Sex differences in cardiac recovery and ventricular gene expression in a rat model of donation after circulatory death

Sex differences in cardiac recovery and ventricular gene expression in a rat model of donation after circulatory death | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sex differences in cardiac recovery and ventricular gene expression in a rat model of donation after circulatory death Anja Helmer, Alexia Clavier, Maria Arnold, Adrian Segiser, Heidi E. L. Lischer, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8722911/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 27 You are reading this latest preprint version Abstract Background Heart donation after circulatory death (DCD) is a promising strategy to increase graft supply. However, in contrast to conventional heart transplantation, in which organs are retrieved from heart-beating donors, DCD hearts are subjected to damaging conditions before and during warm ischemia in the donor, leading to ischemia-reperfusion injury (IRI). Although sex differences have been identified in other contexts of cardiac IRI, such as myocardial infarction, they remain underexplored in DCD. Therefore, we aimed to investigate whether sex differences induce changes in the expression of genes in response to cardiac DCD conditions, including IRI, which may contribute to sexual dimorphism in graft quality. Methods Male, female, and ovariectomized (OVX) Wistar rats underwent simulated DCD with no or 22 minutes of warm in situ ischemia, followed by oxygenated reperfusion under left-ventricular loading. Functional recovery was assessed and left-ventricular tissue was analyzed by bulk RNA-sequencing. Results Recovery of left ventricular function was decreased by warm ischemia, but significantly better in females than in males, with OVX resembling the males. Reperfusion induced inflammatory and hypoxia-responsive gene programs in all groups. Expression of 110 genes correlated with recovery, many of which were more abundant in females compared to males, consistent with a role in improved post-ischemic function. Among these genes, Igfbp3, Fam78b, and Galnt10 were enriched in females compared to males and OVX, supporting a role for female sex hormones. Conclusions Compared to male hearts, cardiac recovery is significantly higher in female hearts after exposure to DCD conditions and is accompanied by an increased expression of genes related to core homeostatic programs that correlate with recovery of ventricular function. Significantly higher expression of genes related to energy metabolism, including fatty acid metabolism and inflammatory pathways, was revealed in males compared to females and is associated with decreased recovery. This study identifies potential new therapeutic targets for optimizing cardiac DCD graft quality, and highlights the importance of underlying sex differences, eg. in inflammatory pathways and metabolic adaptations, that should be taken into consideration for the implementation of sex-specific precision therapies. heart transplantation donation after circulatory death (DCD) ex vivo/ex-situ heart perfusion cardioprotection sex as a biological variable (SABV) bulk RNA Sequencing (RNA-Seq.) transcriptomics Full Text Additional Declarations No competing interests reported. Supplementary Files Sexdifferencestranscriptomicssupp.materialAH.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 16 Feb, 2026 Reviews received at journal 15 Feb, 2026 Reviews received at journal 13 Feb, 2026 Reviews received at journal 11 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviews received at journal 10 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviews received at journal 07 Feb, 2026 Reviews received at journal 06 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviews received at journal 04 Feb, 2026 Reviewers agreed at journal 04 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers invited by journal 30 Jan, 2026 Editor assigned by journal 29 Jan, 2026 Submission checks completed at journal 29 Jan, 2026 First submitted to journal 28 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8722911","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583568623,"identity":"cb1ba51c-0184-4d87-bfa2-d1a2b6b1909a","order_by":0,"name":"Anja Helmer","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Anja","middleName":"","lastName":"Helmer","suffix":""},{"id":583568624,"identity":"96bc260a-2edc-44a9-8448-6fd773b781d5","order_by":1,"name":"Alexia Clavier","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Alexia","middleName":"","lastName":"Clavier","suffix":""},{"id":583568625,"identity":"cdc08945-bc24-41fd-88e1-fd0ea1b4176d","order_by":2,"name":"Maria Arnold","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Arnold","suffix":""},{"id":583568626,"identity":"35def68b-a747-46f2-818a-6143f83792d4","order_by":3,"name":"Adrian Segiser","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Adrian","middleName":"","lastName":"Segiser","suffix":""},{"id":583568627,"identity":"4559c6cf-a03e-445d-921d-ef49cadf53e3","order_by":4,"name":"Heidi E. L. Lischer","email":"","orcid":"","institution":"University of Bern","correspondingAuthor":false,"prefix":"","firstName":"Heidi","middleName":"E. L.","lastName":"Lischer","suffix":""},{"id":583568628,"identity":"20564ca5-e0dd-4bd2-9713-614821dcd578","order_by":5,"name":"Selianne Graf","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Selianne","middleName":"","lastName":"Graf","suffix":""},{"id":583568629,"identity":"de1f844b-bf65-4dc6-9934-75db9f54f89a","order_by":6,"name":"Mojgan Masoodi","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Mojgan","middleName":"","lastName":"Masoodi","suffix":""},{"id":583568630,"identity":"a0d2edcf-b99b-4a30-97a3-4fa61a8dd354","order_by":7,"name":"Georgia Beer","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Georgia","middleName":"","lastName":"Beer","suffix":""},{"id":583568631,"identity":"6ab1ed38-8e6e-4c47-a786-0982221282a5","order_by":8,"name":"Rahel Ottersberg","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Rahel","middleName":"","lastName":"Ottersberg","suffix":""},{"id":583568632,"identity":"69bba508-fab8-44c2-985a-b2c118daa14f","order_by":9,"name":"Manuel Egle","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Manuel","middleName":"","lastName":"Egle","suffix":""},{"id":583568633,"identity":"d244aabf-adc8-456a-a3d2-a4c32a5cdf23","order_by":10,"name":"Matthias Siepe","email":"","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":false,"prefix":"","firstName":"Matthias","middleName":"","lastName":"Siepe","suffix":""},{"id":583568634,"identity":"29d65fe5-6e3f-4a43-8dba-433f0a294a47","order_by":11,"name":"Sarah Longnus","email":"data:image/png;base64,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","orcid":"","institution":"University Hospital of Bern","correspondingAuthor":true,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Longnus","suffix":""}],"badges":[],"createdAt":"2026-01-28 15:42:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8722911/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8722911/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101687263,"identity":"4cc7c0b0-0cba-45d7-976e-55775566e0c1","added_by":"auto","created_at":"2026-02-02 15:29:01","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1930654,"visible":true,"origin":"","legend":"","description":"","filename":"SexdifferencestranscriptomicsmanuscriptAH.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8722911/v1_covered_025e632d-942a-430f-a8e8-44c827213f68.pdf"},{"id":101687197,"identity":"154ea545-786e-4147-8bc0-3d152871474a","added_by":"auto","created_at":"2026-02-02 15:28:46","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":6386350,"visible":true,"origin":"","legend":"","description":"","filename":"Sexdifferencestranscriptomicssupp.materialAH.docx","url":"https://assets-eu.researchsquare.com/files/rs-8722911/v1/8d24702a7bed8f4c9e36a11f.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sex differences in cardiac recovery and ventricular gene expression in a rat model of donation after circulatory death","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"biology-of-sex-differences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bosd","sideBox":"Learn more about [Biology of Sex Differences](http://bsd.biomedcentral.com)","snPcode":"13293","submissionUrl":"https://submission.nature.com/new-submission/13293/3","title":"Biology of Sex Differences","twitterHandle":"@BiologySexDiff","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"heart transplantation, donation after circulatory death (DCD), ex vivo/ex-situ heart perfusion, cardioprotection, sex as a biological variable (SABV), bulk RNA Sequencing (RNA-Seq.), transcriptomics","lastPublishedDoi":"10.21203/rs.3.rs-8722911/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8722911/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHeart donation after circulatory death (DCD) is a promising strategy to increase graft supply. However, in contrast to conventional heart transplantation, in which organs are retrieved from heart-beating donors, DCD hearts are subjected to damaging conditions before and during warm ischemia in the donor, leading to ischemia-reperfusion injury (IRI). Although sex differences have been identified in other contexts of cardiac IRI, such as myocardial infarction, they remain underexplored in DCD. Therefore, we aimed to investigate whether sex differences induce changes in the expression of genes in response to cardiac DCD conditions, including IRI, which may contribute to sexual dimorphism in graft quality.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eMale, female, and ovariectomized (OVX) Wistar rats underwent simulated DCD with no or 22 minutes of warm \u003cem\u003ein situ\u003c/em\u003e ischemia, followed by oxygenated reperfusion under left-ventricular loading. Functional recovery was assessed and left-ventricular tissue was analyzed by bulk RNA-sequencing.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eRecovery of left ventricular function was decreased by warm ischemia, but significantly better in females than in males, with OVX resembling the males. Reperfusion induced inflammatory and hypoxia-responsive gene programs in all groups. Expression of 110 genes correlated with recovery, many of which were more abundant in females compared to males, consistent with a role in improved post-ischemic function. Among these genes, Igfbp3, Fam78b, and Galnt10 were enriched in females compared to males and OVX, supporting a role for female sex hormones.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCompared to male hearts, cardiac recovery is significantly higher in female hearts after exposure to DCD conditions and is accompanied by an increased expression of genes related to core homeostatic programs that correlate with recovery of ventricular function. Significantly higher expression of genes related to energy metabolism, including fatty acid metabolism and inflammatory pathways, was revealed in males compared to females and is associated with decreased recovery. This study identifies potential new therapeutic targets for optimizing cardiac DCD graft quality, and highlights the importance of underlying sex differences, eg. in inflammatory pathways and metabolic adaptations, that should be taken into consideration for the implementation of sex-specific precision therapies.\u003c/p\u003e","manuscriptTitle":"Sex differences in cardiac recovery and ventricular gene expression in a rat model of donation after circulatory death","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 15:26:46","doi":"10.21203/rs.3.rs-8722911/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-16T15:13:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T00:59:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T16:18:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-11T18:30:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T16:10:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T09:50:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T02:22:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T04:30:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T13:39:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T09:04:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-04T21:49:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"130871021233645368284550747852172287293","date":"2026-02-04T18:43:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"271998432198954965685123841778005363265","date":"2026-02-02T09:36:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51632883728272920565740838100500378059","date":"2026-02-02T07:06:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333626211277924609873083282741081954051","date":"2026-02-01T18:30:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"205463964302087837530885051532536435407","date":"2026-02-01T14:06:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199965308812277367972254886931063598350","date":"2026-01-31T15:49:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166510025798611180400538821919437734357","date":"2026-01-31T10:20:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"102226758361888076428803021959665559326","date":"2026-01-31T08:07:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4300752869224301179559490967412416963","date":"2026-01-30T15:38:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20709846469567306490254950824865714999","date":"2026-01-30T15:12:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"88185114811283022112400046835706623952","date":"2026-01-30T14:57:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94175674740477524869398044549892641289","date":"2026-01-30T14:25:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-30T14:06:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-29T08:41:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-29T08:35:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"Biology of Sex Differences","date":"2026-01-28T14:24:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"biology-of-sex-differences","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bosd","sideBox":"Learn more about [Biology of Sex Differences](http://bsd.biomedcentral.com)","snPcode":"13293","submissionUrl":"https://submission.nature.com/new-submission/13293/3","title":"Biology of Sex Differences","twitterHandle":"@BiologySexDiff","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7af1726d-c75d-4460-b535-fe6a02e74628","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T10:53:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-02 15:26:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8722911","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8722911","identity":"rs-8722911","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}