypassing the lungs.
  • The defect is attributed to disturbances in secondary heart field or cardiac neural crest formation, and, therefore, is often associated with ventricular septal defect (recall the aorticopulmonary septum contributes to the membranous portion of the interventricular septum.

Transposition of the Great Vessels

  • Occurs when the conotruncal ridges fail to spiral, and the aorticopulmonary septum creates two distinct vessels.
  • The right ventricle continuously pumps low-oxygen blood to the body through the aorta, while the left ventricle continuously pumps high oxygen blood to the lungs through the pulmonary trunk.
  • Thus, blood from the right heart never enters the lungs for re-oxygenation, and blood from the left heart never reaches body tissues.
  • Newborn viability depends on accompanying septal defects and patent ductus arteriosus to provide opportunities for blood mixing.

Tricuspid Atresia

  • The right atrioventricular valve, aka, tricuspid valve, doesn’t properly form. Instead of ensuring unidirectional blood flow from the right atrium to the right ventricle, it blocks flow.
  • Associated characteristics are septal defects and/or patent ductus arteriosus that allow blood mixture, and a hypoplastic (smaller than usual) right ventricle.
  • Corrective surgeries are necessary to establish healthy blood flow.

Tetralogy of Fallot

  • Venous blood from the right heart and mixed blood from the left heart are pumped through the pulmonary trunk and aorta.
    Characterized by 4 defects:
    • Pulmonary stenosis (narrowing of pulmonary trunk)
    • Rightward displaced aorta, with opening over right ventricle (aka, overriding aorta)
    • Ventricular septal defect, specifically, of the membranous portion
    • Right ventricular hypertrophy, which occurs in response to increased work load to pump blood through stenotic pulmonary trunk

Total Anomalous Pulmonary Venous Return

  • Characterized by pulmonary veins that drain into the right atrium via the coronary sinus, superior vena cava, brachiocephalic vein, etc.
    Example:
  • Paired right and left pulmonary veins also draining into the right atrium via the coronary sinus.
    • In this case, viability requires an accompanying shunt that allows oxygenated blood to reach the left side of the heart.

Vesicular Budding and Fusion

STEPS OF VESICULAR BUDDING AND FUSION (+ PROTEINS INVOLVED)

  • Cargo selection (cargo receptor, adaptor protein)
  • Vesicular budding (adaptor proteins, coat proteins)
  • Fission from donor membrane (dynamin)
  • Vesicular coat dissociates
  • Vesicular targeting and transport (Rab-GTPase, tethering protein)
  • Fusion with target membrane (V-snare and T-snare)

PROTEINS OF VESICULAR BUDDING AND FUSION

  • Cargo receptors – select and concentrate molecules to be transported in vesicle
  • Adaptor proteins – bind cargo receptor and coat proteins
  • Coat proteins – form protein scaffold around vesicle that facilitate facilitate vesicular budding
  • Dynamin – GTPase involved in vesicular fission
  • RabGTPase – associates with vesicle after coat has dissociated. Facilitates transport of vesicle to appropriate target membrane. Locks vesicle to target membrane by attaching tethering proteins
  • Tethering proteins – anchored in target membrane, attach rabGTPase. Move vesicle close to target membrane for vesicular fusion.
  • V-snares(vesicular) and T-snares(target membrane) – Play role in vesicular fusion

COAT PROTEINS DIRECT VESICLE TRANSPORT

  • Clathrin +adaptin 1: Golgi → Lysosome
  • Clathrin + adaptin 2: Plasma membrane → Endosomes (endocytosis)
  • COP 1: Cis golgi → ER AND Later cisternae → Earlier ones (retrograde transport)
  • COP II: ER → Cis golgi

Vesicular Transport Overview

3 PATHWAYS OF VESICULAR TRANSPORT

  • Secretory pathway: delivers cargo to the plasma membrane.
  • Endocytic pathway: uptake cargo from the plasma membrane.
  • Retrieval pathway: recycles cellular molecules.

KEY FACTS ABOUT VESICULAR TRANSPORT:

  • Compartment lumens mix via the transport intermediate.
  • The membrane of each vesicle maintains its orientation.
  • If the cell is growing, the secretory pathway is more active than the endocytic pathway.

STEPS IN SECRETORY PATHWAY

  • Transport vesicles bud from the ER and carry content away from it to cis side of Golgi.
  • Vesicular budding and fusion mediates the transport of cargo through the Golgi stacks, from cis to trans side.
  • Cargo exits the Golgi via a transport vesicle on trans side.
  • Transport vesicles fuse with plasma membrane or with endosomes (and then lysosomes).

STEPS IN ENDOCYTOTIC PATHWAY

  • Early endosome forms from plasma membrane and extracellular materials.
  • Early endosome targets cargo to late endosomes.
  • Late endosomes then deliver cargo to lysosomes, which degrade cargo.

THE RETRIEVAL PATHWAY TAKES SEVERAL FORMS

  • Endosomes can return cargo to the cell surface via recycling endosomes.
  • Cargo in early and late endosomes can also return to the Golgi for reuse.
  • Vesicles can deliver proteins from the trans face to the cis face of the Golgi.
  • Vesicles can return proteins from the golgi to the ER as well.

3 STEPS OF VESICULAR FORMATION

  • Cargo selection. Incorporation of cargo into a vesicle is carefully regulated to ensure that only the correct cargo gets transported.
  • Vesicular budding. deformation of the hydrophobic membrane bilayer and breaking off of the membrane into a vesicle
  • Vesicular targeting and fusion. Highly regulated just like cargo selection.

Cellular compartments are topologically equivalent when:

• Molecules can get from one to another without having to cross a membrane.
• Nuclear envelope, ER, Golgi, transport vesicles, endosomes, lysosomes, and extracellular space = topologically equivalent

Protein Folding and Glycosylation in the Endoplasmic Reticulum

KEY PROCESSES IN ER

• Protein glycosylation
• Protein folding

N-GLYCOSYLATION

• Is an ER event
• Is a Co-translational event.
• Occurs on Asn-X-Ser/Thr residues

O-linked glycosylation occurs in the Golgi apparatus

EVENTS OF N-GLYCOSYLATION

• Nascent protein imports co-translationally through translocon.
• Oligosaccharyl transferase transfers oligossacharide from dolichol to N-side group of Asn residue
• 3 sugars trimmed from the 14 sugar oligossacharide as protein exits translocon.
• Chaperones help protein fold in lumen

Protein Insertion into the ER Membrane

4 TYPES OF TRANSMEMBRANE PROTEINS

  • Type I membrane proteins have a signal sequence at their N-terminus and an internal stop-transfer sequence. They have no cytosolic tail because signal peptidase cleaves it.
  • Type II have an internal signal. Their C term is luminal, and their N term is cytosolic.
  • Type III have an internal signal sequence. Their C term is cytosolic, and their N term is luminal.
  • Type IV are multipass membrane proteins that have multiple internal stop transfer sequences and start transfer sequences.

Protein Import into the Endoplasmic Reticulum

PROTEINS FOR IMPORT
• Water-soluble proteins
• Transmembrane proteins

KEY MECHANISMS
• Cotranslational: ribosomes continue synthesizing protein as it crosses membrane
• Post-translational: protein imports after it is completely synthesized by cytosolic ribosomes

SIGNAL SEQUENCE
• Hydrophobic sequence (15-60 residues): directs proteins to specific organelles (i.e. ER membrane)

COTRANSLATIONAL IMPORT OF WATER-SOLUBLE PROTEINS

  1. SRP (signal recognition particle) recognizes and binds signal sequence on a nascent protein in the cytosol; halts translation
  2. SRP (with ribosomal complex) binds SRP receptor
  3. SRP released from complex
  4. Signal sequence inserts into translocon, translocon opens and translation resumes
  5. Signal peptidase cleaves signal sequence and releases protein in ER lumen
  6. Chaperones help protein fold correctly

POST-TRANSLATIONAL IMPORT OF WATER-SOLUBLE PROTEINS

  1. Chaperones maintain newly synthesized protein’s unfolded conformation in cytosol
  2. Translocon/SRP receptor complex recognizes signal sequence
  3. Protein enters translocon; chaperone in lumen prevents peptide from sliding back through translocon

CLINICAL CORRELATION

Alzheimer’s and Parkinson’s

• Neurodegenerative diseases that involve improper folding of proteins in endoplasmic reticulum

Protein Import into Mitochondria

MITOCHONDRIA

  • Generate energy for the cell
  • Have numerous metabolic functions
  • Comprise mitochondrial proteins (most encoded by nuclear genes)
  • Compartmental organization:
    i. Outer membrane ii. Intermembrane space iii. Inner membrane iv. Matrix

IMPORT INTO MITOCHONDRIA
• Prospective matrix protein unfolded in cytosol
• Presequence: signal sequence at N-terminus; positively charged residues
• TOM (translocase of outer membrane): import receptor and translocator
• TIM (translocase of inner membrane): import receptor and translocator
• Protein passes through TOM and enters intermembrane space; then passes through TIM to enter matrix

TOM-TIM alignment: research suggests that TIM tethers to the outer membrane and diffuses laterally until it comes into contact with the TOM/presequence complex

• Protein can enter matrix in energy-dependent manner (presequence cleaved by peptidase and chaperones assist in folding)
• Protein’s transmembrane domain can diffuse laterally out of TIM and embed in inner membrane

CLINICAL CORRELATION
Neurodegenerative disorders
• Often caused by defects in translocases
• Genetic disorder in TIM production results in deafness and dystonia

Protein Sorting Overview

KEY MECHANISMS OF PROTEIN TRANSPORT

  • Gated transport: energy-dependent (nuclear pores)
  • Translocation across membranes: mediated by protein translocators (mitochondrion, post-translational and cotranslational import into ER or peroxisomes)
  • Vesicular transport: proteins do not cross membranes (from ER to Golgi, through Golgi stacks or to plasma membrane)

PROTEIN TRANSLATION
• Synthesis of almost all proteins begins in the cytoplasm
• 3 possible outcomes depending on signal sequence (or lack thereof):
i. remain in cytosol ii. post-translational import into organelle (mitochondrion, peroxisome, nucleus, ER) iii. cotranslational import to ER

SIGNAL SEQUENCES
• Short amino acid sequences at the terminal end of proteins (address labels)
• 15-60 residues long
• Direct proteins to specific organelles
• Proteins without signal sequences remain in the cytosol

MEMBRANE TOPOLOGY
• Compartments are topologically equivalent if molecules can get from one to another without having to cross a membrane
• ER, Golgi, vesicle, perinuclear space in nuclear envelope are all topologically equivalent
• Mitochondrion, nucleus and peroxisomes are topologically distinct

Protein Degradation

  • Removes misfolded proteins
  • Regulates the amount of a protein in the cell at a time

Two major pathways

  1. Ubiquitin-dependent pathway
  2. Autophagy (targets old and worn-out organelles)

Proteolysis

Break down of proteins into smaller peptides or amino acids

Clinical Correlation

  • Pathologic accumulation of misfolded proteins results in various diseases such as sickle cell anemia and certain neurodegenerative illnesses (Huntington’s disease, Alzheimer’s disease, and Creutzfeldt-Jacob disease)

PROTEASOME STRUCTURE – 26S Mammalian proteasome

  1. 20S Subunit
  • “Central cylinder”
  • Comprised of four rings – two inner rings (seven beta subunits each) and two outer rings (seven alpha subunits each)
  • Has protease activity
  1. 19S Subunits
  • “Cap” subunit
  • ATPas sites – provide energy for protein degradation and unfolding by using ATP
  • Ubiquitin binding sites – recognize proteins tagged for degradation

UBIQUITIN-DEPENDENT PROTEIN DEGRADATION PATHWAY

Protein tagging with ubiquitin

  1. Ubiquitin added to cysteine side chain of the E1 protein (ubiquitin-activating enzyme)
  2. E1 protein becomes bound to E2 (ubiquitin conjugating enzyme) and E3 protein complex (ubiquitin ligase)
  3. Ubiquitin transferred to cysteine side chain on the E2 protein
  4. Misfolded protein becomes bound to E3 protein
  5. Ubiquitin transferred to lysine side chain on the misfolded protein
  6. Repeat steps 1-5 to polyubiquitinate the misfolded protein – polyubiquitin chain is the signal for protein degradation in the proteasome

Proteasomal degradation of the tagged protein

  1. Misfolded protein with polyubiquitin chain is recognized by 19S cap of the proteasome
  2. Using ATP as an energy source, protein is unfolded, ubiquitin is released, and the protein is translocated into the 20S subunit to be degraded (unknown if unfolding or removal of ubiquitin happens first, but both must occur before translocation can happen)
  3. When translocated protein reaches the proteolytic sites, it is cleaved and peptide fragments are released into the cytoplasm for further degradation