Acute molecular effects of pressure-controlled intermittent coronary sinus occlusion in patients with advanced heart failure

Plasma microRNA-143 and microRNA-145 levels are elevated in patients with left ventricular dysfunction

MicroRNA(miR)-143 and miR-145 are mainly expressed in vascular smooth muscle cells. However, the relationship between plasma miR-143 or miR-145 levels and the left ventricular (LV) function in patients with heart diseases remains unclear. Blood samples were taken from the antecubital vein in patients with heart diseases (n = 52), such as coronary artery disease, old myocardial infarction, cardiomyopathy, and valvular heart disease, and controls without heart diseases (n = 22). We measured plasma miR-143 and -145 levels by quantitative RT-PCR using TaqMan MicroRNA Assays and THUNDERBIRD Probe qPCR Mix. Plasma BNP levels were also measured. Echocardiography was performed to measure the LV ejection fraction (LVEF) and LV dilation. Plasma miR-143 and miR-145 levels were significantly higher in patients with heart diseases than in controls, respectively. Plasma miR-143 and miR-145 levels were significantly higher in patients with LVEF < 50% than in those with LVEF ≧ 50%, respectively. Plasma miR-143 and miR-145 levels were inversely correlated with LVEF, respectively. Plasma miR-143 and miR-145 levels were positively correlated with LV end-systolic dimension, respectively. Plasma miR-143 and -145 levels were positively correlated with plasma BNP levels, respectively. Plasma BNP levels were inversely correlated with LVEF. Plasma miR-143 and miR-145 levels are elevated in patients with LV dysfunction and may counteract LV dysfunction.

Circulating microRNAs and cardiomyocyte proliferation in heart failure patients related to 10 years survival

AIMS

Mechanochemical signalling drives organogenesis and is highly conserved in mammal evolution. Regaining recovery in myocardial jeopardy by inducing principles linking cardiovascular therapy and clinical outcome has been the dream of scientists for decades. Concepts involving embryonic pathways to regenerate adult failing hearts became popular in the early millennium. Since then, abundant data on stem cell research have been published, never reaching widespread application in heart failure therapy. Another conceptual access, using mechanotransduction in cardiac veins to limit myocardial decay, is pressure-controlled intermittent coronary sinus occlusion (PICSO). Recently, we reported acute molecular signs and signals of PICSO activating regulatory miRNA and inducing cell proliferation mimicking cardiac development in adult failing hearts. According to a previously formulated hypothesis, 'embryonic recall', this study aimed to define molecular signals involved in endogenous heart repair during PICSO and study their relation to patient survival.

METHODS AND RESULTS

We previously reported a study on the acute molecular effects of PICSO in an observational non-randomized study. Eight out of the thirty-two patients with advanced heart failure undergoing cardiac resynchronization therapy (CRT) were treated with PICSO. Survival was monitored over 10 years, and coronary sinus blood samples were collected during intervention before and after 20 min and tested for miRNA signalling and proliferation when co-cultured with cardiomyocytes. A numerically lower death rate post-CRT and PICSO as compared with control CRT only, and a non-significant reduction in all-cause mortality risk of 42% was observed (37.5% vs. 54.0%, relative risk = 0.58, 95% confidence interval: 0.17-2.05; P = 0.402). Four miRNAs involved in cell cycle, proliferation, morphogenesis, embryonic development, and apoptosis significantly increased concomitantly in survivors and PICSO compared with a decrease in non-survivors (hsa-miR Let7b, P < 0.01; hsa-miR- 421, P < 0.006; hsa-miR 363-3p, P < 0.03 and hsa-miR 19b-3p P < 0.01). In contrast, three miRNAs involved in proliferation and survival, determining cell fate, and recycling endosomes decreased in survivors and PICSO (hsa miR 101-3p, P < 0.03; hsa-miR 25-3p, P < 002; hsa-miR 30d-5p P < 0.04). In vitro cellular proliferation increased in survivors and lowered in non-survivors showing a pattern distinction, discriminating longevity according to up to 10-year survival in heart failure patients.

CONCLUSIONS

This study proposes that generating regenerative signals observed during PICSO intervention relate to patient outcomes. Morphogenetic pathways induced by periods of flow reversal in cardiac veins in a domino-like pattern transform embryonic into regenerative signals. Studies supporting the conversion of mechanochemical signals into regenerative molecules during PICSO are warranted to substantiate predictive power on patient longevity, opening new therapeutic avenues in otherwise untreatable heart failure.

Apoptosis and heart failure: The role of non-coding RNAs and exosomal non-coding RNAs

Heart failure is a condition that affects the cardio vascular system and occurs if the heart cannot adequately pump the oxygen and blood to the body. Myocardial infarction, reperfusion injury, and this disease is the only a few examples of the numerous cardiovascular illnesses that are impacted by the closely controlled cell deletion process known as apoptosis. Attention has been paid to the creation of alternative diagnostic and treatment modalities for the condition. Recent evidences have shown that some non-coding RNAs (ncRNAs) influence the stability of proteins, control of transcription factors, and HF apoptosis through a variety of methods. Exosomes make a significant paracrine contribution to the regulation of illnesses as well as to the communication between nearby and distant organs. However, it has not yet been determined whether exosomes regulate the cardiomyocyte-tumor cell interaction in ischemia HF to limit the vulnerability of malignancy to ferroptosis. Here, we list the numerous ncRNAs in HF that are connected to apoptosis. In addition, we emphasize the significance of exosomal ncRNAs in the HF.

Signs and signals limiting myocardial damage using PICSO: a scoping review decoding paradigm shifts toward a new encounter

Background

Inducing recovery in myocardial ischemia is limited to a timely reopening of infarct vessels and clearing the cardiac microcirculation, but additional molecular factors may impact recovery.

Objective

In this scoping review, we identify the paradigm shifts decoding the branching points of experimental and clinical evidence of pressure-controlled intermittent coronary sinus occlusion (PICSO), focusing on myocardial salvage and molecular implications on infarct healing and repair.

Design

The reporting of evidence was structured chronologically, describing the evolution of the concept from mainstream research to core findings dictating a paradigm change. All data reported in this scoping review are based on published data, but new evaluations are also included.

Results

Previous findings relate hemodynamic PICSO effects clearing reperfused microcirculation to myocardial salvage. The activation of venous endothelium opened a new avenue for understanding PICSO. A flow-sensitive signaling molecule, miR-145-5p, showed a five-fold increase in porcine myocardium subjected to PICSO.Verifying our theory of "embryonic recall," an upregulation of miR-19b and miR-101 significantly correlates to the time of pressure increase in cardiac veins during PICSO (r2 = 0.90, p < 0.05; r2 = 0.98, p < 0.03), suggesting a flow- and pressure-dependent secretion of signaling molecules into the coronary circulation. Furthermore, cardiomyocyte proliferation by miR-19b and the protective role of miR-101 against remodeling show another potential interaction of PICSO in myocardial healing.

Conclusion

Molecular signaling during PICSO may contribute to retroperfusion toward deprived myocardium and clearing the reperfused cardiac microcirculation. A burst of specific miRNA reiterating embryonic molecular pathways may play a role in targeting myocardial jeopardy and will be an essential therapeutic contribution in limiting infarcts in recovering patients.

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery

In the United States, about one million people are seen to visit the operating theater for cardiac surgery annually. However, nearly half of these visits result in complications such as renal, neurological, and cardiac injury of varying degrees. Historically, many mechanisms and approaches have been explored in attempts to reduce injuries associated with cardiac surgery and percutaneous procedures. Devices such as cardioplegia, mechanical circulatory support, and other methods have shown promising results in managing and preventing life-threatening cardiac-surgery-related outcomes such as heart failure and cardiogenic shock. Comparably, cardioprotective devices such as TandemHeart, Impella family devices, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) have also been proven to show significant cardioprotection through mechanical support. However, their use as interventional agents in the prevention of hemodynamic changes due to cardiac surgery or percutaneous interventions has been correlated with adverse effects. This can lead to a rebound increased risk of mortality in high-risk patients who undergo cardiac surgery. Further research is necessary to delineate and stratify patients into appropriate cardioprotective device groups. Furthermore, the use of one device over another in terms of efficacy remains controversial and further research is necessary to assess device potential in different settings. Clinical research is also needed regarding novel strategies and targets, such as transcutaneous vagus stimulation and supersaturated oxygen therapy, aimed at reducing mortality among high-risk cardiac surgery patients. This review explores the recent advances regarding the use of cardioprotective devices in patients undergoing percutaneous procedures and cardiac surgery.

Pressure-Controlled Intermittent Coronary Sinus Occlusion: A Novel Approach to Improve Microvascular Flow and Reduce Infarct Size in STEMI

Despite successful primary percutaneous coronary intervention (PCI) for treatment of ST-segment elevation myocardial infarction (STEMI), myocardial salvage is frequently suboptimal resulting in large infarctions with increased rates of heart failure and death. Microvascular dysfunction after the procedure is frequently present and contributes directly to poor outcomes in STEMI. Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) is a novel technology designed to mitigate microvascular dysfunction in STEMI. Non-randomized studies have suggested that PiCSO use during primary PCI in STEMI is safe, improves microvascular perfusion and reduces infarct size. Randomized trials are ongoing to investigate the safety and effectiveness of PiCSO in high-risk patients with anterior STEMI undergoing primary PCI.

New Interventional Therapies beyond Stenting to Treat ST-Segment Elevation Acute Myocardial Infarction

Myocardial infarction remains the principal cause of death in Europe. In patients with ST-segment-elevation myocardial infarction (STEMI), a promptly revascularization with primary percutaneous intervention (PCI) has transformed prognosis in the last decades. However, despite increasing successful PCI procedures, mortality has remained unchanged in recent years. Also, due to an unsatisfactory reperfusion, some patients have significant myocardial damage and suffer left ventricular adverse remodeling with reduced function—all that resulting in the onset of heart failure with all its inherent clinical and socioeconomic burden. As a consequence of longer ischemic times, distal thrombotic embolization, ischemia-reperfusion injury and microvascular dysfunction, the resultant myocardial infarct size is the major prognostic determinant in STEMI patients. The improved understanding of all the pathophysiology underlying these events has derived to the development of several novel therapies aiming to reduce infarct size and to improve clinical outcomes in these patients. In this article, based on the mechanisms involved in myocardial infarction prognosis, we review the new interventional strategies beyond stenting that may solve the suboptimal results that STEMI patients still experience.

Effect of Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) on infarct size in anterior STEMI: PiCSO in ACS study

BACKGROUND

The aim of this clinical research was to investigate the effects of Pressure-controlled intermittent Coronary Sinus Occlusion (PiCSO) on infarct size at 5 days after primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS AND RESULTS

This comparative study was carried out in four UK hospitals. Forty-five patients with anterior STEMI presenting within 12 h of symptom onset received pPCI plus PiCSO (initiated after reperfusion; n = 45) and were compared with a propensity score-matched control cohort from INFUSE-AMI (n = 80). Infarct size (% of LV mass, median [interquartile range]) measured by cardiac magnetic resonance (CMR) at day 5 was significantly lower in the PiCSO group (14.3% [95% CI 9.2-19.4%] vs. 21.2% [95% CI 18.0-24.4%]; p = 0.023). There were no major adverse cardiac events (MACE) related to the PiCSO intervention.

CONCLUSIONS

PiCSO, as an adjunct to pPCI, was associated with a lower infarct size at 5 days after anterior STEMI in a propensity score-matched population.

Circulating MicroRNAs as Potential Noninvasive Biomarkers of Spontaneous Intracerebral Hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is a common and severe neurological disorder that has been associated with high rates of mortality and morbidity. It is urgent to find new biomarkers for the early diagnosis and prevention of ICH. In recent years, micro-RNAs (miRNAs) have been proved to play an important role in vascular damage and inflammation in cerebrovascular diseases, including ICH. In the peripheral blood, circulating miRNAs will be present at a remarkably steady level. In the present study, we explored the circulating plasma microRNA (miR)-181b, miR-223, miR-155, and miR-145 as new potential biomarkers for the diagnosis of ICH.

METHODS

The plasma samples from 106 patients with ICH and 50 patients without ICH (control group) were collected and subjected to quantitative real-time polymerase chain reaction analyses for the expression levels of circulating miR-181b, miR-223, miR-155, and miR-145.

RESULTS

The expression levels of plasma circulating miR-145 (P < 0.001), miR-223, and miR-155 were increased in patients with ICH compared with those in the control group (P < 0.05). However, the expression of plasma circulating miR-181b was decreased in patients with ICH compared with that in the control group (P < 0.001). Receiver operating characteristic curve analyses were performed to determine the diagnostic sensitivity and specificity of miR-145 and miR-181b to detect ICH. The area under the curve for miR-145 was 0.766 (95% confidence interval, 0.689-0.838) and for miR-181b was 0.78 (95% confidence interval, 0.70-0.86), suggesting that circulating miR-145 and miR-181b can be used to differentiate patients with ICH from those without ICH.

CONCLUSION

Our results have shown that measurement of circulating miR-181b, miR-223, miR-155, and miR-145 in plasma samples could serve as a potential noninvasive tool for ICH detection.

Increased plasma sestrin2 concentrations in patients with chronic heart failure and predicted the occurrence of major adverse cardiac events: A 36-month follow-up cohort study

BACKGROUND

Previous study had demonstrated that sestrin2 (Sesn2) expression was increased in human failing heart. Although, the circulating Sesn2 concentrations in patients with chronic heart failure (CHF) remains unknown. This study investigated plasma Sesn2 concentrations in patients with CHF and the role between Sesn2 and the occurrence of major adverse cardiac events.

METHODS

A total of 80 control subjects and 220 CHF patients were enrolled and the Sesn2 concentrations of each sample were measured. Additionally, the occurrence of major adverse cardiac events in each CHF patient were followed prospectively for 36 months.

RESULTS

Increased plasma Sesn2 concentrations were found in CHF patients and gradually increased from New York Heart Association (NYHA) functional class II to IV. The Sesn2 concentrations were positively correlated with N-terminal B-type natriuretic peptide (NT-pro BNP) but negatively correlated with left ventricular ejection fraction (LVEF) in CHF patients. The ROC curve suggested that Sesn2 had a certain value in predicting major adverse cardiac events during CHF patients, although, the predictive role of Sesn2 is not as good as NT-pro BNP. In addition, the multivariate Cox hazard analysis was performed after the CHF patients were divided into 3 groups (low, middle, and high) base on the plasma Sesn2 concentrations category, and the results showed that both high and middle Sesn2 concentrations increased the incidence of major adverse cardiac events when compared with low Sesn2 group. Furthermore, CHF patients with major adverse cardiac events showed higher Sesn2 concentrations when compared with CHF without major adverse cardiac events. The Kaplan-Meier analysis was performed after the CHF patients were divided into 2 groups according to the median Sesn2 concentrations and the results revealed that patients with high Sesn2 concentrations had a higher risk of major adverse cardiac events compared with those with low Sesn2.

CONCLUSIONS

Plasma Sesn2 concentrations were increased in CHF patients and positively correlated with the severity of CHF. Increased Sesn2 concentrations significantly increased the occurrence of major adverse cardiac events and suggested poor outcome in CHF patients.

Acute molecular effects of pressure-controlled intermittent coronary sinus occlusion in patients with advanced heart failure

Aims

Cardiac repair has steered clinical attention and remains an unmet need, because available regenerative therapies lack robust mechanistic evidence. Pressure‐controlled intermittent coronary sinus occlusion (PICSO), known to induce angiogenetic and vasoactive molecules as well as to reduce regional ischemia, may activate endogenous regenerative processes in failing myocardium. We aimed to investigate the effects of PICSO in patients with advanced heart failure undergoing cardiac resynchronization therapy.

Methods and results

Eight out of 32 patients were treated with PICSO, and the remainder served as controls. After electrode testing including left ventricular leads, PICSO was performed for 20 min. To test immediate molecular responses, in both patient groups, coronary venous blood samples were taken at baseline and after 20 min, the time required for the intervention. Sera were tested for microRNAs and growth factors. To test the ability of up‐regulated soluble factors on cell proliferation and expression of transcription factors [e.g. Krüppel‐like factor 4 (KLF‐4)], sera were co‐cultured with human cardiomyocytes and fibroblasts. As compared with controls, significant differential expression (differences between pre‐values and post‐values in relation to both patient cohorts) of microRNA patterns associated with cardiac development was observed with PICSO. Importantly, miR‐143 (P < 0.048) and miR‐145 (P < 0,047) increased, both targeting a network of transcription factors (including KLF‐4) that promote differentiation and repress proliferation of vascular smooth muscle cells. Additionally, an increase of miR‐19b (P < 0.019) known to alleviate endothelial cell apoptosis was found, whereas disadvantageous miR‐320b (P < 0.023) suspect to impair expression of c‐myc, normally provoking cell cycle re‐entry in post‐mitotic myocytes and miR‐25 (P < 0.023), decreased, a target of anti‐miR application to improve contractility in the failing heart. Co‐cultured post‐PICSO sera significantly increased cellular proliferation both in fibroblasts (P < 0.001) and adult cardiomycytes (P < 0.004) sampled from a transplant recipient as compared with controls. Adult cardiomyocytes showed a seven‐fold increase of the transcription factor KLF‐4 protein when co‐cultured with treated sera as compared with controls.

Conclusions

Here, we show for the first time that PICSO, a trans‐coronary sinus catheter intervention, is associated with an increase in morphogens secreted into cardiac veins, normally present during cardiac development, and a significant induction of cell proliferation. Present findings support the notion that epigenetic modifications, that is, haemodynamic stimuli on venous vascular cells, may reverse myocardial deterioration. Further investigations are needed to decipher the maze of complex interacting molecular pathways in failing myocardium and the potential role of PICSO to reinitiate developmental processes to prevent further myocardial decay eventually reaching clinical significance.