. Myocardial fibrosis blunts nitric oxide synthase-related preload reserve in human dilated cardiomyopathy. Am J Physiol Heart Circ Physiol 284: H10-H16, 2003; 10.1152/ajpheart.00401.2002.-The purpose of the study was to investigate interactions between myocardial nitric oxide synthase (NOS) and myocardial fibrosis, both of which determine left ventricular (LV) preload reserve in patients with nonischemic dilated cardiomyopathy (DCM). In previous animal experiments, chronic inhibition of NOS induced myocardial fibrosis and limited LV preload reserve. Twenty-eight DCM patients underwent LV catheterization, balloon caval occlusions (BCO; n ϭ 8), intracoronary substance P infusion (n ϭ 8), and procurement of LV endomyocardial biopsies for determinations of collagen volume fraction (CVF), of gene expression of NOS2, NOS3, heme oxygenase (HO)-1, and TNF-␣, and of NOS2 protein. CVF was unrelated to the intensity of NOS2, NOS3, HO-1, or TNF-␣ gene expression or of NOS2 protein expression. Preload recruitable LV stroke work (PR-LVSW) correlated directly with NOS2 gene expression (P ϭ 0.001) and inversely with CVF (P ϭ 0.04). High CVF (Ͼ10%) reduced baseline LVSW and PR-LVSW at each level of NOS2 gene expression. In DCM, myocardial fibrosis is unrelated to the intensity of myocardial gene expression of NOS, antioxidative enzymes (HO-1), or cytokines (TNF-␣) and blunts NOS2-related recruitment of LV preload reserve. collagen; diastole; myocardial contraction HIGHER LEFT VENTRICULAR (LV) endomyocardial nitric oxide (NO) synthase (NOS) gene expression enables patients with dilated cardiomyopathy (DCM) to recruit LV preload reserve as evident from their higher LV stroke work (LVSW) at elevated LV filling pressures (13). This ability to recruit LV preload reserve could result from an acute direct myocardial action of NO, because intracoronary infusion of substance P, which releases NO from the coronary endothelium, induces an instantaneous increase in LVSW in DCM patients with elevated LV filling pressures (13). This increase in LVSW is accompanied by a rightward shift of the diastolic LV pressure-volume relation. A similar NOrelated rightward shift of the diastolic LV pressurevolume relation was previously observed in control and aortic stenosis patients after intracoronary infusion of a NO donor (20,24) and in DCM patients after intracoronary infusion of enalaprilat (37). Acute effects of NO on myocardial diastolic distensibility have also been reported in experimental preparations. In isolated rat cardiomyocytes, exposure to cGMP, the second messenger of NO, increases diastolic cell length (32), and, in isolated guinea pig hearts, a coronary perfusate containing a specific NOS inhibitor results in an acute reduction of LV stroke volume because of a leftward shift of the diastolic LV pressure-volume relation (27).The ability of NO to preserve LV diastolic distensibility could result not only from its acute direct myocardial actions but also from chronic effects on LV hypertrophy and on collagen turnover within the cardiac i...