Dilated cardiomyopathy in mice deficient for the
lysosomal cysteine peptidase cathepsin L
Jo ¨rg Stypmann*†, Kerstin Gla ¨ser*‡, Wera Roth§¶, Desmond J. Tobin?, Ivonne Petermann§, Rainer Matthias**,
Gerold Mo ¨nnig†, Wilhelm Haverkamp†, Gu ¨nter Breithardt†, Wolfgang Schmahl‡, Christoph Peters§††,
and Thomas Reinheckel§
†Medizinische Klinik und Poliklinik C (Kardiologie und Angiologie), Zentrale Projektgruppe Kleintierdiagnostik des Interdisziplina ¨ren Zentrums fu ¨r Klinische
Forschung Mu ¨nster, Universita ¨tsklinikum Westfa ¨lische Wilhelms-Universita ¨t Mu ¨nster, D-48149 Mu ¨nster, Germany;‡Institut fu ¨r Tierpathologie, Lehrstuhl fu ¨r
Allegmeine Pathologie und Neuropathologie, Tiera ¨rztliche Fakulta ¨t, Ludwig-Maximilians-Universita ¨t, D-80539 Munich, Germany;§Institut fu ¨r Molekulare
Medizin und Zellforschung, Albert-Ludwigs-Universita ¨t Freiburg, D-79106 Freiburg, Germany;?Department of Biomedical Sciences, University of Bradford,
Bradford, United Kingdom BD7 1DP; and **Klinik fu ¨r Chirurgie, Otto-von-Guericke Universita ¨t, D-39112 Magdeburg, Germany
Edited by William S. Sly, St. Louis University School of Medicine, St. Louis, MO, and approved March 8, 2002 (received for review November 30, 2001)
Dilated cardiomyopathy is a frequent cause of heart failure and is
associated with high mortality. Progressive remodeling of the
myocardium leads to increased dimensions of heart chambers. The
role of intracellular proteolysis in the progressive remodeling that
underlies dilated cardiomyopathy has not received much attention
yet. Here, we report that the lysosomal cysteine peptidase cathep-
sin L (CTSL) is critical for cardiac morphology and function. One-
year-old CTSL-deficient mice show significant ventricular and atrial
enlargement that is associated with a comparatively small increase
in relative heart weight. Interstitial fibrosis and pleomorphic nuclei
were found in the myocardium of the knockout mice. By electron
microscopy, CTSL-deficient cardiomyocytes contained multiple
large and apparently fused lysosomes characterized by storage of
electron-dense heterogeneous material. Accordingly, the assess-
ment of left ventricular function by echocardiography revealed
severely impaired myocardial contraction in the CTSL-deficient
likely represents an adaptive response to cardiac impairment. The
histomorphological and functional alterations of CTSL-deficient
hearts result in valve insufficiencies. Furthermore, abnormal heart
rhythms, like supraventricular tachycardia, ventricular extrasysto-
les, and first-degree atrioventricular block, were detected in the
lation, decreased contractility of the myocardium, and conges-
tive heart failure. Among the presently known causes of DCM
are enteroviral infections, ischemia, and mutations in genes
encoding sarcomeric and structural proteins essential for gen-
eration and transmission of contractile forces within the cardi-
omyocyte. These proteins include cardiac ?-myosin, troponin C,
cardiac ?-actin, desmin, dystrophin, ?-sarcoglycan, and the nu-
clear envelope protein lamin A?C (1–6). Nevertheless, the
etiology of DCM remains elusive in about 50% of the patients
(7). To elucidate further the pathophysiology of the disease,
gain-of-function and loss-of-function mouse lines for the respec-
tive genes have been generated. Some of these lines, e.g.,
deletions of ?-sarcoglycan and the actin-associated muscle LIM
protein MLP or a R403N point mutation in the cardiac myosin
heavy chain, resemble the phenotype of human hereditary DCM
(8–10). On the other hand, multiple genetically altered mouse
lines developing hereditary DCM are currently lacking human
counterparts, e.g., overexpression of tumor necrosis factor ? or
retinoic receptor ?, inactivation of the cAMP response element-
binding protein, and deletion of the bradikinin B2 receptor and
the mitochondrial transcription factor A (Tfam; 11–17).
The lysosomal?endosomal cellular compartment is
equipped with multiple glycosidases, nucleases, lipases, phos-
phatases, sulfatases, and peptidases for terminal degradation
of macromolecules (18). Lysosomal peptidases comprise as-
ilated cardiomyopathy (DCM) describes a heterogeneous
group of myocardial diseases characterized by cardiac di-
partic and cysteine peptidases. Most lysosomal cysteine-
peptidases belong to the family of papain-like peptidases
characterized by a catalytic triad, including an active-site
cysteine residue (19). Seven of these papain-like lysosomal
peptidases, the cathepsins B, C, F, H, L, O, and Z, are
ubiquitously expressed in mammalian tissues, with myocar-
dium among them. Other members of the family exhibit
cell-type-specific expression; e.g., cathepsin S is expressed in
peripheral antigen-presenting cells, but cathepsin K is mainly
found in osteoclasts (20). Lysosomal cysteine peptidases are
involved in unspecific bulk proteolysis in the lysosomes (21).
However, evidence is growing for specific in vivo functions of
papain-like cysteine peptidases in limited proteolysis during
physiological and pathological processes such as MHC class
II-mediated antigen presentation, prohormone processing,
bone development, and tumor invasion (22–24). In mice, the
ubiquitously expressed lysosomal cysteine peptidase cathepsin
L (CTSL) is critical for epidermal homeostasis, regulation of
the hair cycle, and MHC II-mediated antigen presentation in
epithelial cells of the thymus (25, 26). Cardiomyopathies have
been described in hereditary deficiencies of lysosomal glyco-
sidases, like in mucopolysaccharidoses and glycogenoses (27).
Furthermore, deficiency of the lysosomal membrane glycop-
rotein LAMP-2 has recently been shown to be the cause of
Danon disease, which presents with severe cardiopathy-
myopathy (28, 29).
Here we show that CTSL is essential for regular cardiac
function in the mouse, because CTSL-deficient mice develop
pathomorphological, histological, and functional cardiac alter-
ations that closely resemble human DCM.
Materials and Methods
mice have been generated by gene targeting in mouse embryonic
stem cells as described (26). The maintenance and breeding of
the animals used in this study, as well as all of the subsequent
experiments including echocardiographic and electrocardio-
graphic recordings, were performed in accordance with our
This paper was submitted directly (Track II) to the PNAS office.
ECG, electrocardiographic recording.
*J.S. and K.G. contributed equally to this work.
¶Present address: Genzentrum, Institut fu ¨r Biochemie, Ludwig-Maximilians-Universita ¨t,
D-81377 Munich, Germany.
††To whom reprint requests should be addressed. E-mail: email@example.com-
The publication costs of this article were defrayed in part by page charge payment. This
article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C.
§1734 solely to indicate this fact.
April 30, 2002 ?
vol. 99 ?
Histological and Histomorphometrical Analyses. The body-to-heart
weight ratio was determined by weighing the body immediately
after death and the heart after removal of main vessels. After
fixation in 7% unbuffered formalin and paraffin embedding,
serial sections of 2-?m thickness were cut and stained with
hematoxylin?eosin or Masson’s trichrome. The proportion of
interstitial connective tissue was determined by using the ‘‘point
counting method’’ at 40? resolution with grid points of 18-?m
distance (30). The number of cardiomyocyte nuclei per unit
volume of myocardium (numeric density) was estimated by using
a Physical Dissector (31, 32).
High-Resolution Light Microscopy and Transmission Electron Micros-
copy. Hearts were removed from 12-month-old ctsl?/?(n ? 2)
and ctsl?/?mice (n ? 2) and immediately fixed in Karnovsky’s
fixative as 1-mm3tissue cubes. The tissues were postfixed in 2%
osmium tetroxide and embedded in resin as described (33).
Semithin sections were stained with toluidine blue?borax, ex-
amined by light microscopy, and photographed (Leitz). Ultra-
thin sections were stained with uranyl acetate and lead citrate
and were examined and photographed with a Jeol ?1,200
Echocardiography and Cardiac Doppler Examination. Echocardio-
graphic examination of 40 mice was performed after intraperi-
toneal sedation with ketamine (50 ?g?g)?xylazine (5 ?g?g).
Transthoracic Doppler echocardiography was performed with a
digital cardiac ultrasound machine equipped with either a 12-
MHz short focal-length-phased or a 15-MHz linear array trans-
ducer (SONOS 5500, B1 software package, Agilent Technologies,
Andover, MA). Both parasternal long-axis and short-axis views
were obtained. M-mode and Doppler recordings were per-
posterior wall thickness at the end of diastole as well as end-
diastolic and end-systolic dimensions of the left ventricle were
measured by using leading edge to leading edge reglementation
with electronic caliper in M-mode. The percentage of fractional
shortening, end-diastolic and end-systolic volume, ejection frac-
tion, mass of left ventricle, and left ventricle mass index were
calculated with conversion formulas as described (34). For
determination of systolic outflow of the left ventricle, pulsed-
wave Doppler signals were obtained by placing the sample
volume parallel to flow during long-axis view into the left
ventricular outflow tract and the ascending aorta. Diastolic
inflow was detected apical to the mitral valve within the left
ventricle. Both valves were examined for regurgitation with
Electrocardiographic Recordings (ECGs). Telemetric ECGs were
recorded by using a commercially available implantable trans-
mitter and acquisition system (TA10ETA-F20-L20; DSI, St.
Paul, MN), which was implanted in ketamine (50 ?g?g)?xylazine
(10 ?g?g)-anesthetized mice according to the operative proce-
dure described by Kramer et al. (35). After a recovery phase of
10 days and achievement of baseline body weight, the mice were
positioned on the acquisition system. ECGs were recorded for
24 h and analyzed in LABVIEW format. Six lead-surface ECGs
were recorded noninvasively (Mega-card; Siemens, Iselin, NJ) in
back-spine position with tissue-covered clips with electrode gel.
Statistical Analysis. All data are reported as mean and SD.
10.0; SPSS, Chicago). All data were subjected to a one-way
ANOVA accounting for the four categories: wild-type (ctsl?/?),
heterozygous ctsl?/?, CTSL-deficient mice without (ctsl?/?) and
with manifest DCM (ctsl?/?/DCM). Whenever significant dif-
ferences were detected, groups were analyzed by using Bonfer-
significant differences between the groups.
CTSL-Deficient Mice Exhibit Altered Histology and Morphology of the
Heart. CTSL-deficient mice are fertile and show normal breeding
behavior. Pups devoid of CTSL exhibit a mortality rate of 15%,
which is slightly higher than the 6% mortality observed for their
wild-type littermates. Thereafter, mortality of both groups did
not show any significant differences up to 1 year of age (26).
Histological and histomorphometrical analyses of the hearts of
1-year-old mice revealed a marked increase of connective tissue
in the myocardium of ctsl?/?mice (Fig. 1). Cardiomyocytes of
ctsl?/?mice exhibit about twice as many nuclei per mm3than
cardiomyocytes of control mice (Fig. 1). Consequently, the
volume of cytoplasm per nucleus significantly decreased from an
average of 30 ?m3in ctsl?/?mice to about 15 ?m3in ctsl?/?mice.
In addition, many nuclei of CTSL-deficient cardiomyocytes
characteristic of cardiomyopathies (Fig. 1). Note that inflam-
closer investigation of cellular ultrastructure, electron micros-
copy was performed in myocard samples of 12-month-old mice
(Fig. 2). Ctsl?/?mice show the normal ultrastructure of heart
muscle cells with rare, small, and singly scattered lysosomes. By
contrast, most cells in the myocardium of age-matched ctsl?/?
mice contain multiple large, and apparently fused, lysosomes
Trichrome stain of myocardium of wild-type mice (ctsl?/?) and CTSL-deficient
pleomorphic nucleus (P) in CTSL-deficient myocardium as compared with a
normal nucleus (N). Masson’s trichrome stain at 100-fold resolution. Note the
distinct interstitial collagen staining in the absence of CTSL. (C) Histomorpho-
metric determination of left ventricular connective tissue of wild-type (black)
and CTSL-deficient (gray) mice. (D) Numeric density of nuclei in cardiomyo-
comparison of wild-type (10 females, seven males) and knockout (nine fe-
males, five males) mice.
Histological and histomorphometric analysis of myocardium. (A)
Stypmann et al.PNAS ?
April 30, 2002 ?
vol. 99 ?
no. 9 ?
of large amounts of electron-dense heterogeneous materials and
were seen most often in the perikaryon of the cell next to
commonly dystrophic nuclei (Fig. 2e). The gross phenotype of
the hearts, the amount of interstitial connective tissue (data not
shown), and the relative heart weights were not altered in
CTSL-deficient at 6–8 weeks of age (Fig. 3). First patches of
interstitial fibrosis were observed in ctsl?/?hearts at 4 months
(data not shown). From about 6 months of age on, the relative
heart weights of CTSL-deficient mice tended to increase as
compared with age-matched ctsl?/?controls (Fig. 3). By 12
months, hearts of all CTSL-deficient mice seemed enlarged as
compared with wild-type and heterozygous mice (Fig. 3). How-
ever, about 25% of CTSL-deficient mice showed extremely
enlarged hearts (Fig. 3). Because of only a moderate increase in
heart weight, these mice were suspected to suffer from DCM.
Hence, these findings required closer investigation of morpho-
logical and functional parameters of ctsl?/?hearts in vivo.
Dilation and Reduced Contraction of CTSL-Deficient Hearts.Bymeans
of echocardiography, a CTSL-genotype-dependent increase of
left ventricular dimensions was observed in 1-year-old mice (Fig.
4). Again, four of the 14 ctsl?/?mice investigated by echocar-
diography exhibited a severe enlargement of the left ventricle
with a 2- to 3-fold increase in the volumes of the left ventricle at
the end of systole and diastole, which was accompanied by a
1.5-fold higher mass of the left ventricle and by enlargement of
the left atrium. These observations point to the presence of
DCM in this subgroup of mice (Fig. 4). However, some func-
tional parameters of the left ventricle proved to be significantly
impaired in all ctsl?/?hearts, which can be explained by the
histopathological alterations that affect the myocardium of all
CTSL-deficient mice. For example, fractional shortening, which
provides a measure of left ventricular contraction, was signifi-
cantly reduced in all CTSL-deficient mice, whereas the occur-
rence of more extreme ventricular enlargement did not further
reduce contraction (Fig. 5). Accordingly, the diameter and
volume of the left ventricle at maximal contraction, e.g., the end
of systole, was also significantly enhanced in all ctsl?/?mice (Fig.
5, Table 1). The extreme dilation of hearts in about 25% of
CTSL-deficient mice results in even more severe functional
alterations that are unique to this subgroup of mice (Table 1).
Doppler echocardiography was used for assessment of blood
flow across the aortic and mitral valves (Fig. 6). By means of this
technique, the maximal and average pressure gradients at the
aortic valve of ctsl?/?mice with extremely dilated hearts were
shown to be elevated 3- to 4-fold as compared with all other
and ctsl?/?mice. (A) Low-power view of cardiac muscle cells (CMC) of ctsl?/?
heart showing several typical cylindrical, striated, muscle cells (transversely
cut) with a centrally located clear nucleus (N). (B) Medium-power view of
single cardiac muscle cell with central clear nucleus (N) surrounded by numer-
ous mitochondria (Mt) and myofibrils (MF). (C) High-power view of cardiac
packed mitochondria (MT) and sarcoplasmic reticulum. Note that lysosomes
cells of ctsl?/?heart showing two cylindrical striated muscle cells (longitudi-
nally cut). Several lysosomes (Ly) are distributed around nuclei that may be
morphologically normal (N1) or undergoing lysis (N2). (E) Higher-power view
of a single cardiac muscle cell in ctsl?/?heart. Large lysosomes (Ly) are
distributed close to a dystrophic nucleus (N) and surrounded by numerous
mitochondria (Mt) and myofibrils (MF). (Inset) High-power view of lysosomes
(Ly) surrounded by myofibrils (MF) and mitochondria (Mt). Lysosomes contain
heterogeneous electron-dense materials. (A and D) High-resolution light
microscopy, toluidine blue stain. [Scale bars: A and D, 20 ?m; B, C, and E
(transmission electron microscopy, uranyl acetate, and lead citrate), B, 2 ?m;
C, 1 ?m; E, 1 ?m; Inset, 0.3 ?m.]
Electron microscopic analysis of myocardium in 12-month-old ctsl?/?
female (B) ctsl?/?(I, n ? 58) and ctsl?/?(E, n ? 69) mice. A 6-month-old
wild-type mouse with severely enlarged heart is indicated by*. This mouse
presented the only ‘‘spontaneous’’ heart disease seen in the 131 investigated
wild-type mice. (C) Hearts of wild-type (ctsl?/?) and CTSL-deficient (ctsl?/?)
mice at 12 months of age are shown. About 75% of ctsl?/?hearts show slight
enlargement with severe functional impairment, manifest DCM.
www.pnas.org?cgi?doi?10.1073?pnas.092637699 Stypmann et al.
investigated groups. In addition, observation of regurgitation at
the mitral and aortic valves confirmed the presence of valve
insufficiencies in the dilated hearts (Fig. 6). In consequence, the
cardiac index, which describes the amount of heart work needed
increased in mice with severe ventricular and atrial dilation.
in Conduction. Changes in electrophysiology of the heart assessed
alterations of heart rhythm were either not reported or not
studied in many of the available mouse models for DCM. The
heart rate of freely moving ctsl?/?and wild-type mice was similar
in telemetric recording 10 days after transmitter implantation
higher R-wave voltages in standard limb lead II (1.45 vs. 0.95
mV) as an electrocardiographic sign of left ventricular hyper-
trophy. Additionally, the interval between the R- and T-waves of
the ECG that reports activation and repolarization time of the
ventricle is prolonged in ctsl?/?mice (50 vs. 30 ms), especially in
telemetric recording (45 vs. 22 ms), with a pathologic flat and
wide T-wave morphology (data not shown). Supraventricular
tachycardia was observed in three of the 14 ctsl?/?mice inves-
tigated. However, tachycardia was not specifically limited to the
CTSL-deficient mice with manifest DCM, because one mouse
with episodes of tachycardia was also detected in the group of 12
heterozygous ctsl?/?animals. Furthermore, one mouse with
atrioventricular block and one with monomorphic ventricular
extrabeats were found in the ctsl?/?group (data not shown).
This article reports a critical role of the lysosomal cysteine
peptidase for cardiac homeostasis in ctsl?/?mice. Except for a
slightly increased length of the left ventricle, heterozygous mice
do not show major alterations in morphology or function of the
heart. A complete deficiency of CTSL in the ‘‘knockout’’ mice
causes interstitial fibrosis in the myocardium and pleomorphic
nuclei of cardiomyocytes that represent histological alterations
characteristic of human cardiomyopathies. Accordingly, left
ventricular contractility, assessed by echocardiographic deter-
Histological, echocardiographic and electrocardiographic find-
ings point to the development of moderate left ventricular
hypertrophy, which most likely represents an adaptive response
to impaired cardiac function. In addition, pathological impair-
ment of heart rhythm, e.g., supraventricular tachycardia, ven-
tricular extrasystoles, and first-degree atrioventricular block, was
detected in CTSL-deficient mice. However, these heterogeneous
conduction defects did not occur in all ctsl?/?mice. Thus, it
seems likely that these electrophysiological alterations are not
caused by the lack of CTSL in cardiomyocytes or in the cells of
the conduction system, but are rather indicative of the structural
changes of the heart in the course of cardiomyopathy. Further-
more, about 25% of the hearts of ctsl?/?mice had developed a
severe enlargement at 12 months of age, which resulted in
phy. (A) Two-dimensional echocardiographic picture of a normal-sized left
ventricle in a 12-month-old wild-type mouse. Ao, aortic valve; LV, left ventri-
cle; LA, left atrium; IVS, interventricular septum; PW, posterior wall. (B)
dependent increase in the length of left ventricle. ctsl?/?, wild-type mice;
ctsl?/?, heterozygous mice; ctsl?/?, CTSL-deficient mice; ctsl?/?DCM, CTSL-
deficient mice with manifest DCM. (a) P ? 0.05 compared with ctsl?/?, (b) P ?
0.05 compared with ctsl?/?, (c) P ? 0.05 compared with ctsl?/?.
In vivo assessment of left ventricular dimensions by echocardiogra-
showing normal contraction of the interventricular septum and the posterio-
lateral wall in the heart of a wild-type mouse. LV, left ventricle; IVS, interven-
tricular septum; PW, posterior wall; LVEDD, left ventricular end-diastolic
diameter; LVESD, left ventricular end-systolic diameter. (B) Reduced contrac-
tion of interventricular septum and posteriolateral wall in a CTSL-deficient
ventricular end-systolic volume in wild-type mice (ctsl?/?), heterozygous mice
(ctsl?/?), CTSL-deficient mice (ctsl?/?), and CTSL-deficient mice with manifest
DCM (ctsl?/?DCM). (a) P ? 0.05 compared with ctsl?/?, (b) P ? 0.05 compared
with ctsl?/?, (c) P ? 0.05 compared with ctsl?/?.
Determination of heart contraction. (A) M-mode echocardiography
Stypmann et al. PNAS ?
April 30, 2002 ?
vol. 99 ?
no. 9 ?
significantly impaired cardiac performance and led to valve
insufficiencies in four of the 14 CTSL-deficient mice investigated
by Doppler echocardiography. Despite these histomorphological
with many other transgenic mouse models of DCM in which
symptoms occur early in life and result in death only days or a
few weeks after onset of the disease (9, 10, 14, 16, 17, 36). Thus,
CTSL-deficient mice represent a model of a chronic progressive
DCM that is comparable to the adult form of the human disease
in many respects. This model could greatly serve the study of
effects of additional exercise on morphology and function of the
heart and the long-term assessment of novel treatment options.
To date, multiple genetic loci affected in familiar DCM have
been identified. However, the disease-causing gene is often not
known yet (37). Most notably, the gene encoding human CTSL
is located at chromosome 9q21-q22, which corresponds to the
genetic mapping of a familiar DCM trait with an unidentified
disease-causing gene at chromosome 9q13-q22 (38). Thus, in
combination with the present findings in ctsl?/?mice, CTSL is a
potential DCM-causing gene in humans.
Most notably, a complete deficiency of CTSL in mice causes
accumulation of heterogeneous electron-dense material in sig-
nificantly enlarged lysosomes, which is clearly indicative for
lysosomal storage that would place the heart phenotype of
CTSL-deficient mice in a group of lysosomal metabolic car-
diomypopathies, such as the deficiency of the lysosomal mem-
brane protein Lamp-2 (Danon disease) or constitutively activat-
ing AMP kinase mutations that cause lysosomal glycogen
storage (28, 29, 39). However, although the latter disorders show
impaired cardiac function, they are not characterized by ven-
tricular dilation. Thus, the pathogenesis of the heart dilation
caused by CTSL deficiency still needs to be elucidated. Cur-
rently, the leading hypothesis regarding the pathogenesis of
DCM is focused on alterations in production of contractile force
in the sarcomere and?or impaired force transmission to the
plasma membrane of cardiomyocytes (37). Although electron
microscopy revealed intact cardiac sarcomeres of ctsl?/?mice,
multiple possibilities remain how CTSL maintains the contrac-
tile function of cardiomyocytes. First, lysosomal cysteine pepti-
dases, among them CTSL, are responsible for up to 40% of
intracellular protein turnover (40, 41). Many proteins of the
cytoskeleton with relatively long biological half-life are consid-
ered to be subject to lysosomal degradation. Thus, partial
impairment of lysosomal proteolysis by the constitutive absence
of CTSL may lead to an altered balance between synthesis and
degradation of cytoskeletal proteins. This altered balance could
result in a functional disturbance of the contractile apparatus
and in subsequent cardiac remodeling that eventually progresses
into maladaptive DCM in some of the ctsl?/?mice. Second,
lysosomal cysteine peptidases of the papain family exhibit high
collagenolytic and elastinolytic activity. In fact, the plant pro-
tease papain is a common meat tenderizer (23). Although CTSL
is located mainly in the endosomal?lysosomal compartment,
about 10% of the zymogen is physiologically secreted and can be
extracellularly activated (42). There, it is capable of processing
Table 1. Echocardiographic findings in cathepsin L-deficient mice
ctsl?/?(n ? 12) ctsl?/?(n ? 14)ctsl?/?(n ? 10) ctsl?/?(n ? 4) DCM
CI, ml?min per g
2.24 ? 0.35
71 ? 17
4.01 ? 0.44
88 ? 14
2.12 ? 0.28
68.3 ? 11.0
1.91 ? 0.62
0.97 ? 0.28
0.35 ? 0.09
1.90 ? 0.37
49 ? 15
3.41 ? 0.41
90 ? 17
2.35 ? 0.41
69.9 ? 14.2
2.02 ? 0.79
1.05 ? 0.36
0.32 ? 0.69
2.98 ? 0.20*†
68 ? 12
3.95 ? 0.29
100 ? 18
2.38 ? 0.49
73.4 ? 19.5
2.29 ? 1.29
1.23 ? 0.63
0.46 ? 0.13
4.44 ? 1.41*†‡
166 ? 105*†‡
5.57 ? 1.67*†‡
148 ? 63*†‡
3.38 ? 0.94*†‡
116 ? 81.0*†‡
7.36 ? 10.2*†‡
4.39 ? 6.47*†‡
0.63 ? 0.25*†‡
ctsl?/?, wild-type mice; ctsl?/?, heterozygous mice; ctsl?/?, cathepsin L-deficient mice; ctsl?/?DCM, cathepsin
L-deficient mice with manifest dilated cardiomyopathy; LVESD, left ventricular end-systolic diameter; EDV,
end-diastolic volume; LV-mass, calculated mass of left ventricle; LVEDD, left ventricular end-diastolic diameter;
LA, diameter of left atrium; AoVmax, maximum velocity of flow in pw-doppler over aortic valve; AoPGmax,
maximum aortic pressure gradient; AoPGmean, average aortic pressure gradient; CI, cardiac index; AI, aortic valve
insufficiency; MI, mitralic valve insufficiency.
*Statistical significance by Wilcoxon rank sum test: P ? 0.05 compared with ctsl?/?.
†Statistical significance by Wilcoxon rank sum test: P ? 0.05 compared with ctsl?/?.
‡Statistical significance by Wilcoxon rank sum test: P ? 0.05 compared with ctsl?/?.
echocardiography. (A) Wild-type mouse showing normal antegrade flow
through the aortic valve. (B) Aortic regurgitation and high velocity of aortic
antegrade flow as hallmarks of aortic valve insufficiency in a ctsl?/?mouse.
Functional assessment of heart valves by pulse-waved Doppler-
www.pnas.org?cgi?doi?10.1073?pnas.092637699Stypmann et al.
and types I, IV, and XVIII collagen (42, 43). For example, CTSL
can cleave within the nonhelical regions at the ends of native
collagen, which leads to destabilization of the fibrils and pro-
motes further cleavage by other proteases like matrix metal-
loproteinases (43). Extracellular CTSL is also able to activate
other proteases such as urokinase-type plasminogen activators
(44). Hence, the absence of CTSL could lead to gradually
increasing interstitial fibrosis caused by defective degradation of
proteins in the ECM. Because the ECM provides the ‘‘anchor’’
for the contractile forces produced by the sarcomere, changes in
composition and organization of ECM could result in impaired
force transmission and, therefore, cardiac dilation or hypertro-
phy. This possibility is supported by recent findings that matrix
metalloproteinases, which function primarily in degradation of
ECM, are critically involved in the development of heart failure
in several mouse models (45).
In summary, a function for the lysosomal peptidase CTSL has
been found in the maintenance of heart structure and function.
Absence of CTSL results in lysosomal impairment that causes
the development of a heart disease that resembles many features
of human DCM. CTSL is a candidate gene for the human
hereditary DCM mapped to chromosome 9q13-q22. To date, the
molecular mechanisms by which CTSL serves its essential func-
tion in the heart remain elusive, but nevertheless, CTSL-
deficient mice could serve as a DCM model for the study of
challenge phenotypes and treatment options.
C.P. dedicates this work to Friedhelm Beyersdorf (Freiburg). This work
was supported by the Deutsche Forschungsgemeinschaft SFB 556 (Teil-
projekt Z2; to W.H.) and the Fonds der Chemischen Industrie (to C.P.).
1. Kamisago, M., Sharma, S. D., DePalma, S. R., Solomon, S., Sharma, P.,
McDonough, B., Smoot, L., Mullen, M. P., Woolf, P. K., Wigle, E. D., et al.
(2000) N. Engl. J. Med. 343, 1688–1696.
2. Olson, T. M., Michels, V. V., Thibodeau, S. N., Tai, Y. S. & Keating, M. T.
(1998) Science 280, 750–752.
3. Li, D., Tapscoft, T., Gonzalez, O., Burch, P. E., Quinones, M. A., Zoghbi,
W. A., Hill, R., Bachinski, L. L., Mann, D. L. & Roberts, R. (1999) Circulation
4. Towbin, J. A., Hejtmancik, J. F., Brink, P., Gelb, B., Zhu, X. M., Chamberlain,
J. S., McCabe, E. R. & Swift, M. (1993) Circulation 87, 1854–1865.
5. Tsubata, S., Bowles, K. R., Vatta, M., Zintz, C., Titus, J., Muhonen, L., Bowles,
N. E. & Towbin, J. A. (2000) J. Clin. Invest. 106, 655–662.
6. Brodsky, G. L., Muntoni, F., Miocic, S., Sinagra, G., Sewry, C. & Mestroni, L.
(2000) Circulation 101, 473–476.
7. Follath, F. (1999) J. Cardiovasc. Pharmacol. 33, Suppl. 3, S31–S35.
8. Coral-Vazquez, R., Cohn, R. D., Moore, S. A., Hill, J. A., Weiss, R. M.,
Davisson, R. L., Straub, V., Barresi, R., Bansal, D., Hrstka, R. F., et al. (1999)
Cell 98, 465–474.
9. Arber, S., Hunter, J. J., Ross, J., Hongo, M., Sansig, G., Borg, J., Perriard, J. C.,
Chien, K. R. & Caroni, P. (1997) Cell 88, 393–403.
10. Fatkin, D., Christe, M. E., Aristizabal, O., McConnell, B. K., Srinivasan, S.,
Schoen, F. J., Seidman, C. E., Turnbull, D. H. & Seidman, J. G. (1999) J. Clin.
Invest. 103, 147–153.
11. Bryant, D., Becker, L., Richardson, J., Shelton, J., Franco, F., Peshock, R.,
Thompson, M. & Giroir, B. (1998) Circulation 97, 1375–1381.
12. Kubota, T., McTiernan, C. F., Frye, C. S., Slawson, S. E., Lemster, B. H.,
Koretsky, A. P., Demetris, A. J. & Feldman, A. M. (1997) Circ. Res. 81,
13. Colbert, M. C., Hall, D. G., Kimball, T. R., Witt, S. A., Lorenz, J. N., Kirby,
M. L., Hewett, T. E., Klevitsky, R. & Robbins, J. (1997) J. Clin. Invest. 100,
14. Fentzke, R. C., Korcarz, C. E., Lang, R. M., Lin, H. & Leiden, J. M. (1998)
J. Clin. Invest. 101, 2415–2426.
Salis, M. B., Straino, S., Capogrossi, M. C., Olivetti, G. & Madeddu, P. (1999)
Circulation 100, 2359–2365.
16. Li, H., Wang, J., Wilhelmsson, H., Hansson, A., Thoren, P., Duffy, J., Rustin,
P. & Larsson, N. G. (2000) Proc. Natl. Acad. Sci. USA 97, 3467–3472.
17. Wang, J., Wilhelmsson, H., Graff, C., Li, H., Oldfors, A., Rustin, P., Bruning,
J. C., Kahn, C. R., Clayton, D. A., Barsh, G. S., et al. (1999) Nat. Genet. 21,
18. Kornfeld, S. & Mellman, I. (1989) Annu. Rev. Cell Biol. 5, 483–525.
19. Rawlings, N. D. & Barrett, A. J. (2000) Nucleic Acids Res. 28, 323–325.
20. Turk, B., Turk, D. & Turk, V. (2000) Biochim. Biophys. Acta 1477, 98–111.
21. Barrett, A. J. (1992) Ann. N. Y. Acad. Sci. 674, 1–15.
22. Villadangos, J. A., Bryant, R. A., Deussing, J., Driessen, C., Lennon-Dumenil,
A. M., Riese, R. J., Roth, W., Saftig, P., Shi, G. P., Chapman, H. A., et al. (1999)
Immunol. Rev. 172, 109–120.
23. Chapman, H. A., Riese, R. J. & Shi, G. P. (1997) Annu. Rev. Physiol. 59, 63–88.
24. Kirschke, H., Eerola, R., Hopsu-Havu, V. K., Bromme, D. & Vuorio, E. (2000)
Eur. J. Cancer 36, 787–795.
25. Nakagawa, T., Roth, W., Wong, P., Nelson, A., Farr, A., Deussing, J.,
Villadangos, J. A., Ploegh, H., Peters, C. & Rudensky, A. Y. (1998) Science 280,
26. Roth, W., Deussing, J., Botchkarev, V. A., Pauly-Evers, M., Saftig, P., Hafner,
A., Schmidt, P., Schmahl, W., Scherer, J., Anton-Lamprecht, I., Von Figura, K.,
Paus, R. & Peters, C. (2000) FASEB J. 14, 2075–2086.
27. Guertl, B., Noehammer, C. & Hoefler, G. (2000) Int. J. Exp. Pathol. 81,
28. Tanaka, Y., Guhde, G., Suter, A., Eskelinen, E. L., Hartmann, D., Lullmann-
Rauch, R., Janssen, P. M., Blanz, J., von Figura, K. & Saftig, P. (2000) Nature
(London) 406, 902–906.
29. Nishino, I., Fu, J., Tanji, K., Yamada, T., Shimojo, S., Koori, T., Mora, M.,
Riggs, J. E., Oh, S. J., Koga, Y., et al. (2000) Nature (London) 406, 906–910.
30. Cruz-Orive, L. M. & Weibel, E. R. (1990) Am. J. Physiol. 258, L148–L156.
31. Gundersen, H. J. (1986) J. Microsc. (Oxford) 143, 3–45.
32. Gundersen, H. J. & Jensen, E. B. (1987) J. Microsc. (Oxford) 147, 229–263.
33. Tobin, D. J., Fenton, D. A. & Kendall, M. D. (1991) Am. J. Dermatopathol. 13,
34. Collins, K. A., Korcarz, C. E., Shroff, S. G., Bednarz, J. E., Fentzke, R. C., Lin,
H., Leiden, J. M. & Lang, R. M. (2001) Am. J. Physiol. 280, H1954–H1962.
35. Kramer, K., van Acker, S. A., Voss, H. P., Grimbergen, J. A., van der Vijgh,
W. J. & Bast, A. (1993) J. Pharmacol. Toxicol. Methods 30, 209–215.
36. Sussman, M. A., Welch, S., Cambon, N., Klevitsky, R., Hewett, T. E., Price, R.,
Witt, S. A. & Kimball, T. R. (1998) J. Clin. Invest. 101, 51–61.
37. Seidman, J. G. & Seidman, C. (2001) Cell 104, 557–567.
38. Krajinovic, M., Pinamonti, B., Sinagra, G., Vatta, M., Severini, G. M., Milasin,
J., Falaschi, A., Camerini, F., Giacca, M. & Mestroni, L. (1995) Am. J. Hum.
Genet. 57, 846–852.
39. Arad, M., Benson, D. W., Perez-Atayde, A. R., McKenna, W. J., Sparks, E. A.,
Kanter, R. J., McGarry, K., Seidman, J. G. & Seidman, C. E. (2002) J. Clin.
Invest. 109, 357–362.
40. Shaw, E. & Dean, R. T. (1980) Biochem. J. 186, 385–390.
41. Knop, M., Schiffer, H. H., Rupp, S. & Wolf, D. H. (1993) Curr. Opin. Cell Biol.
42. Felbor, U., Dreier, L., Bryant, R. A., Ploegh, H. L., Olsen, B. R. & Mothes, W.
(2000) EMBO J. 19, 1187–1194.
43. Maciewicz, R. A. & Etherington, D. J. (1988) Biochem. J. 256, 433–440.
44. Lah, T. T. & Kos, J. (1998) Biol. Chem. 379, 125–130.
45. Lee, R. T. & Libby, P. (2000) J. Clin. Invest. 106, 827–828.
Stypmann et al. PNAS ?
April 30, 2002 ?
vol. 99 ?
no. 9 ?