Liver-to-Atria Inflammatory Axis Driving Arrhythmia

BackgroundMetabolic dysfunction-associated steatohepatitis (MASH) is emerging as a risk factor of cardiometabolic diseases, including the atrial fibrillation (AF) - the most common sustained arrhythmia. Given that the liver is a major source of inflammatory mediators, lipids, and hepatokines under metabolic stress, we hypothesized that hepatocyte-derived factors in MASH may accelerate atrial remodeling and arrhythmogenesis. MethodsAnalysis of the Atherosclerosis Risk in Communities (ARIC) visit 5 cohort was performed to determine the association between the FIB-4 index - a classic indicator of liver fibrosis, and AF risk, with multivariable adjustment for common comorbidities. A murine model of MASH was induced using the GAN (Gubra-Amylin NASH) diet. Programmed intracardiac stimulation and echocardiography were performed to assess AF susceptibility and cardiac function. Calcium imaging, histology, flow cytometry, plasma proteomics, and single-nucleus RNA sequencing (snRNA-seq) analyses were employed to elucidate the role of recruited inflammatory macrophages via hepatocyte-derived osteopontin (OPN) in MASH-induced atrial remodeling. ResultsAnalysis of the ARIC cohort confirmed a higher cumulative incidence of AF and an elevated adjusted hazard ratio (HR) in patients with intermediate and high FIB-4 indices compared to individuals with low FIB-4 scores. MASH mice exhibited increased susceptibility to pacing-induced AF, accompanied by enhanced proarrhythmic calcium release events, atrial enlargement, and fibrosis, independent of ventricular dysfunction. Proteomics and snRNA-seq revealed that the hepatocyte-secreted OPN under MASH conditions promoted the differentiation and recruitment of TGFBR1+ inflammatory macrophages to the atria, leading to gasdermin D (GSDMD) activation - an effector of inflammasome signaling and consequent proarrhythmic atrial remodeling. Activation of the monocyte-derived pro-inflammatory TGFBR1+ macrophages was dependent on the OPN receptor CD44. Furthermore, the MASH-induced atrial fibroinflammatory milieu and enhanced AF susceptibility were mitigated through several strategies, including hepatocyte-specific Spp1 (encoding OPN) deletion, neutralization of circulating OPN, ablation of CD44 or GSDMD. ConclusionsThese findings establish a pathogenic role of the hepatokine osteopontin in driving activation and recruitment of TGFBR1+ inflammatory macrophages into the atria, leading to proarrhythmic atrial remodeling under MASH. Osteopontin-targeted therapy or GSDMD inhibition prevents AF, indicating a novel therapeutic strategy for liver disease-related atrial arrhythmogenesis. Clinical PerspectiveO_ST_ABSWhat is new?C_ST_ABSO_LIIn the ARIC cohort, metabolic dysfunction-associated steatohepatitis (MASH) is associated with increased risk of atrial fibrillation (AF) after adjusting for common comorbidities. Elevated levels of circulating osteopontin (encoded by SPP1) predict an increased risk of AF in patients with MASH-induced liver fibrosis. C_LIO_LIMASH enhances hepatocyte secretion of osteopontin, leading to expansion of myeloid cells and recruitment of inflammatory macrophages into atria. This liver-to-atrial inflammatory circuit promotes the development of a substrate conducive to AF, which can be attenuated by hepatocyte-specific Spp1 deletion or neutralizing anti-anti-osteopontin antibody treatment to eliminate the mediator, or ablation of inflammasome effector gasdermin D to correct the atrial response. C_LI What are the clinical implications?O_LIOsteopontin may serve as a biomarker for AF in MASH cohorts. C_LIO_LIAnti-osteopontin therapy through neutralizing antibodies may serve as a novel therapeutic strategy for liver disease-related atrial arrhythmia. C_LI