Reperfusion of the heart after a period of ischaemia leads to the opening of a nonspecific pore in the inner mitochondrial membrane, known as the
mitochondrial permeability transition pore (MPTP). This transition causes mitochondria to become uncoupled and capable of hydrolysing rather than synthesising
ATP. Unrestrained, this will lead to the loss of ionic homeostasis and ultimately necrotic cell death. The functional recovery of the Langendorff-perfused heart from ischaemia inversely correlates with the extent of pore opening, and inhibition of the
MPTP provides protection against
reperfusion injury. This may be mediated either by a direct interaction with the
MPTP [e.g., by
Cyclosporin A (CsA) and
Sanglifehrin A (SfA)], or indirectly by decreasing
calcium loading and
reactive oxygen species (ROS; key inducers of pore opening) or lowering intracellular pH. Agents working in this way may include
pyruvate,
propofol, Na+/H+
antiporter inhibitors, and ischaemic preconditioning (IPC). Mitochondrial
KATP channels have been implicated in preconditioning, but our own data suggest that the channel openers and blockers used in these studies work through alternative mechanisms. In addition to its role in
necrosis, transient opening of the
MPTP may occur and lead to the release of
cytochrome c and other proapoptotic molecules that initiate the apoptotic cascade. However, only if subsequent
MPTP closure occurs will
ATP levels be maintained, ensuring that cell death continues down an apoptotic, rather than a necrotic, pathway.