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Gać P, Jaworski A, Grajnert F, Kicman K, Trejtowicz-Sutor A, Witkowski K, Poręba M, Poręba R. Aortic Valve Calcium Score: Applications in Clinical Practice and Scientific Research-A Narrative Review. J Clin Med 2024; 13:4064. [PMID: 39064103 PMCID: PMC11277735 DOI: 10.3390/jcm13144064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/29/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
In this narrative review, we investigate the essential role played by the computed tomography Aortic Valve Calcium Score (AVCS) in the cardiovascular diagnostic landscape, with a special focus on its implications for clinical practice and scientific research. Calcific aortic valve stenosis is the most prevalent type of aortic stenosis (AS) in industrialized countries, and due to the aging population, its prevalence is increasing. While transthoracic echocardiography (TTE) remains the gold standard, AVCS stands out as an essential complementary tool in evaluating patients with AS. The advantage of AVCS is its independence from flow; this allows for a more precise evaluation of patients with discordant findings in TTE. Further clinical applications of AVCS include in the assessment of patients before transcatheter aortic valve replacement (TAVR), as it helps in predicting outcomes and provides prognostic information post-TAVR. Additionally, we describe different AVCS thresholds regarding gender and the anatomical variations of the aortic valve. Finally, we discuss various scientific studies where AVCS was applied. As AVCS has some limitations, due to the pathophysiologies of AS extending beyond calcification and gender differences, scientists strive to validate contrast-enhanced AVCS. Furthermore, research on developing radiation-free methods of measuring calcium content is ongoing.
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Affiliation(s)
- Paweł Gać
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
- Department of Population Health, Division of Environmental Health and Occupational Medicine, Wroclaw Medical University, J. Mikulicza-Radeckiego 7, 50-345 Wrocław, Poland
| | - Arkadiusz Jaworski
- Healthcare Team “County Hospital” in Sochaczew, Batalionow Chlopskich 3/7, 96-500 Sochaczew, Poland
| | - Filip Grajnert
- 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland;
| | - Katarzyna Kicman
- Healthcare Team “County Hospital” in Sochaczew, Batalionow Chlopskich 3/7, 96-500 Sochaczew, Poland
| | - Agnieszka Trejtowicz-Sutor
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
| | - Konrad Witkowski
- Centre of Diagnostic Imaging, 4th Military Hospital, Rudolfa Weigla 5, 50-981 Wrocław, Poland; (P.G.); (A.T.-S.); (K.W.)
| | - Małgorzata Poręba
- Department of Paralympic Sports, Wroclaw University of Health and Sport Sciences, Witelona 25a, 51-617 Wrocław, Poland
| | - Rafał Poręba
- Department of Internal and Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, Borowska 213, 50-556 Wrocław, Poland;
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Heidari Moghadam R, Babajani F, Karami A, Elieh-Ali-Komi D, Hoseini F, Salehi N, Elahirad S, Mohammadi-Noori E, Mohammadi H, Kiani A. Association of Matrix Metalloproteinase-2 (MMP-2) and MMP-9 Promoter Variants, Their Serum Levels, and Activities with Aortic Valve Calcification (AVC) in a Population from Western Iran. Genet Test Mol Biomarkers 2024; 28:223-232. [PMID: 38708584 DOI: 10.1089/gtmb.2023.0370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background: Matrix metalloproteinase (MMP) enzyme gene polymorphisms MMP-2-1575G/A and MMP-9-1562C/T promoter polymorphism, their serum levels, and activity are associated with aortic valve calcification (AVC). Materials and Methods: The synergistic link between the risk of AVC and the alleles T and A of MMP-9 and MMP-2 was investigated, respectively. Ninety-two cases with AVC and 92 healthy individuals from the west of Iran were included, and MMP- 2-1575G/A and MMP-9-1562C/T promoter polymorphisms were detected using PCR-RFLP. The serum levels and activity of MMP-2 and -9 were assessed using ELISA and gelatin zymography methods, respectively. In addition, serum biochemical markers, including FBS, urea and creatinine, cholesterol, triglyceride, HDL, LDL, calcium, phosphorus, and blood pressure: systolic blood pressure and diastolic blood pressure were measured. Results: Heart valve calcification disease was associated with a comparatively higher frequency of the A allele of the MMP2-1575 variation (p = 0.002). In addition, the frequency of T allele of the MMP9-1562 variant was higher than the control group (p = 0.007). Conclusion: MMP-2 and MMP-9 serum levels and activities were observed to be considerably higher in the experimental group than in the control group (p < 0.001). Patients are more susceptible to cardiovascular disease than the control group due to elevated serum levels and activity of MMP-2 and MMP-9.
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Affiliation(s)
- Reza Heidari Moghadam
- Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fatemeh Babajani
- Students Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Afshin Karami
- Regenerative Medicine Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Daniel Elieh-Ali-Komi
- Institute of Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Faeghe Hoseini
- Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Nahid Salehi
- Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Saeed Elahirad
- Cardiovascular Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ehsan Mohammadi-Noori
- Pharmaceutical Sciences Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Hossein Mohammadi
- Students Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Amir Kiani
- Regenerative Medicine Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
- Pharmaceutical Sciences Research Center, Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Subramani K, Bander J, Chen S, Suárez-Fariñas M, Venkatesan T, Subrahmanian S, Varshney R, Kini A, Sharma S, Rifkin DB, Cho J, Coller BS, Ahamed J. Evidence That Anemia Accelerates AS Progression Via Shear-Induced TGF-β1 Activation: Heyde's Syndrome Comes Full Circle. JACC Basic Transl Sci 2024; 9:185-199. [PMID: 38510715 PMCID: PMC10950403 DOI: 10.1016/j.jacbts.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/07/2023] [Accepted: 09/07/2023] [Indexed: 03/22/2024]
Abstract
The severity of aortic stenosis (AS) is associated with acquired von Willebrand syndrome (AVWS) and gastrointestinal bleeding, leading to anemia (Heyde's syndrome). We investigated how anemia is linked with AS and AVWS using the LA100 mouse model and patients with AS. Induction of anemia in LA100 mice increased transforming growth factor (TGF)-β1 activation, AVWS, and AS progression. Patients age >75 years with severe AS had higher plasma TGF-β1 levels and more severe anemia than AS patients age <75 years, and there was a correlation between TGF-β1 and anemia. These data are compatible with the hypothesis that the blood loss anemia of Heyde's syndrome contributes to AS progression via WSS-induced activation of platelet TGF-β1 and additional gastrointestinal bleeding via WSS-induced AVWS.
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Affiliation(s)
- Kumar Subramani
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Jeffrey Bander
- Icahn School of Medicine at Mount Sinai New York, New York, USA
| | - Sixia Chen
- University of Oklahoma Health Sciences Centers, Oklahoma City, Oklahoma, USA
| | | | - Thamizhiniyan Venkatesan
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Sandeep Subrahmanian
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Rohan Varshney
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Annapoorna Kini
- Icahn School of Medicine at Mount Sinai New York, New York, USA
| | - Samin Sharma
- Icahn School of Medicine at Mount Sinai New York, New York, USA
| | - Daniel B. Rifkin
- Departments of Cell Biology and Medicine, New York University, New York, New York, USA
| | - Jaehyung Cho
- Washington University School of Medicine, St. Louis, Missouri, USA
| | - Barry S. Coller
- Laboratory of Blood and Vascular Biology, Rockefeller University, New York, New York, USA
| | - Jasimuddin Ahamed
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
- University of Oklahoma Health Sciences Centers, Oklahoma City, Oklahoma, USA
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Optimal threshold score of aortic valve calcification for identification of significant aortic stenosis on non-electrocardiographic-gated computed tomography. Eur Radiol 2023; 33:1243-1253. [PMID: 36066729 DOI: 10.1007/s00330-022-09114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/07/2022] [Accepted: 08/15/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES This study evaluated the association between aortic valve calcification (AVC) and aortic stenosis (AS) by scoring the AVC to determine the threshold scores for significant AS on non-electrocardiographic (ECG)-gated computed tomography (CT). METHODS We retrospectively analyzed the AVC scores of 5385 patients on non-contrast non-ECG-gated CT, who underwent transthoracic echocardiography (TTE) from March 1, 2013, to December 26, 2019, at our institution. Multivariable logistic regression models were used to identify potential risk factors for significant AS. The thresholds for significant AS were computed using receiver operator characteristic (ROC) curves, based on the AVC scores after propensity score matching. RESULTS A significant association was found between AS and age (p < 0.001; odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06), female sex (p < 0.001; OR, 4.5; 95% CI, 2.75-7.36), bicuspid aortic valve (p < 0.001; OR, 23.2; 95% CI, 7.35-72.9), and AVC score (AVC score/100) (p < 0.001; OR, 1.82; 95% CI, 1.71-1.95). All sex-specific AVC thresholds for significant AS (moderate and over AS severity, moderate and over AS severity without discordance, discordant severe AS, and concordant severe AS) showed high sensitivity and specificity (AUC, 0.939-0.968; sensitivity, 84.6-96%; specificity, 84.2-97.1%). CONCLUSIONS We determined the optimal AVC threshold scores for significant AS, which may aid in diagnosing significant asymptomatic AS on incidental detection of AVC through non-ECG-gated CT for non-cardiac indications. KEY POINTS • Increased frequency of non-electrocardiographic (ECG)-gated computed tomography (CT) for non-cardiac indications has led to the increased incidental identification of aortic valve calcification (AVC). • It is important to identify patients with significant aortic stenosis (AS) who require additional echocardiographic assessment on incidental detection of AVC via non-ECG-gated CT. • We determined the AVC thresholds with high sensitivity and specificity to identify significant AS on non-ECG-gated CT, which could lead to early diagnosis of asymptomatic significant AS and improved prognosis.
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Li G, Shen N, Deng H, Wang Y, Kong G, Shi J, Dong N, Deng C. Abnormal mechanical stress on bicuspid aortic valve induces valvular calcification and inhibits Notch1/NICD/Runx2 signal. PeerJ 2023; 11:e14950. [PMID: 36908813 PMCID: PMC9997191 DOI: 10.7717/peerj.14950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/03/2023] [Indexed: 03/08/2023] Open
Abstract
Background Bicuspid aortic valve (BAV) is a congenital cardiac deformity, increasing the risk of developing calcific aortic valve disease (CAVD). The disturbance of hemodynamics can induce valvular calcification, but the mechanism has not been fully identified. Methods We constructed a finite element model (FEM) of the aortic valve based on the computed tomography angiography (CTA) data from BAV patients and tricuspid aortic valve (TAV) individuals. We analyzed the hemodynamic properties based on our model and investigated the characteristics of mechanical stimuli on BAV. Further, we detected the expression of Notch, NICD and Runx2 in valve samples and identified the association between mechanical stress and the Notch1 signaling pathway. Results Finite element analysis showed that at diastole phase, the equivalent stress on the root of BAV was significantly higher than that on the TAV leaflet. Correspondingly, the expression of Notch1 and NICH decreased and the expression of Runx2 elevated significantly on large BAV leaflet belly, which is associated with equivalent stress on leaflet. Our findings indicated that the root of BAV suffered higher mechanical stress due to the abnormal hemodynamic environment, and the disturbance of the Notch1/NICD/Runx2 signaling pathway caused by mechanical stimuli contributed to valvular calcification.
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Affiliation(s)
- Guangzhou Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Na Shen
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huifang Deng
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yixuan Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gangcheng Kong
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiawei Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cheng Deng
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Fleury M, Annabi M, Voisine M, Hervault M, Boilard A, Shen M, Marette A, Côté N, Clavel M. Impact of sex and sex hormones on pathophysiology and progression of aortic stenosis in a murine model. Physiol Rep 2022; 10:e15433. [PMID: 36029186 PMCID: PMC9419154 DOI: 10.14814/phy2.15433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/15/2022] [Accepted: 08/01/2022] [Indexed: 06/15/2023] Open
Abstract
The lesions observed in AS have been shown to be sex specific, with women presenting extensive fibrotic remodeling while men developing more calcification deposit. We thus aimed to evaluate the influence of sex and sex hormones on the pathophysiology of aortic valve stenosis (AS) in our mouse model of AS. LDLr-/- ApoB100/100 IGF-II+/- mice (n = 210) were separated in six different groups: (1) intact male (IM), (2) intact female (IF), (3) castrated male (CM), (4) ovariectomized females (OF), (5) CM with testosterone supplementation (CMT), and (6) OF with 17β-estradiol supplementation (OFE). Mice were fed a high-fat/high-sucrose/high-cholesterol diet for 6 months. Hemodynamic progression of AS was followed by transthoracic echocardiography (at 12 and 36 weeks) and analyzed in all mice alive at 36 weeks. Aortic valves were collected for histological and digital droplet PCR* analysis. Increases in peak velocity were comparable in IF and IM (24.2 ± 5.7 vs. 25.8 ± 5.3 cm/s; p = 0.68), but IF presented with less severe AS. Between the three groups of male mice, AS progression was more important in IM (increase in peak velocity: 24.2 ± 5.7 cm/s; p < 0.001) compared to CM (6.2 ± 1.4; p = 0.42), and CMT (15.1 ± 3.5; p = 0.002). In the three groups of female mice, there were no statistical differences in AS progression. Digital PCR analysis revealed an important upregulation of the osteogenic gene RunX2 in IM (p < 0.0001) and downregulation of the pro-calcifying gene ALPL in IF (p < 0.05). Male sex and testosterone play an important role in upregulation of pro-calcifying genes and hemodynamic progression of AS. However, female mice appeared to be protected against calcification, characterized by downregulation of pro-osteogenic genes, but presented a similar AS hemodynamic progression.
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Affiliation(s)
- Marie‐Ange Fleury
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
| | - Mohamed‐Salah Annabi
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
| | - Martine Voisine
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
| | - Maxime Hervault
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
| | - Anne‐Julie Boilard
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
| | - Mylène Shen
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
| | - André Marette
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
| | - Nancy Côté
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
| | - Marie‐Annick Clavel
- Institut universitaire de cardiologie et de pneumologie de Québec‐Université Laval / Québec Heart and Lung Institute, Université LavalQuébec cityCanada
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Boureau AS, Karakachoff M, Le Scouarnec S, Capoulade R, Cueff C, de Decker L, Senage T, Verhoye JP, Baufreton C, Roussel JC, Dina C, Probst V, Schott JJ, Le Tourneau T. Heritability of aortic valve stenosis and bicuspid enrichment in families with aortic valve stenosis. Int J Cardiol 2022; 359:91-98. [DOI: 10.1016/j.ijcard.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/10/2022] [Accepted: 04/08/2022] [Indexed: 11/05/2022]
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Hiltner E, Zinonos S, Kostis JB, Cabrera J, Cosgrove NM, Moreyra AE, Moussa I, Kostis WJ. A Twenty-Year Analysis of Demographics, Surgical Management, and Outcomes of Aortic Stenosis in New Jersey. Am J Cardiol 2021; 150:82-88. [PMID: 34006369 DOI: 10.1016/j.amjcard.2021.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/12/2021] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
We investigated the incidence and characteristics of 14,996 patients with aortic stenosis (AS) who were hospitalized in New Jersey between the years 1995 to 2015. The average age was 72, the majority were Caucasian males and common co-morbidities were hypertension, coronary artery disease and hypercholesterolemia. Hospital admission for AS declined between 1995 to 2007, to 10/100,000 patients, and increased to 15/100,000 patients in 2015 (p for trend <0.001). During the study period, the percentage of patients who received aortic valve replacement (AVR) increased (p <0.001). All-cause and cardiovascular mortality were higher among patients who did not undergo AVR at 1-year (HR 1.98 CI 1.75 to 2.23, p <0.001 and HR 1.82 CI 1.57 to 2.11, p <0.001, respectively) and 3-years (HR 2.16 CI 1.96 to 2.38, p <0.001 and HR 2.16 CI 1.90 to 2.45, p <0.001, respectively). The probability for readmission for AS was higher in patients who did not receive AVR compared to patients who had AVR at 1 year (HR 92.95 CI 57.85 to 149.35, p <0.001) and 3 years (HR 70.36 CI 47.18 to 104.95, p <0.001). These data imply that earlier diagnosis of AS and AVR when indicated will improve outcomes.
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Bergmark BA, O'Donoghue ML, Murphy SA, Kuder JF, Ezhov MV, Ceška R, Gouni-Berthold I, Jensen HK, Tokgozoglu SL, Mach F, Huber K, Gaciong Z, Lewis BS, Schiele F, Jukema JW, Pedersen TR, Giugliano RP, Sabatine MS. An Exploratory Analysis of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibition and Aortic Stenosis in the FOURIER Trial. JAMA Cardiol 2021; 5:709-713. [PMID: 32347887 DOI: 10.1001/jamacardio.2020.0728] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Importance Despite recent advances in treatment of severe aortic valve stenosis (AS), AS remains a life-threatening condition with no proven disease-modifying therapy. Low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp[a]) have been implicated in the pathobiology of AS. The proprotein convertase subtilisin/kexin type 9 inhibitor evolocumab reduces circulating LDL-C concentrations by 50% to 60% and Lp(a) by 20% to 30%. Objective To determine whether evolocumab reduces the risk of AS events in patients with atherosclerotic cardiovascular disease. Interventions Patients were randomized 1:1 to evolocumab or placebo. Design, Setting, and Participants Exploratory analysis of the FOURIER trial, which enrolled 27 564 patients with stable atherosclerotic cardiovascular disease who were taking statin therapy at 1242 sites in 49 countries from February 2013 to November 2016. Patients were randomized to evolocumab or placebo and followed up for a median (interquartile range) of 2.2 (1.8-2.5) years. This post hoc analysis was performed from September 2019 to February 2020. Main Outcomes and Measures Site-reported adverse events of new or worsening AS or aortic valve replacement (termed AS events). The adjusted risk of AS events was calculated with a multivariable model including concentrations of Lp(a) and LDL-C corrected for Lp(a) content, plus age, sex, diabetes, hypertension, current smoking, and estimated glomerular filtration rate. Evolocumab efficacy was tested using a Cox proportional hazards model. Results Aortic stenosis events occurred in 63 patients (48 men [76%]; mean [SD] age, 69 [9] years) over a median of 2.2 years. Elevated Lp(a) concentration was associated with higher rates of AS events (adjusted hazard ratio [aHR], 1.55 [95% CI, 1.17-2.05] per SD; P = .002), including aortic valve replacement (aHR, 2.22 [95% CI, 1.38-3.58] per SD; P = .001), after multivariable adjustment. The corrected LDL-C concentration was not significantly associated with AS events (aHR, 1.23 [95% CI, 0.93-1.61] per SD; P = .14). The overall HR for AS events with evolocumab was 0.66 (95% CI, 0.40-1.09), with no apparent association in the first year (HR, 1.09 [95% CI, 0.48-2.47]) but an HR of 0.48 (95% CI, 0.25-0.93) after the first year of treatment. Conclusions and Relevance In this exploratory analysis of the FOURIER trial, higher Lp(a) levels, but not Lp(a)-corrected LDL-C levels, were associated with a higher risk of subsequent AS events, including aortic valve replacement. Long-term therapy with evolocumab may reduce AS events, and this raises the possibility that specific pharmacologic lipid-lowering therapy could offer a means to prevent or slow the progression of AS. These exploratory findings merit further investigation with a dedicated randomized clinical trial. Trial Registration ClinicalTrials.gov Identifier: NCT01764633.
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Affiliation(s)
- Brian A Bergmark
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julia F Kuder
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marat V Ezhov
- National Medical Research Center of Cardiology, Moscow, Russia
| | - Richard Ceška
- Third Internal Medicine Clinic, Center for Preventive Cardiology, University General Hospital, First Medical Faculty, Charles University, Prague, Czech Republic
| | - Ioanna Gouni-Berthold
- Polyclinic for Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
| | - Henrik K Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | | | - François Mach
- Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
| | - Kurt Huber
- Cardiology and Intensive Care Medicine, Wilhelminenhospital, Third Department of Medicine, Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Disease, the Medical University of Warsaw, Warsaw, Poland
| | - Basil S Lewis
- The Ruth and Bruce Rappaport School of Medicine, Lady Davis Carmel Medical Center, Technion-IIT, Haifa, Israel
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, the Netherlands.,Netherlands Heart Institute, Utrecht, the Netherlands
| | - Terje R Pedersen
- Oslo University Hospital, Ullevål and Medical Faculty, University of Oslo, Oslo, Norway
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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Agstam S, Agarwal T, Gupta A, Bansal S. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in aortic stenosis - Is this the light at the end of the tunnel for patients with aortic stenosis? Indian Heart J 2021; 73:249-252. [PMID: 33865531 PMCID: PMC8065365 DOI: 10.1016/j.ihj.2021.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 01/01/2021] [Accepted: 01/14/2021] [Indexed: 11/01/2022] Open
Abstract
The exploratory analysis of FOURIER trial has offered a ray of hope for patients with nonrheumatic aortic stenosis (AS). At present, the only definitive treatment of severe AS is aortic valve replacement (AVR). Despite transaortic valvular replacement revolutionizing the treatment of AS, it still remains a progressive condition, with no disease-modifying pharmacotherapy. Angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, eplerenone, nitrates and statins all have been tried previously but failed to slow down the progression of aortic stenosis. Recently, there has been an emerging role of lipoprotein A [Lp(a)] in the pathogenesis of AS. This raises the possibility that long-term therapy with specific emphasis on Lp(a) reduction may reduce or slow the progression of AS.
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11
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Córdova-Palomera A, Tcheandjieu C, Fries JA, Varma P, Chen VS, Fiterau M, Xiao K, Tejeda H, Keavney BD, Cordell HJ, Tanigawa Y, Venkataraman G, Rivas MA, Ré C, Ashley E, Priest JR. Cardiac Imaging of Aortic Valve Area From 34 287 UK Biobank Participants Reveals Novel Genetic Associations and Shared Genetic Comorbidity With Multiple Disease Phenotypes. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2020; 13:e003014. [DOI: 10.1161/circgen.120.003014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The aortic valve is an important determinant of cardiovascular physiology and anatomic location of common human diseases.
Methods:
From a sample of 34 287 white British ancestry participants, we estimated functional aortic valve area by planimetry from prospectively obtained cardiac magnetic resonance imaging sequences of the aortic valve. Aortic valve area measurements were submitted to genome-wide association testing, followed by polygenic risk scoring and phenome-wide screening, to identify genetic comorbidities.
Results:
A genome-wide association study of aortic valve area in these UK Biobank participants showed 3 significant associations, indexed by rs71190365 (chr13:50764607,
DLEU1
,
P
=1.8×10
−9
), rs35991305 (chr12:94191968,
CRADD
,
P
=3.4×10
−8
), and chr17:45013271:C:T (
GOSR2
,
P
=5.6×10
−8
). Replication on an independent set of 8145 unrelated European ancestry participants showed consistent effect sizes in all 3 loci, although rs35991305 did not meet nominal significance. We constructed a polygenic risk score for aortic valve area, which in a separate cohort of 311 728 individuals without imaging demonstrated that smaller aortic valve area is predictive of increased risk for aortic valve disease (odds ratio, 1.14;
P
=2.3×10
−6
). After excluding subjects with a medical diagnosis of aortic valve stenosis (remaining n=308 683 individuals), phenome-wide association of >10 000 traits showed multiple links between the polygenic score for aortic valve disease and key health-related comorbidities involving the cardiovascular system and autoimmune disease. Genetic correlation analysis supports a shared genetic etiology with between aortic valve area and birth weight along with other cardiovascular conditions.
Conclusions:
These results illustrate the use of automated phenotyping of cardiac imaging data from the general population to investigate the genetic etiology of aortic valve disease, perform clinical prediction, and uncover new clinical and genetic correlates of cardiac anatomy.
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Affiliation(s)
- Aldo Córdova-Palomera
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
| | - Catherine Tcheandjieu
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
| | - Jason A. Fries
- Department of Computer Science (J.F., V.S.C., M.F., C.R.), Stanford University, CA
- Center for Biomedical Informatics Research (J.F.), Stanford University, CA
| | - Paroma Varma
- Department of Electrical Engineering (P.V.), Stanford University, CA
| | - Vincent S. Chen
- Department of Computer Science (J.F., V.S.C., M.F., C.R.), Stanford University, CA
| | - Madalina Fiterau
- Department of Computer Science (J.F., V.S.C., M.F., C.R.), Stanford University, CA
| | - Ke Xiao
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
| | - Heliodoro Tejeda
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
| | - Bernard D. Keavney
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom (B.K.)
- Division of Medicine, Manchester University National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom (B.K.)
| | - Heather J. Cordell
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, United Kingdom (H.J.C.)
| | - Yosuke Tanigawa
- Department of Biomedical Data Science (Y.T., G.V., M.R.), Stanford University, CA
| | - Guhan Venkataraman
- Department of Biomedical Data Science (Y.T., G.V., M.R.), Stanford University, CA
| | - Manuel A. Rivas
- Department of Biomedical Data Science (Y.T., G.V., M.R.), Stanford University, CA
| | - Christopher Ré
- Department of Computer Science (J.F., V.S.C., M.F., C.R.), Stanford University, CA
| | - Euan Ashley
- Department of Medicine (E.A.), Stanford University, CA
- Chan Zuckerberg Biohub, San Francisco, CA (E.A., J.R.P.)
| | - James R. Priest
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA (A.C.-P., C.T., K.X., H.T., J.R.P.)
- Chan Zuckerberg Biohub, San Francisco, CA (E.A., J.R.P.)
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12
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Alishiri G, Heshmat-Ghahdarijani K, Hashemi M, Zavar R, Farahani MM. Alendronate slows down aortic stenosis progression in osteoporotic patients: An observational prospective study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2020; 25:65. [PMID: 33088302 PMCID: PMC7554420 DOI: 10.4103/jrms.jrms_408_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/21/2020] [Accepted: 05/14/2020] [Indexed: 11/07/2022]
Abstract
Background: Aortic stenosis (AS) is the most common primary valvular disease. Currently, there is no pharmacological approach for the medical management of AS. We investigated the effect of osteoporosis therapy with alendronate on hemodynamic progression in patients concurrently affected by AS and osteoporosis. Materials and Methods: In this observational prospective study, we enrolled 37 women more than 60 years old with diagnosis of AS and concurrent osteoporosis from August 2017 to December 2019. These patients were treated with alendronate 70 mg every week added to their routine treatment for AS, and their outcomes were compared with 33 patients only affected by AS. Echocardiographic changes and N-terminal-prohormone of brain natriuretic peptide (NT-pro-BNP) level were evaluated during about 2 years of follow-up. Results: The mean follow-up time for the treated and nontreated groups was 20.89 ± 2.73 and 20.84 ± 2.76 months, respectively. Mean gradient (P = 0.02) and peak gradient (P = 0.04) of aortic valve were significantly different between the groups after follow-up. Aortic valve area was decreased 0.09 cm2 in the treated group by alendronate and 0.23 cm2 in the other group (P = 0.001). Furthermore, NT-pro-BNP was significantly decreased in patients treated by alendronate (P = 0.01), but it was increased in nontreated patients (P = 0.04). Conclusion: Treatment with alendronate in patients with AS and concurrent osteoporosis slows down the progression of stenosis and improves their prognosis. This study could open a new pathway for the treatment of AS. Further studies, particularly randomized controlled clinical trial, should be done for providing more evidence.
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Affiliation(s)
- Gholamhossein Alishiri
- Chemical Injuries Research Center, Systems Biology and Poisonings Institute, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Hashemi
- Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reihaneh Zavar
- Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
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13
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The E, Yao Q, Zhang P, Zhai Y, Ao L, Fullerton DA, Meng X. Mechanistic Roles of Matrilin-2 and Klotho in Modulating the Inflammatory Activity of Human Aortic Valve Cells. Cells 2020; 9:cells9020385. [PMID: 32046115 PMCID: PMC7072362 DOI: 10.3390/cells9020385] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Calcific aortic valve disease (CAVD) is a chronic inflammatory disease. Soluble extracellular matrix (ECM) proteins can act as damage-associated molecular patterns and may induce valvular inflammation. Matrilin-2 is an ECM protein and has been found to elevate the pro-osteogenic activity in human aortic valve interstitial cells (AVICs). Klotho, an anti-aging protein, appears to have anti-inflammatory properties. The effect of matrilin-2 and Klotho on AVIC inflammatory responses remains unclear. METHODS AND RESULTS Isolated human AVICs were exposed to matrilin-2. Soluble matrilin-2 induced the production of ICAM-1, MCP-1, and IL-6. It also induced protein kinase R (PKR) activation via Toll-like receptor (TLR) 2 and 4. Pretreatment with PKR inhibitors inhibited NF-κB activation and inflammatory mediator production induced by matrilin-2. Further, recombinant Klotho suppressed PKR and NF-κB activation and markedly reduced the production of inflammatory mediators in human AVICs exposed to matrilin-2. CONCLUSIONS This study revealed that soluble matrilin-2 upregulates AVIC inflammatory activity via activation of the TLR-PKR-NF-κB pathway and that Klotho is potent to suppress AVIC inflammatory responses to a soluble ECM protein through inhibiting PKR. These novel findings indicate that soluble matrilin-2 may accelerate the progression of CAVD by inducing valvular inflammation and that Klotho has the potential to suppress valvular inflammation.
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Affiliation(s)
| | | | | | | | | | | | - Xianzhong Meng
- Correspondence: ; Tel.: +1-303-724-6303; Fax: +1-303-724-6330
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14
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Cardoso-Saldaña G, Fragoso JM, Lale-Farjat S, Torres-Tamayo M, Posadas-Romero C, Vargas-Alarcón G, Posadas-Sánchez R. The rs10455872-G allele of the LPA gene is associated with high lipoprotein(a) levels and increased aortic valve calcium in a Mexican adult population. Genet Mol Biol 2019; 42:519-525. [PMID: 31188921 PMCID: PMC6905440 DOI: 10.1590/1678-4685-gmb-2017-0371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 11/28/2018] [Indexed: 11/22/2022] Open
Abstract
Polymorphisms in the LPA gene have been associated with aortic
valve calcification (AVC). There are wide differences in the allelic
frequencies, Lp(a) levels, and the association with AVC among ethnic groups. The
aim of this study was to determine the association of the LPA
gene polymorphisms with Lp(a) levels and risk of developing AVC, in
Mexican-Mestizos population. Six LPA polymorphisms (rs10455872,
rs7765803, rs6907156, rs1321195, rs12212807 and rs6919346) were genotyped by
TaqMan assays in 1,265 individuals without premature coronary artery disease.
The presence of AVC was determined by computed tomography. The association of
the LPA polymorphisms with AVC, Lp(a), and other cardiovascular
risk factors (CVRF) was evaluated using logistic regression analysis. Compared
to AA genotype, subjects with AG+GG genotypes had high prevalence of Lp(a) ≥ 30
mg/dL (7.1% vs. 23.7%, p<0.001) and AVC (19.0% vs. 29.4%,
p=0.007). In a model adjusted for several CVRF, the
LPA rs10455872-G allele was associated with high Lp(a)
levels and AVC. Carriers of G allele had a high risk of Lp(a) ≥ 30 mg/dL (OR=
3.86, CI 95%: 2.2 - 6.7, p=0.001) and AVC (OR= 2.54, CI 95%:
1.56 - 4.14, p=0.001), independently of other CVRF. In this
population, carriers of rs10455872-G allele had 3.86 and 2.54 higher risk of
Lp(a) ≥ 30 mg/dL or presence of AVC, respectively.
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Affiliation(s)
- Guillermo Cardoso-Saldaña
- Department of Endocrinology, Instituto Nacional de Cardiología - Ignacio Chávez, México City, México
| | - José Manuel Fragoso
- Department of Molecular Biology, Instituto Nacional de Cardiología - Ignacio Chávez, México City, México
| | - Shamar Lale-Farjat
- Department of Endocrinology, Instituto Nacional de Cardiología - Ignacio Chávez, México City, México
| | - Margarita Torres-Tamayo
- Department of Endocrinology, Instituto Nacional de Cardiología - Ignacio Chávez, México City, México
| | - Carlos Posadas-Romero
- Department of Endocrinology, Instituto Nacional de Cardiología - Ignacio Chávez, México City, México
| | - Gilberto Vargas-Alarcón
- Department of Molecular Biology, Instituto Nacional de Cardiología - Ignacio Chávez, México City, México
| | - Rosalinda Posadas-Sánchez
- Department of Endocrinology, Instituto Nacional de Cardiología - Ignacio Chávez, México City, México
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15
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Tada H, Takamura M, Kawashiri MA. Lipoprotein(a) as an Old and New Causal Risk Factor of Atherosclerotic Cardiovascular Disease. J Atheroscler Thromb 2019; 26:583-591. [PMID: 31061262 PMCID: PMC6629747 DOI: 10.5551/jat.rv17034] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 04/02/2019] [Indexed: 12/16/2022] Open
Abstract
Lipoprotein(a) [Lp(a)], discovered in 1963, has been associated with atherosclerotic cardiovascular disease (ASCVD) independent of other traditional risk factors, including LDL cholesterol. Lp(a) is an apolipoprotein B (apoB)-containing lipoprotein, which contains an LDL-like particle. Unlike LDL, which is a primary therapeutic target to decrease ASCVD, current guidelines recommend measuring Lp(a) for risk assessments because there is no clear evidence demonstrating the clinical benefit of decreasing Lp(a) using classical drugs such as niacin. However, recent Mendelian randomization studies indicate that Lp(a) causally correlates with ASCVD. In addition, novel drugs, including PCSK9 inhibitors, as well as antisense oligonucleotide for apo(a), have exhibited efficacy in decreasing Lp(a) substantially, invigorating a discussion whether Lp(a) could be a novel therapeutic target for further ASCVD risk reduction. This review aims to provide current understanding, and future perspectives, of Lp(a), which is currently considered a mere biomarker but may emerge as a novel therapeutic target in future clinical settings.
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Affiliation(s)
- Hayato Tada
- Department of Cardiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Masayuki Takamura
- Department of Cardiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Masa-aki Kawashiri
- Department of Cardiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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16
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Perrot N, Thériault S, Dina C, Chen HY, Boekholdt SM, Rigade S, Després AA, Poulin A, Capoulade R, Le Tourneau T, Messika-Zeitoun D, Trottier M, Tessier M, Guimond J, Nadeau M, Engert JC, Khaw KT, Wareham NJ, Dweck MR, Mathieu P, Pibarot P, Schott JJ, Thanassoulis G, Clavel MA, Bossé Y, Arsenault BJ. Genetic Variation in LPA, Calcific Aortic Valve Stenosis in Patients Undergoing Cardiac Surgery, and Familial Risk of Aortic Valve Microcalcification. JAMA Cardiol 2019; 4:620-627. [PMID: 31141105 PMCID: PMC6547086 DOI: 10.1001/jamacardio.2019.1581] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/30/2019] [Indexed: 12/24/2022]
Abstract
Importance Genetic variants at the LPA locus are associated with both calcific aortic valve stenosis (CAVS) and coronary artery disease (CAD). Whether these variants are associated with CAVS in patients with CAD vs those without CAD is unknown. Objective To study the associations of LPA variants with CAVS in a cohort of patients undergoing heart surgery and LPA with CAVS in patients with CAD vs those without CAD and to determine whether first-degree relatives of patients with CAVS and high lipoprotein(a) (Lp[a]) levels showed evidence of aortic valve microcalcification. Design, Setting, and Participants This genetic association study included patients undergoing cardiac surgery from the Genome-Wide Association Study on Calcific Aortic Valve Stenosis in Quebec (QUEBEC-CAVS) study and patients with CAD, patients without CAD, and control participants from 6 genetic association studies: the UK Biobank, the European Prospective Investigation of Cancer (EPIC)-Norfolk, and Genetic Epidemiology Research on Aging (GERA) studies and 3 French cohorts. In addition, a family study included first-degree relatives of patients with CAVS. Data were collected from January 1993 to September 2018, and analysis was completed from September 2017 to September 2018. Exposures Case-control studies. Main Outcomes and Measures Presence of CAVS according to a weighted genetic risk score based on 3 common Lp(a)-raising variants and aortic valve microcalcification, defined as the mean tissue to background ratio of 1.25 or more, measured by fluorine 18-labeled sodium fluoride positron emission tomography/computed tomography. Results This study included 1009 individuals undergoing cardiac surgery and 1017 control participants in the QUEBEC-CAVS cohort; 3258 individuals with CAVS and CAD, 41 100 controls with CAD, 2069 individuals with CAVS without CAD, and 380 075 control participants without CAD in the UK Biobank, EPIC-Norfolk, and GERA studies and 3 French cohorts combined; and 33 first-degree relatives of 17 patients with CAVS and high Lp(a) levels (≥60 mg/dL) and 23 control participants with normal Lp(a) levels (<60 mg/dL). In the QUEBEC-CAVS study, each SD increase of the genetic risk score was associated with a higher risk of CAVS (odds ratio [OR], 1.35 [95% CI, 1.10-1.66]; P = .003). Each SD increase of the genetic risk score was associated with a higher risk of CAVS in patients with CAD (OR, 1.30 [95% CI, 1.20-1.42]; P < .001) and without CAD (OR, 1.33 [95% CI, 1.14-1.55]; P < .001). The percentage of individuals with a tissue to background ratio of 1.25 or more or CAVS was higher in first-degree relatives of patients with CAVS and high Lp(a) (16 of 33 [49%]) than control participants (3 of 23 [13%]; P = .006). Conclusions and Relevance In this study, a genetically elevated Lp(a) level was associated with CAVS independently of the presence of CAD. These findings support further research on the potential usefulness of Lp(a) cascade screening in CAVS.
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Affiliation(s)
- Nicolas Perrot
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Sébastien Thériault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Molecular Biology, Medical Biochemistry and Pathology, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Christian Dina
- L'Institut du Thorax, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Université de Nantes, Nantes, France
| | - Hao Yu Chen
- McGill University Health Center Research Institute, Montreal, Québec, Canada
| | | | - Sidwell Rigade
- L'Institut du Thorax, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Université de Nantes, Nantes, France
| | - Audrey-Anne Després
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Anthony Poulin
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
| | - Romain Capoulade
- L'Institut du Thorax, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Université de Nantes, Nantes, France
| | - Thierry Le Tourneau
- L'Institut du Thorax, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Université de Nantes, Nantes, France
| | - David Messika-Zeitoun
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mikaël Trottier
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
| | - Michel Tessier
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
| | - Jean Guimond
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
| | - Maxime Nadeau
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
| | - James C Engert
- McGill University Health Center Research Institute, Montreal, Québec, Canada
| | - Kay-Tee Khaw
- Medical Research Council Epidemiology Unit, Cambridge, United Kingdom
| | - Nicholas J Wareham
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom
| | - Patrick Mathieu
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Surgery, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Philippe Pibarot
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Jean-Jacques Schott
- L'Institut du Thorax, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Université de Nantes, Nantes, France
| | - George Thanassoulis
- McGill University Health Center Research Institute, Montreal, Québec, Canada
| | - Marie-Annick Clavel
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Yohan Bossé
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Molecular Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Benoit J Arsenault
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
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17
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Mathieu P, Boulanger MC. Autotaxin and Lipoprotein Metabolism in Calcific Aortic Valve Disease. Front Cardiovasc Med 2019; 6:18. [PMID: 30881959 PMCID: PMC6405425 DOI: 10.3389/fcvm.2019.00018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/12/2019] [Indexed: 02/06/2023] Open
Abstract
Calcific aortic valve disease (CAVD) is a complex trait disorder characterized by calcific remodeling of leaflets. Genome-wide association (GWA) study and Mendelian randomization (MR) have highlighted that LPA, which encodes for apolipoprotein(a) [apo(a)], is causally associated with CAVD. Apo(a) is the protein component of Lp(a), a LDL-like particle, which transports oxidized phospholipids (OxPLs). Autotaxin (ATX), which is encoded by ENPP2, is a member of the ecto-nucleotidase family of enzymes, which is, however, a lysophospholipase. As such, ATX converts phospholipids into lysophosphatidic acid (LysoPA), a metabolite with potent and diverse biological properties. Studies have recently underlined that ATX is enriched in the Lp(a) lipid fraction. Functional experiments and data obtained in mouse models suggest that ATX mediates inflammation and mineralization of the aortic valve. Recent findings also indicate that epigenetically-driven processes lower the expression of phospholipid phosphatase 3 (PLPP3) and increased LysoPA signaling and inflammation in the aortic valve during CAVD. These recent data thus provide novel insights about how lipoproteins mediate the development of CAVD. Herein, we review the implication of lipoproteins in CAVD and examine the role of ATX in promoting the osteogenic transition of valve interstitial cells (VICs).
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Affiliation(s)
- Patrick Mathieu
- Laboratory of Cardiovascular Pathobiology, Department of Surgery, Research Center, Quebec Heart and Lung Institute, Laval University, Quebec, QC, Canada
| | - Marie-Chloé Boulanger
- Laboratory of Cardiovascular Pathobiology, Department of Surgery, Research Center, Quebec Heart and Lung Institute, Laval University, Quebec, QC, Canada
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18
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Rostagno C. Heart valve disease in elderly. World J Cardiol 2019; 11:71-83. [PMID: 30820277 PMCID: PMC6391621 DOI: 10.4330/wjc.v11.i2.71] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/13/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
The incidence of heart valve disease increases significantly with age. Degenerative abnormalities associated with severe aortic stenosis and mitral and tricuspid regurgitation are found in not less than 10% of the population aged ≥ 75 years. Surgical treatment has been considered for years to be the treatment of choice. However, it was not uncommonly associated with high perioperative morbidity and mortality due to frequent comorbidities and overall frailty conditions of these patients. Conventional risk scores such as Society of Thoracic Surgeons and European System for Cardiac Operative Risk Evaluation may underestimate the risk of surgery in elderly patients, leading to inappropriate surgical indication. On the other hand, at least 30% of patients with severe conditions are left untreated due to prohibitive surgical risk. Interventional procedures, which are in continuous development, may be actually considered for high risk patients and, as recent results suggest, also for intermediate risk patients.
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Affiliation(s)
- Carlo Rostagno
- Department of Internal Medicine, University of Florence, Florence 50134, Italy
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19
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Brown AR, Green JM, Moreman J, Gunnarsson LM, Mourabit S, Ball J, Winter MJ, Trznadel M, Correia A, Hacker C, Perry A, Wood ME, Hetheridge MJ, Currie RA, Tyler CR. Cardiovascular Effects and Molecular Mechanisms of Bisphenol A and Its Metabolite MBP in Zebrafish. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2019; 53:463-474. [PMID: 30520632 PMCID: PMC6333396 DOI: 10.1021/acs.est.8b04281] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/12/2018] [Accepted: 12/06/2018] [Indexed: 05/03/2023]
Abstract
The plastic monomer bisphenol A (BPA) is one of the highest production volume chemicals in the world and is frequently detected in wildlife and humans, particularly children. BPA has been associated with numerous adverse health outcomes relating to its estrogenic and other hormonal properties, but direct causal links are unclear in humans and animal models. Here we simulated measured (1×) and predicted worst-case (10× ) maximum fetal exposures for BPA, or equivalent concentrations of its metabolite MBP, using fluorescent reporter embryo-larval zebrafish, capable of quantifying Estrogen Response Element (ERE) activation throughout the body. Heart valves were primary sites for ERE activation by BPA and MBP, and transcriptomic analysis of microdissected heart tissues showed that both chemicals targeted several molecular pathways constituting biomarkers for calcific aortic valve disease (CAVD), including extra-cellular matrix (ECM) alteration. ECM collagen deficiency and impact on heart valve structural integrity were confirmed by histopathology for high-level MBP exposure, and structural defects (abnormal curvature) of the atrio-ventricular valves corresponded with impaired cardiovascular function (reduced ventricular beat rate and blood flow). Our results are the first to demonstrate plausible mechanistic links between ERE activation in the heart valves by BPA's reactive metabolite MBP and the development of valvular-cardiovascular disease states.
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Affiliation(s)
- A. Ross Brown
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Jon M. Green
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - John Moreman
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Lina M. Gunnarsson
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Sulayman Mourabit
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Jonathan Ball
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Matthew J. Winter
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Maciej Trznadel
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Ana Correia
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Christian Hacker
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Alexis Perry
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Mark E. Wood
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Malcolm J. Hetheridge
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
| | - Richard A. Currie
- Jealott’s
Hill International Research Centre, Syngenta, Bracknell, Berkshire RG42
6EY, U.K.
| | - Charles R. Tyler
- Biosciences,
College of Life and Environmental Sciences, University of Exeter, Geoffrey Pope, Stocker Road, Exeter, Devon EX4 4QD, U.K.
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20
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A transcriptome-wide association study identifies PALMD as a susceptibility gene for calcific aortic valve stenosis. Nat Commun 2018; 9:988. [PMID: 29511167 PMCID: PMC5840407 DOI: 10.1038/s41467-018-03260-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/31/2018] [Indexed: 12/21/2022] Open
Abstract
Calcific aortic valve stenosis (CAVS) is a common and life-threatening heart disease and the current treatment options cannot stop or delay its progression. A GWAS on 1009 cases and 1017 ethnically matched controls was combined with a large-scale eQTL mapping study of human aortic valve tissues (n = 233) to identify susceptibility genes for CAVS. Replication was performed in the UK Biobank, including 1391 cases and 352,195 controls. A transcriptome-wide association study (TWAS) reveals PALMD (palmdelphin) as significantly associated with CAVS. The CAVS risk alleles and increasing disease severity are both associated with decreased mRNA expression levels of PALMD in valve tissues. The top variant identified shows a similar effect and strong association with CAVS (P = 1.53 × 10−10) in UK Biobank. The identification of PALMD as a susceptibility gene for CAVS provides insights into the genetic nature of this disease, opens avenues to investigate its etiology and to develop much-needed therapeutic options. Progressive remodeling and calcification of the aortic valve leads to calcific aortic valve stenosis (CAVS) and, ultimately, heart failure. In a combined GWAS and TWAS approach, Thériault et al. identify PALMD as a candidate causal gene for CAVS, which is further supported by Mendelian randomization.
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21
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Sengeløv M, Cheng S, Biering-Sørensen T, Matsushita K, Konety S, Solomon SD, Folsom AR, Shah AM. Ideal Cardiovascular Health and the Prevalence and Severity of Aortic Stenosis in Elderly Patients. J Am Heart Assoc 2018; 7:JAHA.117.007234. [PMID: 29431107 PMCID: PMC5850241 DOI: 10.1161/jaha.117.007234] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background The relationship between ideal cardiovascular health reflected in the cardiovascular health score (CVHS) and valvular heart disease is not known. The purpose of this study was to determine the association of CVHS attainment through midlife to late life with aortic stenosis prevalence and severity in late life. Methods and Results The following 6 ideal cardiovascular health metrics were assessed in ARIC (Atherosclerosis Risk in Communities) Study participants at 5 examination visits between 1987 and 2013 (visits 1–4 in 1987–1998 and visit 5 in 2011–2013): smoking, body mass index, total cholesterol, blood pressure, physical activity, and blood glucose. Percentage attained CVHS was calculated in 6034 participants as the sum of CVHS at each visit/the maximum possible score. Aortic stenosis was assessed by echocardiography at visit 5 on the basis of the peak aortic valve velocity. Aortic stenosis was categorized sclerosis, mild stenosis, and moderate‐to‐severe stenosis. Mean age was 76±5 years, 42% were men, and 22% were black. Mean percentage attained CVHS was 63±14%, and the prevalence of aortic stenosis stages were 15.9% for sclerosis, 4.3% for mild stenosis, and 0.7% for moderate‐to‐severe stenosis. Worse percentage attained CVHS was associated with higher prevalence of aortic sclerosis (P<0.001 for trend), mild stenosis (P<0.001), and moderate‐to‐severe stenosis (P=0.002), adjusting for age, sex, and race. Conclusions Greater attainment of ideal cardiovascular health in midlife to late life is associated with a lower prevalence of aortic sclerosis and stenosis in late life in a large cohort of older adults.
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Affiliation(s)
- Morten Sengeløv
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Susan Cheng
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Suma Konety
- Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Aaron R Folsom
- Division of Epidemiology and Community Health, and School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
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22
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Lurins J, Lurina D, Tretjakovs P, Mackevics V, Lejnieks A, Rapisarda V, Baylon V. Increased serum chemerin level to predict early onset of aortic valve stenosis. Biomed Rep 2017; 8:31-36. [PMID: 29387388 PMCID: PMC5768061 DOI: 10.3892/br.2017.1010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/23/2017] [Indexed: 11/29/2022] Open
Abstract
Inflammation appears to be the cause of aortic valve (AoV) stenosis and identification of predictive biomarkers is therefore imperative. The aim of the current study was to evaluate the potential role of serum chemerin and fibroblast growth factor-21 (FGF-21) in the pathogenesis of the disease. A total of 102 patients were selected based on certain criteria and divided into an aortic stenosis group and a control group. Patients with AoV stenosis were subdivided into three groups depending on the severity according to the echocardiography criteria: Aortic jet velocity, Vmax (m/sec); mean pressure gradient, PG (mmHg); aortic valve area (AVA), cm2; and indexed AVA, cm2/m2. Patients were graded as: Severe: Vmax >4 m/sec, PG >40 mmHg, AVA <1.0 cm2, indexed AVA <0.6; moderate: Vmax 3.0–4.0 m/sec, PG 20–40 mmHg, AVA 1.0–1.5 cm2, indexed AVA 0.60–0.85; mild: Vmax 2.5–2.9 m/sec, PG <20 mmHg, AVA >1.5 cm2, indexed AVA >0.85. ELISA was used for the detection of chemerin and FGF-21. Post-hoc analysis with Tukey's correction was performed. The highest chemerin levels were found in mild and moderate AoV stenosis and decreased along with the grade of severity, compared with the control group. The FGF-21 level was increased in all the stenosis groups, reaching the highest level at severe stenosis. Receiver-operating characteristic analysis of chemerin in all the AoV stenosis groups without grading the severity included, area under the curve (AUC)=0.76; 0.70–0.80= fair; P<0.001 and for mild AoV stenosis was AUC=0.82; 0.80–0.90= good; P<0.001. In conclusion, chemerin is a good diagnostic biomarker for mild AoV stenosis, while FGF-21 is a moderate diagnostic marker.
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Affiliation(s)
- Juris Lurins
- Department of Doctoral Studies, Riga Stradins University, Riga, LV 1007, Latvia
| | - Dace Lurina
- Zemgale Health Centre, Jelgava, LV 3001, Latvia
| | - Peteris Tretjakovs
- Faculty of Medicine, Department of Human Physiology and Biochemistry, Riga Stradins University, Riga, LV 1007, Latvia
| | - Vitolds Mackevics
- Faculty of Medicine, Department of Internal Diseases, Riga Stradins University, Riga, LV 1002, Latvia
| | - Aivars Lejnieks
- Faculty of Medicine, Department of Internal Diseases, Riga Stradins University, Riga, LV 1002, Latvia
| | - Venerando Rapisarda
- Department of Clinical and Experimental Medicine, Occupational Medicine, University Hospital 'Policlinico-Vittorio Emanuele', University of Catania, I-95123 Catania, Italy
| | - Vincenzo Baylon
- Newton Lewis Institute-ISR - Life Science Park, San Gwann 3000, Malta
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23
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Coronary Artery Disease Affects Symptomatology of Aortic Valve Stenosis. J Am Coll Cardiol 2017; 70:1103-1104. [DOI: 10.1016/j.jacc.2017.04.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 04/11/2017] [Indexed: 11/15/2022]
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24
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Izquierdo-Gómez MM, Hernández-Betancor I, García-Niebla J, Marí-López B, Laynez-Cerdeña I, Lacalzada-Almeida J. Valve Calcification in Aortic Stenosis: Etiology and Diagnostic Imaging Techniques. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5178631. [PMID: 28812017 PMCID: PMC5546080 DOI: 10.1155/2017/5178631] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 06/20/2017] [Indexed: 12/30/2022]
Abstract
Aortic stenosis is the most common valvulopathy in the Western world. Its prevalence has increased significantly in recent years due to population aging; hence, up to 8% of westerners above the age of 84 now have severe aortic stenosis (Lindroos et al., 1993). This causes increased morbidity and mortality and therein lies the importance of adequate diagnosis and stratification of the degree of severity which allows planning the best therapeutic option in each case. Long understood as a passive age-related degenerative process, it is now considered a rather more complex entity involving mechanisms and factors similar to those of atherosclerosis (Stewart et al., 1997). In this review, we summarize the pathophysiological mechanisms underlying the onset and progression of the disease and analyze the current role of cardiac imaging techniques for diagnosis.
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Affiliation(s)
| | | | - Javier García-Niebla
- Servicios Sanitarios del Área de Salud de El Hierro, Valle del Golfo Health Center, El Hierro, Spain
| | - Belén Marí-López
- Department of Cardiology, Hospital Universitario de Canarias, Tenerife, Spain
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25
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Abstract
Calcific aortic stenosis (AS) is the most prevalent heart valve disorder in developed countries. It is characterized by progressive fibro-calcific remodelling and thickening of the aortic valve leaflets that, over years, evolve to cause severe obstruction to cardiac outflow. In developed countries, AS is the third-most frequent cardiovascular disease after coronary artery disease and systemic arterial hypertension, with a prevalence of 0.4% in the general population and 1.7% in the population >65 years old. Congenital abnormality (bicuspid valve) and older age are powerful risk factors for calcific AS. Metabolic syndrome and an elevated plasma level of lipoprotein(a) have also been associated with increased risk of calcific AS. The pathobiology of calcific AS is complex and involves genetic factors, lipoprotein deposition and oxidation, chronic inflammation, osteoblastic transition of cardiac valve interstitial cells and active leaflet calcification. Although no pharmacotherapy has proved to be effective in reducing the progression of AS, promising therapeutic targets include lipoprotein(a), the renin-angiotensin system, receptor activator of NF-κB ligand (RANKL; also known as TNFSF11) and ectonucleotidases. Currently, aortic valve replacement (AVR) remains the only effective treatment for severe AS. The diagnosis and staging of AS are based on the assessment of stenosis severity and left ventricular systolic function by Doppler echocardiography, and the presence of symptoms. The introduction of transcatheter AVR in the past decade has been a transformative therapeutic innovation for patients at high or prohibitive risk for surgical valve replacement, and this new technology might extend to lower-risk patients in the near future.
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Affiliation(s)
- Brian R Lindman
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marie-Annick Clavel
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
| | - Patrick Mathieu
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
| | - Bernard Iung
- Cardiology Department, AP-HP, Bichat Hospital, Paris, France
- Paris-Diderot University, DHU Fire, Paris, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic and CHU Sart Tilman, Liège, Belgium
- Grupo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - Catherine M Otto
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, USA
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada
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26
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Abstract
Calcified aortic stenosis is one of the most common causes of heart failure in the elderly. Current guidelines recommend aortic valve replacement in patients with severe disease and evidence of decompensation based on either symptoms or impaired systolic ejection fraction. However, symptoms are often subjective whilst impaired ejection fraction is not a sensitive marker of ventricular decompensation. Interest has surrounded the use of cardiac biochemical markers as objective measures of left ventricular decompensation in aortic stenosis. We will first examine mechanisms of release of biochemical markers associated with myocardial wall stress (BNP/NT-proBNP), myocardial fibrosis (markers of collagen metabolism, galectin-3, soluble ST2) and myocyte death/myocardial ischemia (high-sensitivity cardiac troponins, heart-type fatty acid binding protein, myosin-binding protein C); and discuss future directions of these markers.
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Affiliation(s)
- Calvin W L Chin
- a Department of Cardiovascular Medicine , National Heart Center Singapore , Singapore .,b Duke-NUS Graduate Medical School , Singapore
| | - Andie H Djohan
- c Barts and the London School of Medicine & Dentistry, Queen Mary, University of London , London , UK , and
| | - Chim C Lang
- d Division of Cardiovascular and Diabetes Medicine , University of Dundee , Dundee , UK
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27
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Cells and extracellular matrix interplay in cardiac valve disease: because age matters. Basic Res Cardiol 2016; 111:16. [PMID: 26830603 DOI: 10.1007/s00395-016-0534-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/27/2015] [Accepted: 01/19/2016] [Indexed: 12/18/2022]
Abstract
Cardiovascular aging is a physiological process affecting all components of the heart. Despite the interest and experimental effort lavished on aging of cardiac cells, increasing evidence is pointing at the pivotal role of extracellular matrix (ECM) in cardiac aging. Structural and molecular changes in ECM composition during aging are at the root of significant functional modifications at the level of cardiac valve apparatus. Indeed, calcification or myxomatous degeneration of cardiac valves and their functional impairment can all be explained in light of age-related ECM alterations and the reciprocal interplay between altered ECM and cellular elements populating the leaflet, namely valvular interstitial cells and valvular endothelial cells, is additionally affecting valve function with striking reflexes on the clinical scenario. The initial experimental findings on this argument are underlining the need for a more comprehensive understanding on the biological mechanisms underlying ECM aging and remodeling as potentially constituting a pharmacological therapeutic target or a basis to improve existing prosthetic devices and treatment options. Given the lack of systematic knowledge on this topic, this review will focus on the ECM changes that occur during aging and on their clinical translational relevance and implications in the bedside scenario.
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28
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White MP, Theodoris CV, Liu L, Collins WJ, Blue KW, Lee JH, Meng X, Robbins RC, Ivey KN, Srivastava D. NOTCH1 regulates matrix gla protein and calcification gene networks in human valve endothelium. J Mol Cell Cardiol 2015; 84:13-23. [PMID: 25871831 PMCID: PMC4468000 DOI: 10.1016/j.yjmcc.2015.04.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 04/02/2015] [Accepted: 04/07/2015] [Indexed: 01/07/2023]
Abstract
Valvular and vascular calcification are common causes of cardiovascular morbidity and mortality. Developing effective treatments requires understanding the molecular underpinnings of these processes. Shear stress is thought to play a role in inhibiting calcification. Furthermore, NOTCH1 regulates vascular and valvular endothelium, and human mutations in NOTCH1 can cause calcific aortic valve disease. Here, we determined the genome-wide impact of altering shear stress and NOTCH signaling on human aortic valve endothelium. mRNA-sequencing of primary human aortic valve endothelial cells (HAVECs) with or without knockdown of NOTCH1, in the presence or absence of shear stress, revealed NOTCH1-dependency of the atherosclerosis-related gene connexin 40 (GJA5), and numerous repressors of endochondral ossification. Among these, matrix gla protein (MGP) is highly expressed in aortic valve and vasculature, and inhibits soft tissue calcification by sequestering bone morphogenetic proteins (BMPs). Altering NOTCH1 levels affected MGP mRNA and protein in HAVECs. Furthermore, shear stress activated NOTCH signaling and MGP in a NOTCH1-dependent manner. NOTCH1 positively regulated endothelial MGP in vivo through specific binding motifs upstream of MGP. Our studies suggest that shear stress activates NOTCH1 in primary human aortic valve endothelial cells leading to downregulation of osteoblast-like gene networks that play a role in tissue calcification.
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Affiliation(s)
- Mark P White
- Gladstone Institute of Cardiovascular Disease and University of California, San Francisco, USA
| | - Christina V Theodoris
- Gladstone Institute of Cardiovascular Disease and University of California, San Francisco, USA
| | - Lei Liu
- Gladstone Institute of Cardiovascular Disease and University of California, San Francisco, USA
| | - William J Collins
- Gladstone Institute of Cardiovascular Disease and University of California, San Francisco, USA
| | - Kathleen W Blue
- Gladstone Institute of Cardiovascular Disease and University of California, San Francisco, USA
| | - Joon Ho Lee
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Xianzhong Meng
- University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Robert C Robbins
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Kathryn N Ivey
- Gladstone Institute of Cardiovascular Disease and University of California, San Francisco, USA
| | - Deepak Srivastava
- Gladstone Institute of Cardiovascular Disease and University of California, San Francisco, USA.
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29
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Mathieu P, Bossé Y, Huggins GS, Della Corte A, Pibarot P, Michelena HI, Limongelli G, Boulanger MC, Evangelista A, Bédard E, Citro R, Body SC, Nemer M, Schoen FJ. The pathology and pathobiology of bicuspid aortic valve: State of the art and novel research perspectives. JOURNAL OF PATHOLOGY CLINICAL RESEARCH 2015; 1:195-206. [PMID: 27499904 PMCID: PMC4939890 DOI: 10.1002/cjp2.21] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 03/25/2015] [Indexed: 12/12/2022]
Abstract
Bicuspid aortic valve is the most prevalent cardiac valvular malformation. It is associated with a high rate of long‐term morbidity including development of calcific aortic valve disease, aortic regurgitation and concomitant thoracic aortic aneurysm and dissection. Recently, basic and translational studies have identified some key processes involved in the development of bicuspid aortic valve and its morbidity. The development of aortic valve disease and thoracic aortic aneurysm and dissection is the result of complex interactions between genotypes, environmental risk factors and specific haemodynamic conditions created by bicuspid aortic valve anatomy. Herein, we review the pathobiology of bicuspid aortic valve with a special emphasis on translational aspects of these basic findings. Important but unresolved problems in the pathology of bicuspid aortic valve and thoracic aortic aneurysm and dissection are discussed, along with the molecular processes involved.
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Affiliation(s)
- Patrick Mathieu
- Laboratoire d'Études Moléculaires des Valvulopathies (LEMV), Groupe de Recherche en Valvulopathies (GRV), Department of Surgery Quebec Heart and Lung Institute/Research Center, Laval University Quebec Canada
| | - Yohan Bossé
- Department of Molecular Medicine, Quebec Heart and Lung Institute/Research Center Laval University Québec Canada
| | - Gordon S Huggins
- Molecular Cardiology Research Institute Center for Translational Genomics, Tufts Medical Center Boston Massachussetts USA
| | - Alessandro Della Corte
- Department of Cardiothoracic Sciences, Cardiac Surgery Second University of Naples 80131 Naples Italy
| | - Philippe Pibarot
- Department of Molecular Medicine, Quebec Heart and Lung Institute/Research Center Laval University Québec Canada
| | - Hector I Michelena
- Division of Cardiovascular Diseases, Mayo Clinic Rochester Minnesota USA
| | - Giuseppe Limongelli
- Department of Cardiology and Cardiothoracic and Respiratory Sciences, Cardiologia SUN, Monaldi Hospital, AO Colli Naples Italy
| | - Marie-Chloé Boulanger
- Laboratoire d'Études Moléculaires des Valvulopathies (LEMV), Groupe de Recherche en Valvulopathies (GRV), Department of Surgery Quebec Heart and Lung Institute/Research Center, Laval University Quebec Canada
| | - Arturo Evangelista
- Department of Cardiology Hospital Universitary Vall d'Hebron Barcelona Spain
| | - Elisabeth Bédard
- Department of Molecular Medicine, Quebec Heart and Lung Institute/Research Center Laval University Québec Canada
| | - Rodolfo Citro
- Heart Department University Hospital "San Giovanni di Dio e Ruggi d'Aragona" Salerno Italy
| | - Simon C Body
- Department of Anesthesiology, Perioperative and Pain Medicine Center for Perioperative Genomics, Brigham and Women's Hospital Boston Massachusetts USA
| | - Mona Nemer
- Laboratory for Cardiac Development and Differentiation University of Ottawa Ontario Canada
| | - Frederick J Schoen
- Department of Pathology Brigham and Women's Hospital, Harvard Medical School USA
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30
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Latif N, Sarathchandra P, Chester AH, Yacoub MH. Expression of smooth muscle cell markers and co-activators in calcified aortic valves. Eur Heart J 2015; 36:1335-45. [PMID: 24419809 DOI: 10.1093/eurheartj/eht547] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 10/24/2013] [Indexed: 01/06/2023] Open
Abstract
AIMS Similar risk factors and mediators are involved in calcific aortic stenosis (CAS) and atherosclerosis. Since normal valves harbour a low percentage of smooth muscle cells (SMCs), we hypothesize that the SMC phenotype participates in the pathogenesis of CAS. METHOD AND RESULTS We analysed 12 normal and 22 calcified aortic valves for SMC markers and the expression of co-activators of SMC gene expression, myocardin and myocardin-related transcription factors (MRTF-A/B). Transforming growth factor β (TGFβ1) was used to upregulate SMC markers and co-activators in valve interstitial cells (VICs) and transmission electron microscopy (TEM) was used to detect the presence of SMC in atypical regions of the valve leaflets. Smooth muscle cell markers and co-activators, myocardin, MRTF-A, and MRTF-B, demonstrated an increased incidence and aberrant expression around calcified nodules in all 22 calcified valves as well as in surface and microvessel endothelial cells. Smooth muscle cell markers and MRTF-A were significantly increased in calcified valves. Transforming growth factor β1 (TGFβ1) (10 ng/mL) was able to significantly upregulate the expression of some SMC markers and MRTF-A in VICs. Transmission electron microscopy of the fibrosa layer of calcified valves demonstrated the presence of bundles of SMCs and smooth muscle-derived foam cells. CONCLUSION Smooth muscle cell markers and co-activators, myocardin and MRTFs, were aberrantly expressed in calcified valves. Transforming growth factor β1 was able to significantly upregulate SMC markers and MRTF-A in VICs. Transmission electron microscopy unequivocally identified the presence of SMCs in calcified regions of valve leaflets. These findings provide evidence that the SMC phenotype plays a role in the development of CAS.
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Affiliation(s)
- Najma Latif
- Heart Science Centre, Imperial College, Harefield Hospital, Harefield, Middlesex UB9 6JH, UK QCRC, Qatar Cardiovascular Research Centre, Qatar Foundation, Qatar
| | - Padmini Sarathchandra
- Heart Science Centre, Imperial College, Harefield Hospital, Harefield, Middlesex UB9 6JH, UK QCRC, Qatar Cardiovascular Research Centre, Qatar Foundation, Qatar
| | - Adrian H Chester
- Heart Science Centre, Imperial College, Harefield Hospital, Harefield, Middlesex UB9 6JH, UK QCRC, Qatar Cardiovascular Research Centre, Qatar Foundation, Qatar
| | - Magdi H Yacoub
- Heart Science Centre, Imperial College, Harefield Hospital, Harefield, Middlesex UB9 6JH, UK QCRC, Qatar Cardiovascular Research Centre, Qatar Foundation, Qatar
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Czarny MJ, Resar JR. Diagnosis and management of valvular aortic stenosis. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2014; 8:15-24. [PMID: 25368539 PMCID: PMC4213201 DOI: 10.4137/cmc.s15716] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/03/2014] [Accepted: 06/10/2014] [Indexed: 01/03/2023]
Abstract
Valvular aortic stenosis (AS) is a progressive disease that affects 2% of the population aged 65 years or older. The major cause of valvular AS in adults is calcification and fibrosis of a previously normal tricuspid valve or a congenital bicuspid valve, with rheumatic AS being rare in the United States. Once established, the rate of progression of valvular AS is quite variable and impossible to predict for any particular patient. Symptoms of AS are generally insidious at onset, though development of any of the three cardinal symptoms of angina, syncope, or heart failure portends a poor prognosis. Management of symptomatic AS remains primarily surgical, though transcatheter aortic valve replacement (TAVR) is becoming an accepted alternative to surgical aortic valve replacement (SAVR) for patients at high or prohibitive operative risk.
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Affiliation(s)
- Matthew J Czarny
- Cardiology Division, Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jon R Resar
- Cardiology Division, Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
Background—
Although a previous study has suggested that a genetic variant in the
LPA
region was associated with the presence of aortic valve stenosis (AVS), no prospective study has suggested a role for lipoprotein(a) levels in the pathophysiology of AVS. Our objective was to determine whether lipoprotein(a) levels and a common genetic variant that is strongly associated with lipoprotein(a) levels are associated with an increased risk of developing AVS.
Methods and Results—
Serum lipoprotein(a) levels were measured in 17 553 participants of the European Prospective Investigation into Cancer (EPIC)-Norfolk study. Among these study participants, 118 developed AVS during a mean follow-up of 11.7 years. The rs10455872 genetic variant in
LPA
was genotyped in 14 735 study participants, who simultaneously had lipoprotein(a) level measurements, and in a replication study of 379 patients with echocardiography-confirmed AVS and 404 controls. In EPIC-Norfolk, compared with participants in the bottom lipoprotein(a) tertile, those in the top lipoprotein(a) tertile had a higher risk of AVS (hazard ratio, 1.57; 95% confidence interval, 1.02–2.42) after adjusting for age, sex, and smoking. Compared with rs10455872 AA homozygotes, carriers of 1 or 2 G alleles were at increased risk of AVS (hazard ratio, 1.78; 95% confidence interval, 1.11–2.87, versus hazard ratio, 4.83; 95% confidence interval, 1.77–13.20, respectively). In the replication study, the genetic variant rs10455872 also showed a positive association with AVS (odds ratio, 1.57; 95% confidence interval, 1.10–2.26).
Conclusions—
Patients with high lipoprotein(a) levels are at increased risk for AVS. The rs10455872 variant, which is associated with higher lipoprotein(a) levels, is also associated with increased risk of AVS, suggesting that this association may be causal.
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Honda S, Miyamoto T, Watanabe T, Narumi T, Kadowaki S, Honda Y, Otaki Y, Hasegawa H, Netsu S, Funayama A, Ishino M, Nishiyama S, Takahashi H, Arimoto T, Shishido T, Miyashita T, Kubota I. A Novel Mouse Model of Aortic Valve Stenosis Induced by Direct Wire Injury. Arterioscler Thromb Vasc Biol 2014; 34:270-8. [DOI: 10.1161/atvbaha.113.302610] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective—
The response-to-tissue-injury theory is currently the favorite paradigm to investigate valve pathology. To the best of our knowledge, there are currently no in vivo valve injury models. There are few calcific aortic valve stenosis (AVS) models that develop hemodynamically significant stenosis. Here, we investigated the effect of direct mechanical injury on aortic valves in vivo and developed a novel mouse model of calcific AVS.
Approach and Results—
Aortic valve injury was created by inserting and moving a spring guidewire under echocardiographic guidance into the left ventricle of male C57/BL6 mice via right common carotid artery. Serial echocardiographic measurements revealed that aortic velocity was increased 1 week after injury and persistently increased until 16 weeks after injury. AVS mice showed a higher heart weight/body weight ratio and decreased left ventricular fractioning shortening 4 weeks after injury, compared with sham mice. We found remarkable proliferation of valve leaflets 4 weeks after injury. Proliferative valves showed increased production of reactive oxygen species and expression of inflammatory cytokines and osteochondrogenic factors. Alizarin red staining showed valvular calcification 12 weeks after injury.
Conclusions—
We report a novel calcific AVS model to support the response-to-tissue-injury theory. This model may be a valuable tool for analyzing the mechanism of AVS and assessing therapeutic options.
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Affiliation(s)
- Shintaro Honda
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Takuya Miyamoto
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tetsu Watanabe
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Taro Narumi
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Shinpei Kadowaki
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Yuki Honda
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Yoichiro Otaki
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Hiromasa Hasegawa
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Shunsuke Netsu
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Akira Funayama
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Mitsunori Ishino
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Satoshi Nishiyama
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Hiroki Takahashi
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Takanori Arimoto
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Tetsuro Shishido
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Takehiko Miyashita
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
| | - Isao Kubota
- From the Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
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34
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Ellis SG, Dushman-Ellis S, Luke MM, Murugesan G, Kottke-Marchant K, Ellis GM, Griffin B, Tuzcu EM, Hazen S. Pilot candidate gene analysis of patients ≥ 60 years old with aortic stenosis involving a tricuspid aortic valve. Am J Cardiol 2012; 110:88-92. [PMID: 22483387 DOI: 10.1016/j.amjcard.2012.02.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/21/2012] [Accepted: 02/21/2012] [Indexed: 12/18/2022]
Abstract
The potential genetic basis of aortic stenosis in older people is poorly understood. A total of 265 patients with aortic stenosis involving tricuspid aortic valves and 961 controls were genotyped for ≤660 candidate single nucleotide polymorphisms (SNPs). After dividing the patients and controls into training and validation sets, we tested the correlation of the SNPs with the age-adjusted aortic valve area, determined by echocardiography or cardiac catheterization. A bootstrapped global p value of ≤0.005 was considered evidence of a possible significant correlation. The cases were aged 73 ± 7 years, and 72.7% were men. The median aortic valve area was 1.0 cm(2) (interquartile range 0.7 to 1.5). The controls were aged 69 ± 6 years, and 69.8% were men. The minor allele frequency was 21% ± 15% (37% <0.20). Three SNPs met the criteria for significant correlation (rs2276288 [MYO7A], p = 0.001; rs5194 [AGTR1], p = 0.004; rs207 307 [ELN], p = 0.005). Another 2 SNPs reached borderline significance (p ≤0.008). In conclusion, we report 3 SNPs to be associated with aortic stenosis involving tricuspid aortic valves in older subjects. Given the concerns regarding the problem of multiple statistical testing, validation studies are required to further assess these correlations.
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Alexopoulos A, Kaoukis A, Papadaki H, Pyrgakis V. Pathophysiologic mechanisms of calcific aortic stenosis. Ther Adv Cardiovasc Dis 2012; 6:71-80. [DOI: 10.1177/1753944712439337] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Calcific aortic stenosis (CAS) comprises the leading indication for valve replacement in the Western world. Until recently, progressive calcification was considered to be a passive process. Emerging evidence, however, suggests that degenerative aortic stenosis constitutes an active process involving stimulation of several pathophysiologic pathways such as inflammation and osteogenesis. In addition, CAS and atherosclerosis share common features regarding histopathology of lesions. These novel data raise a new perspective on the prevention and treatment of disease. The current article reviews the most important pathophysiologic mechanisms of senile aortic stenosis.
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Affiliation(s)
- Alexandros Alexopoulos
- Department of Cardiology, Athens General Hospital, Mesogeion Avenue, 154, 15669 Athens, Greece
| | - Andreas Kaoukis
- Department of Cardiology, General Hospital of Athens ‘G. Gennimatas’, Greece, Athens, Greece
| | - Helen Papadaki
- Department of Anatomy, School of Medicine, University of Patras, Greece, Rio, Patras, Greece
| | - Vlassios Pyrgakis
- Department of Cardiology, General Hospital of Athens ‘G. Gennimatas’, Greece, Athens, Greece
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Warnock JN, Nanduri B, Pregonero Gamez CA, Tang J, Koback D, Muir WM, Burgess SC. Gene Profiling of Aortic Valve Interstitial Cells under Elevated Pressure Conditions: Modulation of Inflammatory Gene Networks. Int J Inflam 2011; 2011:176412. [PMID: 21876831 PMCID: PMC3159021 DOI: 10.4061/2011/176412] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 06/06/2011] [Accepted: 06/16/2011] [Indexed: 11/20/2022] Open
Abstract
The study aimed to identify mechanosensitive pathways and gene networks that are stimulated by elevated cyclic pressure in aortic valve interstitial cells (VICs) and lead to detrimental tissue remodeling and/or pathogenesis. Porcine aortic valve leaflets were exposed to cyclic pressures of 80 or 120 mmHg, corresponding to diastolic transvalvular pressure in normal and hypertensive conditions, respectively. Linear, two-cycle amplification of total RNA, followed by microarray was performed for transcriptome analysis (with qRT-PCR validation). A combination of systems biology modeling and pathway analysis identified novel genes and molecular mechanisms underlying the biological response of VICs to elevated pressure. 56 gene transcripts related to inflammatory response mechanisms were differentially expressed. TNF-α, IL-1α, and IL-1β were key cytokines identified from the gene network model. Also of interest was the discovery that pentraxin 3 (PTX3) was significantly upregulated under elevated pressure conditions (41-fold change). In conclusion, a gene network model showing differentially expressed inflammatory genes and their interactions in VICs exposed to elevated pressure has been developed. This system overview has detected key molecules that could be targeted for pharmacotherapy of aortic stenosis in hypertensive patients.
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Affiliation(s)
- James N Warnock
- Department of Agricultural and Biological Engineering, Mississippi State University, Mississippi State, MS 39762, USA
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37
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Holliday CJ, Ankeny RF, Jo H, Nerem RM. Discovery of shear- and side-specific mRNAs and miRNAs in human aortic valvular endothelial cells. Am J Physiol Heart Circ Physiol 2011; 301:H856-67. [PMID: 21705672 DOI: 10.1152/ajpheart.00117.2011] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The role of endothelial cells (ECs) in aortic valve (AV) disease remains relatively unknown; however, disease preferentially occurs in the fibrosa. We hypothesized oscillatory shear (OS) present on the fibrosa stimulates ECs to modify mRNAs and microRNAs (miRNAs) inducing disease. Our goal was to identify mRNAs and miRNAs differentially regulated by OS and laminar shear (LS) in human AVECs (HAVECs) from the fibrosa (fHAVECs) and ventricularis (vHAVECs). HAVECs expressed EC markers as well as some smooth muscle cell markers and functionally aligned with the flow. HAVECs were exposed to OS and LS for 24 h, and total RNA was analyzed by mRNA and miRNA microarrays. We found over 700 and 300 mRNAs down- and upregulated, respectively, by OS; however, there was no side dependency. mRNA microarray results were validated for 26 of 28 tested genes. Ingenuity Pathway Analysis revealed thrombospondin 1 (Thbs1) and NF-κB inhibitor-α (Nfkbia) as highly connected, shear-sensitive genes. miRNA array analysis yielded 30 shear-sensitive miRNAs and 3 side-specific miRNAs. miRNA validation confirmed 4 of 17 shear-sensitive miRNAs and 1 of 3 side-dependent miRNAs. Using miRWalk and several filtering steps, we identified shear-sensitive mRNAs potentially targeted by shear-sensitive miRNAs. These genes and signaling pathways could act as therapeutic targets of AV disease.
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Affiliation(s)
- Casey J Holliday
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
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38
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Abstract
Fibrocalcific aortic stenosis (AS) results from an active process similar to atherosclerosis that involves basement membrane disruption, lipid deposition, inflammatory cell infiltration, and calcification. Consequently, 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) have been extensively studied as potential therapeutic agents capable of slowing the progression of AS. However, two randomized trials, SALTIRE and the SEAS study, showed no benefit with statin therapy for AS. These results have shed doubt over the efficacy of statin therapy for AS, although their potential efficacy at early stages of aortic valve disease remains possible. In this article, we review the pathophysiology of fibrocalcific AS and discuss future directions for its nonsurgical management in the post-SEAS era.
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Affiliation(s)
- Sammy Elmariah
- Hospital of the University of Pennsylvania, Philadelphia, 19104, USA
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39
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Ferdous Z, Jo H, Nerem RM. Differences in valvular and vascular cell responses to strain in osteogenic media. Biomaterials 2011; 32:2885-93. [PMID: 21284997 DOI: 10.1016/j.biomaterials.2011.01.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 01/12/2011] [Indexed: 10/18/2022]
Abstract
Calcification is the primary cause of failure of bioprosthetic and tissue-engineered vascular and valvular grafts. We used tissue-engineered collagen gels containing human aortic smooth muscle cells (HASMC) and human aortic valvular interstitial cells (HAVIC) as a model to investigate cell-mediated differences in early markers of calcification. The HASMCs and HAVICs were isolated from non-sclerotic human tissues. After 21 days of culture in either regular or osteogenic media with or without 10% cyclic strain at 1 Hz, the collagen gels were assessed for DNA content, collagen I, matrix metalloproteinase (MMP)-2 and glycosaminoglycan (GAG) content. The collagen gels containing HASMCs contained significantly greater amounts of collagen I and GAG compared to HAVICs. Although strain increased MMP-2 activity for both cell types, this trend was significant (p ≤ 0.05) only for HAVICs. Cultured gels were also assessed for osteogenic markers calcium content, alkaline phosphatase (ALP), and Runx2 and were present at greater amounts in gels containing HASMCs than HAVICs. Calcium content, Runx2 expression, and ALP activity were also modulated by mechanical strain. The results indicate that cell-mediated differences exist between the vascular and valvular calcification processes. Further investigation is necessary for improved understanding and to detect biomarkers for early detection or prevention of these diseases.
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Affiliation(s)
- Zannatul Ferdous
- Institute of Bioengineering and Biosciences, Georgia Institute of Technology, 315 Ferst Drive, Mail code 0363, Atlanta, GA 30332, USA.
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40
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Gerdts E, Rossebø AB, Pedersen TR, Boman K, Brudi P, Chambers JB, Egstrup K, Gohlke-Bärwolf C, Holme I, Kesäniemi YA, Malbecq W, Nienaber C, Ray S, Skjærpe T, Wachtell K, Willenheimer R. Impact of baseline severity of aortic valve stenosis on effect of intensive lipid lowering therapy (from the SEAS study). Am J Cardiol 2010; 106:1634-9. [PMID: 21094366 DOI: 10.1016/j.amjcard.2010.07.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 07/21/2010] [Accepted: 07/21/2010] [Indexed: 11/28/2022]
Abstract
Retrospective studies have suggested a beneficial effect of lipid-lowering treatment on the progression of aortic stenosis (AS) in milder stages of the disease. In the randomized, placebo-controlled Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study, 4.3 years of combined treatment with simvastatin 40 mg and ezetimibe 10 mg did not reduce aortic valve events (AVEs), while ischemic cardiovascular events (ICEs) were significantly reduced in the overall study population. However, the impact of baseline AS severity on treatment effect has not been reported. Baseline and outcomes data in 1,763 SEAS patients (mean age 67 years, 39% women) were used. The study population was divided into tertiles of baseline peak aortic jet velocity (tertile 1: ≤ 2.8 m/s; tertile 2: > 2.8 to 3.3 m/s; tertile 3: > 3.3 m/s). Treatment effect and interaction were tested in Cox regression analyses. The rates of AVEs and ICEs increased with increasing baseline severity of AS. In Cox regression analyses, higher baseline peak aortic jet velocity predicted higher rates of AVEs and ICEs in all tertiles (all p values < 0.05) and in the total study population (p < 0.001). Simvastatin-ezetimibe treatment was not associated with a statistically significant reduction in AVEs in any individual tertile. A significant quantitative interaction between the severity of AS and simvastatin-ezetimibe treatment effect was demonstrated for ICEs (p < 0.05) but not for AVEs (p = 0.10). In conclusion, the SEAS study results demonstrate a strong relation between baseline the severity of AS and the rate of cardiovascular events but no significant effect of lipid-lowering treatment on AVEs, even in the group with the mildest AS.
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Affiliation(s)
- Eva Gerdts
- Institute of Medicine, University of Bergen, Bergen, Norway.
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Cappelli S, Epistolato MC, Vianello A, Mazzone A, Glauber M, Franzini M, Ottaviano V, Pompella A, Paolicchi A, Tanganelli P. Aortic valve disease and gamma-glutamyltransferase: Accumulation in tissue and relationships with calcific degeneration. Atherosclerosis 2010; 213:385-91. [DOI: 10.1016/j.atherosclerosis.2010.08.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 07/30/2010] [Accepted: 08/13/2010] [Indexed: 01/19/2023]
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42
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Sashida Y, Rodriguez CJ, Boden-Albala B, Jin Z, Elkind MSV, Liu R, Rundek T, Sacco RL, DiTullio MR, Homma S. Ethnic differences in aortic valve thickness and related clinical factors. Am Heart J 2010; 159:698-704. [PMID: 20362732 DOI: 10.1016/j.ahj.2009.12.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Accepted: 12/14/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prior studies suggest that the causes of calcific aortic valve (AV) disease involve chronic inflammation, lipoprotein levels, and calcium metabolism, all of which may differ among race-ethnic groups. We sought to determine whether AV thickness differs by race-ethnicity in a large multiethnic population-based cohort. METHODS The Northern Manhattan Study includes stroke-free community-based Hispanic (57%), non-Hispanic black (22%), and non-Hispanic white (21%) participants. The relation between AV thickness on transthoracic echocardiography and clinical risk factors for atherosclerosis was evaluated among 2,085 participants using polytomous logistic regression models. Aortic valve thickness was graded in 3 categories (normal, mild, and moderate/severe) based on leaflet thickening and calcification. RESULTS Mild AV thickness was present in 44.4% and moderate/severe thickness in 5.7% of the cohort, with the lowest frequency of moderate/severe thickness seen particularly among Hispanic women. In multivariate models adjusting for age, sex, race-ethnicity, body mass index, hypertension, coronary artery disease, blood glucose, and high-density lipoprotein cholesterol, Hispanics had significantly less moderate/severe AV thickness (odds ratio 0.43, 95% CI 0.25-0.73) than non-Hispanic whites. Men were almost 2-fold as likely to have moderate/severe AV thickness compared with women (odds ratio 1.96, 95% CI 1.24-3.10). CONCLUSIONS In this large multiethnic population-based cohort, there were ethnic differences in the degree of AV thickness. Hispanic ethnicity was strongly protective against AV thickness. This effect was not related to traditional risk factors, suggesting that unmeasured factors related to Hispanic ethnicity and AV thickness may be responsible.
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Affiliation(s)
- Yukiko Sashida
- Department of Medicine, Columbia University, New York, NY 10032, USA
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43
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Akat K, Kaden JJ, Schmitz F, Ewering S, Anton A, Klomfaß S, Hoffmann R, Ortlepp JR. Calcium metabolism in adults with severe aortic valve stenosis and preserved renal function. Am J Cardiol 2010; 105:862-4. [PMID: 20211333 DOI: 10.1016/j.amjcard.2009.10.065] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 10/25/2009] [Accepted: 10/25/2009] [Indexed: 10/19/2022]
Abstract
Data suggest a link of aortic stenosis (AS) with calcium and bone metabolism. To further investigate this, the following parameters were analyzed in 38 patients with severe AS and in 38 age- and gender-matched controls, without obstructive coronary artery disease and with preserved renal function: calcium, phosphate, 1,25(OH(2))-vitamin D(3), intact parathyroid hormone (iPTH), and osteoprotegerin. Patients with AS had significantly higher serum levels of calcium (2.63 +/- 0.28 vs 2.48 +/- 0.23 mmol/L, p <0.01) and phosphate (1.56 +/- 0.33 vs 1.38 +/- 0.26 mmol/L, p <0.01) and increased calcium-phosphorus products (4.16 +/- 1.13 vs 3.44 +/- 0.89 mmol/L(2), p = 0.003). Notably, the iPTH concentration in the AS group was lower, and significantly more patients in the AS group had levels less than the study median of 60 ng/L. Osteoprotegerin was elevated in patients with AS, confirming reports in other populations (9.94 +/- 5.96 vs 6.73 +/- 4.28 pmol/L, p = 0.009). The relations of several parameters to iPTH were also altered (AS vs controls): calcium and iPTH, 0.071 +/- 0.034 versus 0.046 +/- 0.023, p <0.0001; phosphate and iPTH, 0.042 +/- 0.020 versus 0.025 +/- 0.013, p <0.0001; vitamin D and iPTH, 0.99 +/- 0.61 versus 0.63 +/- 0.46, p = 0.006; and osteoprotegerin and iPTH, 0.24 +/- 0.15 versus 0.12 +/- 0.09, p <0.0001. In conclusion, these data support a hypothesis connecting (severe) AS to altered calcium and bone homeostasis.
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44
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Otto CM. Calcific aortic valve disease: outflow obstruction is the end stage of a systemic disease process. Eur Heart J 2009; 30:1940-2. [DOI: 10.1093/eurheartj/ehp175] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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45
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Bossé Y, Miqdad A, Fournier D, Pépin A, Pibarot P, Mathieu P. Refining molecular pathways leading to calcific aortic valve stenosis by studying gene expression profile of normal and calcified stenotic human aortic valves. ACTA ACUST UNITED AC 2009; 2:489-98. [PMID: 20031625 DOI: 10.1161/circgenetics.108.820795] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Calcific aortic valve stenosis (AS) is a major societal and economic burden that is rising after the current shift toward an older population. Understanding the pathobiology of AS is crucial to implementing better preventive and therapeutic options. Research conducted during the past decade clearly points to active molecular and cellular processes involved in disease pathogenesis. However, no genomic approaches were used to identify genes and pathways that are differentially regulated in aortic valves of patients with and without AS. METHODS AND RESULTS A large-scale quantitative measurements of gene expression was performed on 5 normal and 5 AS valves using Affymetrix GeneChips. A total of 409 and 306 genes were significantly up- and downregulated in AS valves, respectively. The 2 most highly upregulated genes were matrix metalloproteinase 12 and chitinase 3-like 1. The upregulation of these 2 biologically relevant genes in AS was validated by real-time polymerase chain reaction in 38 aortic valves (12 normal and 26 AS). To provide a global biological validation of the whole-genome gene expression analysis, the microarray experiment was repeated in a second set of aortic valves with (n=5) or without (n=5) AS. There was an overrepresentation of small P values among genes claimed significant in the first microarray experiment. A total of 223 genes were replicated (P<0.05 and fold change >1.2), including matrix metalloproteinase 12 and chitinase 3-like 1. CONCLUSIONS This study reveals many unrecognized genes potentially implicated in the pathogenesis of AS. These new genes were overlaid on known pathological pathways leading to AS to refine our molecular understanding of this disease.
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Affiliation(s)
- Yohan Bossé
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Pavillon Margeritte-d'Youville, Y4190, 2725, Chemin Sainte-Foy, Québec City, Québec, Canada.
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Spargias K, Milewski K, Debinski M, Buszman PP, Cokkinos DV, Pogge R, Buszman P. Drug delivery at the aortic valve tissues of healthy domestic pigs with a Paclitaxel-eluting valvuloplasty balloon. J Interv Cardiol 2009; 22:291-8. [PMID: 19490359 DOI: 10.1111/j.1540-8183.2009.00447.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Restenosis occurs invariably within 1 year following balloon valvulopasty in aortic valve stenosis. The mechanism of restenosis seems to involve a dynamic cellular component that could be a target for drug inhibition. We investigated the feasibility of local drug delivery at the aortic valve tissues of healthy pigs with a paclitaxel-eluting balloon. METHODS Aortic valvuloplasty was performed in eight anesthetized domestic pigs using paclitaxel-eluting balloons (3 micro2) balloon surface area). They were assigned to two or four times 15-second balloon inflations and were sacrificed 30 minutes after final balloon inflation. RESULTS The aortic annulus to balloon diameter ratio was 1.15 +/- 0.07. The mean paclitaxel concentration in the aortic valve leaflets was 0.91 +/- 1.36 micro (0.34 +/- 0.05 micro in the two-inflation group, 1.48 +/- 1.86 micro in the four-inflation group, P = 0.23). The percentage of the total paclitaxel dose recovered in the aortic valve leaflets was 18 +/- 11(-6)% (13 +/- 6(-6)% and 25 +/- 14(-6)% in the two- and four-inflation group, P = 0.16). CONCLUSION Local drug delivery at the aortic valve leaflets of healthy pigs with a paclitaxel-eluting balloon is feasible and concentrations within the therapeutic window are detected 30 minutes after the procedure. The antirestenotic potential of this treatment should be studied.
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Rahimtoola SH. The Year in Valvular Heart Disease. J Am Coll Cardiol 2009; 53:1894-908. [DOI: 10.1016/j.jacc.2009.02.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 01/21/2009] [Accepted: 02/06/2009] [Indexed: 12/01/2022]
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Schoen FJ. Evolving concepts of cardiac valve dynamics: the continuum of development, functional structure, pathobiology, and tissue engineering. Circulation 2008; 118:1864-80. [PMID: 18955677 DOI: 10.1161/circulationaha.108.805911] [Citation(s) in RCA: 269] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Considerable progress has been made in recent years toward elucidating a conceptual framework that integrates the dynamic functional structure, mechanical properties, and pathobiological behavior of the cardiac valves. This communication reviews the evolving paradigm of a continuum of heart valve structure, function, and pathobiology and explores its implications. Specifically, we discuss (1) the interactions of valve biology and biomechanics (eg, correlations of function with structure at the cell, tissue, and organ levels and mechanical considerations, development, endothelial cell and interstitial cell biology, extracellular matrix biology, homeostasis, and adaptation to environmental change); (2) mechanisms of disease (eg, valve cell and matrix pathobiology in congenital anomalies, aortic valve calcification, and mitral valve prolapse); (3) considerations in replacement and repair (eg, cell/matrix biology of tissue valve substitutes and their degeneration and durability of repairs); and (4) the potential for tissue engineering approaches to therapeutic regeneration of the cardiac valves. Opportunities for research and clinical translation are highlighted.
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Affiliation(s)
- Frederick J Schoen
- Department of Pathology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
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Rossebø AB, Pedersen TR, Boman K, Brudi P, Chambers JB, Egstrup K, Gerdts E, Gohlke-Bärwolf C, Holme I, Kesäniemi YA, Malbecq W, Nienaber CA, Ray S, Skjaerpe T, Wachtell K, Willenheimer R. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. N Engl J Med 2008; 359:1343-56. [PMID: 18765433 DOI: 10.1056/nejmoa0804602] [Citation(s) in RCA: 1094] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hyperlipidemia has been suggested as a risk factor for stenosis of the aortic valve, but lipid-lowering studies have had conflicting results. METHODS We conducted a randomized, double-blind trial involving 1873 patients with mild-to-moderate, asymptomatic aortic stenosis. The patients received either 40 mg of simvastatin plus 10 mg of ezetimibe or placebo daily. The primary outcome was a composite of major cardiovascular events, including death from cardiovascular causes, aortic-valve replacement, nonfatal myocardial infarction, hospitalization for unstable angina pectoris, heart failure, coronary-artery bypass grafting, percutaneous coronary intervention, and nonhemorrhagic stroke. Secondary outcomes were events related to aortic-valve stenosis and ischemic cardiovascular events. RESULTS During a median follow-up of 52.2 months, the primary outcome occurred in 333 patients (35.3%) in the simvastatin-ezetimibe group and in 355 patients (38.2%) in the placebo group (hazard ratio in the simvastatin-ezetimibe group, 0.96; 95% confidence interval [CI], 0.83 to 1.12; P=0.59). Aortic-valve replacement was performed in 267 patients (28.3%) in the simvastatin-ezetimibe group and in 278 patients (29.9%) in the placebo group (hazard ratio, 1.00; 95% CI, 0.84 to 1.18; P=0.97). Fewer patients had ischemic cardiovascular events in the simvastatin-ezetimibe group (148 patients) than in the placebo group (187 patients) (hazard ratio, 0.78; 95% CI, 0.63 to 0.97; P=0.02), mainly because of the smaller number of patients who underwent coronary-artery bypass grafting. Cancer occurred more frequently in the simvastatin-ezetimibe group (105 vs. 70, P=0.01). CONCLUSIONS Simvastatin and ezetimibe did not reduce the composite outcome of combined aortic-valve events and ischemic events in patients with aortic stenosis. Such therapy reduced the incidence of ischemic cardiovascular events but not events related to aortic-valve stenosis. (ClinicalTrials.gov number, NCT00092677.)
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Affiliation(s)
- Anne B Rossebø
- Division of Cardiology, Aker University Hospital, Trondheimsveien 235, N-0514 Oslo, Norway.
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