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Matilla L, Martín-Núñez E, Navarro A, Garaikoetxea M, Fernández-Celis A, Goñi-Olóriz M, Gainza A, Fernández-Irigoyen J, Santamaría E, Tamayo I, Álvarez V, Sádaba R, Jover E, López-Andrés N. Neuropilin-1 sex-dependently modulates inflammatory, angiogenic and osteogenic phenotypes in the calcifying valve interstitial cell. Biochem Pharmacol 2024; 226:116336. [PMID: 38844264 DOI: 10.1016/j.bcp.2024.116336] [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] [Received: 12/01/2023] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024]
Abstract
The pathological mechanisms underlying the sex-dependent presentation of calcific aortic stenosis (AS) remain poorly understood. We aim to analyse sex-specific responses of valve interstitial cells (VICs) to calcific environments and to identify new pathological and potentially druggable targets. First, VICs from stenotic patients were modelled using pro-calcifying media (HP). Both male and female VICs were inflamed upon calcific HP challenge, although the inflammatory response was higher in female VICs. The osteogenic and calcification responses were higher in male VICs. To identify new players involved in the responses to HP, proteomics analyses were performed on additional calcifying VICs. Neuropilin-1 (NRP-1) was significantly up-regulated in male calcifying VICs and that was confirmed in aortic valves (AVs), especially nearby neovessels and calcifications. Regardless of the sex, NRP-1 expression was correlated to inflammation, angiogenesis and osteogenic markers, but with stronger associations in male AVs. To further evidence the role of NRP-1, in vitro experiments of silencing or supplementation with soluble NRP-1 (sNRP-1) were performed. NRP-1 silencing or addition of sNRP-1 reduced/mended the expression of any sex-specific response triggered by HP. Moreover, NRP-1 regulation contributed to significantly diminish the baseline enhanced expression of pro-inflammatory, pro-angiogenic and pro-osteogenic markers mainly in male VICs. Validation studies were conducted in stenotic AVs. In summary, pharmacologic targeting of NRP-1 could be used to target sex-specific phenotypes in AS as well as to exert protective effects by reducing the basal expression of pathogenic markers only in male VICs.
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Affiliation(s)
- Lara Matilla
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Ernesto Martín-Núñez
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Adela Navarro
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Mattie Garaikoetxea
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Amaya Fernández-Celis
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Miriam Goñi-Olóriz
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Alicia Gainza
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Joaquín Fernández-Irigoyen
- Clinical Neuroproteomics Unit, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Enrique Santamaría
- Clinical Neuroproteomics Unit, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Ibai Tamayo
- Research Methodology Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
| | - Virginia Álvarez
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Rafael Sádaba
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain
| | - Eva Jover
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain.
| | - Natalia López-Andrés
- Cardiovascular Translational Research, Navarrabiomed, Hospital Universitario de Navarra, Universidad Pública de Navarra, IdiSNA, Pamplona, Spain.
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Azimi-Boulali J, Mahler GJ, Murray BT, Huang P. Multiscale computational modeling of aortic valve calcification. Biomech Model Mechanobiol 2024; 23:581-599. [PMID: 38093148 DOI: 10.1007/s10237-023-01793-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/13/2023] [Indexed: 03/26/2024]
Abstract
Calcific aortic valve disease (CAVD) is a common cardiovascular disease that affects millions of people worldwide. The disease is characterized by the formation of calcium nodules on the aortic valve leaflets, which can lead to stenosis and heart failure if left untreated. The pathogenesis of CAVD is still not well understood, but involves several signaling pathways, including the transforming growth factor beta (TGF β ) pathway. In this study, we developed a multiscale computational model for TGF β -stimulated CAVD. The model framework comprises cellular behavior dynamics, subcellular signaling pathways, and tissue-level diffusion fields of pertinent chemical species, where information is shared among different scales. Processes such as endothelial to mesenchymal transition (EndMT), fibrosis, and calcification are incorporated. The results indicate that the majority of myofibroblasts and osteoblast-like cells ultimately die due to lack of nutrients as they become trapped in areas with higher levels of fibrosis or calcification, and they subsequently act as sources for calcium nodules, which contribute to a polydispersed nodule size distribution. Additionally, fibrosis and calcification processes occur more frequently in regions closer to the endothelial layer where the cell activity is higher. Our results provide insights into the mechanisms of CAVD and TGF β signaling and could aid in the development of novel therapeutic approaches for CAVD and other related diseases such as cancer. More broadly, this type of modeling framework can pave the way for unraveling the complexity of biological systems by incorporating several signaling pathways in subcellular models to simulate tissue remodeling in diseases involving cellular mechanobiology.
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Affiliation(s)
- Javid Azimi-Boulali
- Department of Mechanical Engineering, Binghamton University, Binghamton, NY, 13902, USA
| | - Gretchen J Mahler
- Department of Biomedical Engineering, Binghamton University, Binghamton, NY, 13902, USA
| | - Bruce T Murray
- Department of Mechanical Engineering, Binghamton University, Binghamton, NY, 13902, USA
| | - Peter Huang
- Department of Mechanical Engineering, Binghamton University, Binghamton, NY, 13902, USA.
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3
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Allen JB, Ludtka C, James BD. Sex as a Biological Variable in Tissue Engineering and Regenerative Medicine. Annu Rev Biomed Eng 2023; 25:311-331. [PMID: 37104652 PMCID: PMC10312304 DOI: 10.1146/annurev-bioeng-092222-030857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Although sex differences have been noted in cellular function and behavior, therapy efficacy, and disease incidence and outcomes, the adoption of sex as a biological variable in tissue engineering and regenerative medicine remains limited. Furthering the development of personalized, precision medicine requires considering biological sex at the bench and in the clinic. This review provides the basis for considering biological sex when designing tissue-engineered constructs and regenerative therapies by contextualizing sex as a biological variable within the tissue engineering triad of cells, matrices, and signals. To achieve equity in biological sex within medicine requires a cultural shift in science and engineering research, with active engagement by researchers, clinicians, companies, policymakers, and funding agencies.
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Affiliation(s)
- Josephine B Allen
- Department of Materials Science and Engineering, University of Florida, Gainesville, Florida, USA;
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida, USA;
| | - Christopher Ludtka
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, Florida, USA;
| | - Bryan D James
- Department of Marine Chemistry and Geochemistry, Woods Hole Oceanographic Institution, Woods Hole, Massachusetts, USA;
- Department of Biology, Woods Hole Oceanographic Institution, Woods Hole, Massachusetts, USA
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4
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Simon LR, Scott AJ, Figueroa Rios L, Zembles J, Masters KS. Cellular-scale sex differences in extracellular matrix remodeling by valvular interstitial cells. Heart Vessels 2023; 38:122-130. [PMID: 36070095 PMCID: PMC10120251 DOI: 10.1007/s00380-022-02164-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 08/24/2022] [Indexed: 01/06/2023]
Abstract
Males acquire calcific aortic valve disease (CAVD) twice as often as females, yet stenotic valves from females display significantly higher levels of fibrosis compared to males with similar extent of disease. Fibrosis occurs as an imbalance between the production and degradation of the extracellular matrix (ECM), specifically type I collagen. This work characterizes ECM production and remodeling by male and female valvular interstitial cells (VICs) to better understand the fibrocalcific divergence between sexes evident in CAVD. Male and female VICs were assessed for gene and protein expression of myofibroblastic markers, ECM components, matrix metalloproteinases (MMPs), and tissue inhibitors of MMPs (TIMPs) via qRT-PCR and western blot. Overall metabolic activity was also measured. Activity assays for collagenase and gelatinase were performed to examine degradation behavior. Male VICs produced greater levels of myofibroblastic markers while female VICs showed greater metabolic activity and collagen production. In general, females displayed a greater level of MMP expression and production than males, but no sex differences were observed in TIMP production. Male VICs also displayed a greater level of collagenase and gelatinase activity than female VICs. This work displays sex differences in ECM remodeling by VICs that could be related to the sexual dimorphism in ECM structure seen in clinical CAVD.
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Affiliation(s)
- LaTonya R Simon
- Department of Biomedical Engineering, University of Wisconsin-Madison, 1111 Highland Ave, WIMR 8531, Madison, WI, 53705, USA
| | - Ashley J Scott
- Cellular and Molecular Biology Training Program, University of Wisconsin-Madison, Madison, WI, 53705, USA
| | - Lysmarie Figueroa Rios
- Department of Biomedical Engineering, University of Wisconsin-Madison, 1111 Highland Ave, WIMR 8531, Madison, WI, 53705, USA
| | - Joshua Zembles
- Department of Biomedical Engineering, University of Wisconsin-Madison, 1111 Highland Ave, WIMR 8531, Madison, WI, 53705, USA
| | - Kristyn S Masters
- Department of Biomedical Engineering, University of Wisconsin-Madison, 1111 Highland Ave, WIMR 8531, Madison, WI, 53705, USA.
- Cellular and Molecular Biology Training Program, University of Wisconsin-Madison, Madison, WI, 53705, USA.
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, 53705, USA.
- Department of Materials Science and Engineering, University of Wisconsin-Madison, Madison, WI, 53705, USA.
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5
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Vogt BJ, Peters DK, Anseth KS, Aguado BA. Inflammatory serum factors from aortic valve stenosis patients modulate sex differences in valvular myofibroblast activation and osteoblast-like differentiation. Biomater Sci 2022; 10:6341-6353. [PMID: 36226463 PMCID: PMC9741081 DOI: 10.1039/d2bm00844k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Aortic valve stenosis (AVS) is a sexually dimorphic cardiovascular disease that is driven by fibrosis and calcification of the aortic valve leaflets. Circulating inflammatory factors present in serum from AVS patients contribute to sex differences in valve fibro-calcification by driving the activation of valvular interstitial cells (VICs) to myofibroblasts and/or osteoblast-like cells. However, the molecular mechanisms by which inflammatory factors contribute to sex-specific valve fibro-calcification remain largely unknown. In this study, we identified inflammatory factors present in serum samples from AVS patients that regulate sex-specific myofibroblast activation and osteoblast-like differentiation. After correlating serum proteomic datasets with clinical and in vitro myofibroblast datasets, we identified annexin A2 and cystatin C as candidate inflammatory factors that correlate with both AVS patient severity and myofibroblast activation measurements in vitro. Validation experiments utilizing hydrogel biomaterials as cell culture platforms that mimic the valve extracellular matrix confirmed that annexin A2 and cystatin C promote sex-specific VIC activation to myofibroblasts via p38 MAPK signaling. Additionally, annexin A2 and cystatin C increase osteoblast-like differentiation primarily in male VICs. Our results implicate serum inflammatory factors as potential AVS biomarkers that also contribute to sexually dimorphic AVS progression by driving VIC myofibroblast activation and/or osteoblast-like differentiation. Collectively, the results herein further our overall understanding as to how biological sex may impact inflammation-driven AVS and may lead to the development of sex-specific drug treatment strategies.
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Affiliation(s)
- Brandon J Vogt
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA.
- Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
- Department of Chemical and Biological Engineering, University of Colorado Boulder, CO 80303, USA
| | - Douglas K Peters
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
| | - Kristi S Anseth
- Department of Chemical and Biological Engineering, University of Colorado Boulder, CO 80303, USA
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
| | - Brian A Aguado
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA.
- Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
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6
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Bramsen JA, Alber BR, Mendoza M, Murray BT, Chen MH, Huang P, Mahler GJ. Glycosaminoglycans affect endothelial to mesenchymal transformation, proliferation, and calcification in a 3D model of aortic valve disease. Front Cardiovasc Med 2022; 9:975732. [PMID: 36247482 PMCID: PMC9558823 DOI: 10.3389/fcvm.2022.975732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022] Open
Abstract
Calcific nodules form in the fibrosa layer of the aortic valve in calcific aortic valve disease (CAVD). Glycosaminoglycans (GAGs), which are normally found in the valve spongiosa, are located local to calcific nodules. Previous work suggests that GAGs induce endothelial to mesenchymal transformation (EndMT), a phenomenon described by endothelial cells’ loss of the endothelial markers, gaining of migratory properties, and expression of mesenchymal markers such as alpha smooth muscle actin (α-SMA). EndMT is known to play roles in valvulogenesis and may provide a source of activated fibroblast with a potential role in CAVD progression. In this study, a 3D collagen hydrogel co-culture model of the aortic valve fibrosa was created to study the role of EndMT-derived activated valvular interstitial cell behavior in CAVD progression. Porcine aortic valve interstitial cells (PAVIC) and porcine aortic valve endothelial cells (PAVEC) were cultured within collagen I hydrogels containing the GAGs chondroitin sulfate (CS) or hyaluronic acid (HA). The model was used to study alkaline phosphatase (ALP) enzyme activity, cellular proliferation and matrix invasion, protein expression, and calcific nodule formation of the resident cell populations. CS and HA were found to alter ALP activity and increase cell proliferation. CS increased the formation of calcified nodules without the addition of osteogenic culture medium. This model has applications in the improvement of bioprosthetic valves by making replacements more micro-compositionally dynamic, as well as providing a platform for testing new pharmaceutical treatments of CAVD.
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Affiliation(s)
| | - Bridget R. Alber
- Department of Biomedical Engineering, George Washington University, Washington, DC, United States
| | - Melissa Mendoza
- Department of Biomedical Engineering, Binghamton University, Binghamton, NY, United States
| | - Bruce T. Murray
- Department of Mechanical Engineering, Binghamton University, Binghamton, NY, United States
| | - Mei-Hsiu Chen
- Department of Mathematics and Statistics, Binghamton University, Binghamton, NY, United States
| | - Peter Huang
- Department of Mechanical Engineering, Binghamton University, Binghamton, NY, United States
| | - Gretchen J. Mahler
- Department of Biomedical Engineering, Binghamton University, Binghamton, NY, United States
- *Correspondence: Gretchen J. Mahler,
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Hafiane A, Favari E, Bortnick AE. Measures of high-density lipoprotein function in men and women with severe aortic stenosis. Lipids Health Dis 2022; 21:48. [PMID: 35643498 PMCID: PMC9148512 DOI: 10.1186/s12944-022-01653-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background Calcification of the aortic valve is a common heart valve disorder, in some cases leading to clinically impactful severe aortic stenosis (AS). Sex-specific differences in aortic valve calcification (ACV) exist, with women having a lower burden of calcification than men as measured by computed tomography; however, the pathophysiological mechanism that leads to these differences remains unclear. Methods Using cultured human Tamm-Horsfall protein 1 (THP-1) macrophages and human aortic valve interstitial cells, the effects of high-density lipoprotein (HDL) particles isolated from the plasma of men and women with severe AS were studied for cholesterol efflux capacity (CEC). Results HDL-CEC was assessed in 46 patients with severe AS, n = 30 men, n = 16 women. ATP-Binding Cassette A1 (ABCA1)-mediated HDL-CEC was measured from human cultured THP-1 macrophages to plasma HDL samples. Women with severe AS had more ABCA1-mediated HDL-CEC, as compared to men (8.50 ± 3.90% cpm vs. 6.80 ± 1.50% cpm, P = 0.04). HDL pre-β1 and α-particles were higher in woman than in men by spectral density, (pre-β1 HDL, 20298.29 ± 1076.15 vs. 15,661.74 ± 789.00, P = 0.002, and α-HDL, 63006.35 ± 756.81 vs. 50,447.00 ± 546.52, P = 0.03). Lecithin-cholesterol acyltransferase conversion of free cholesterol into cholesteryl esters was higher in women than men (16.44 ± 9.11%/h vs. 12.00 ± 8.07%/h, P = 0.03). Conclusions Sex-specific changes in various parameters of HDL-CEC were found in patients with severe AS. Sex-based modifications in HDL functionality by HDL-CEC might account for the reduced burden of calcification in women vs. men with severe AS. Therefore, future studies should target sex-related pathways in AS to help to improve understanding and treatment of AS. Graphical abstract Sex specifc differences in AVC and differences associated with HDL function in men and women with severe AS. When compared to men, women had higher preβ-HDL and α-HDL migrating particles, higher cholesterol efflux to HDL, and higher lecithin cholesterol acyl transferase (LCAT) activity, possibly indicating that improved reverse cholesterol transport may be protective against worsened calcification.
![]() Supplementary Information The online version contains supplementary material available at 10.1186/s12944-022-01653-7.
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Aguado BA, Walker CJ, Grim JC, Schroeder ME, Batan D, Vogt BJ, Rodriguez AG, Schwisow JA, Moulton KS, Weiss RM, Heistad DD, Leinwand LA, Anseth KS. Genes That Escape X Chromosome Inactivation Modulate Sex Differences in Valve Myofibroblasts. Circulation 2022; 145:513-530. [PMID: 35000411 PMCID: PMC8844107 DOI: 10.1161/circulationaha.121.054108] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic valve stenosis is a sexually dimorphic disease, with women often presenting with sustained fibrosis and men with more extensive calcification. However, the intracellular molecular mechanisms that drive these clinically important sex differences remain underexplored. METHODS Hydrogel biomaterials were designed to recapitulate key aspects of the valve tissue microenvironment and to serve as a culture platform for sex-specific valvular interstitial cells (VICs; precursors to profibrotic myofibroblasts). The hydrogel culture system was used to interrogate intracellular pathways involved in sex-dependent VIC-to-myofibroblast activation and deactivation. RNA sequencing was used to define pathways involved in driving sex-dependent activation. Interventions with small molecule inhibitors and siRNA transfections were performed to provide mechanistic insight into sex-specific cellular responses to microenvironmental cues, including matrix stiffness and exogenously delivered biochemical factors. RESULTS In both healthy porcine and human aortic valves, female leaflets had higher baseline activation of the myofibroblast marker α-smooth muscle actin compared with male leaflets. When isolated and cultured, female porcine and human VICs had higher levels of basal α-smooth muscle actin stress fibers that further increased in response to the hydrogel matrix stiffness, both of which were higher than in male VICs. A transcriptomic analysis of male and female porcine VICs revealed Rho-associated protein kinase signaling as a potential driver of this sex-dependent myofibroblast activation. Furthermore, we found that genes that escape X-chromosome inactivation such as BMX and STS (encoding for Bmx nonreceptor tyrosine kinase and steroid sulfatase, respectively) partially regulate the elevated female myofibroblast activation through Rho-associated protein kinase signaling. This finding was confirmed by treating male and female VICs with endothelin-1 and plasminogen activator inhibitor-1, factors that are secreted by endothelial cells and known to drive myofibroblast activation through Rho-associated protein kinase signaling. CONCLUSIONS Together, in vivo and in vitro results confirm sex dependencies in myofibroblast activation pathways and implicate genes that escape X-chromosome inactivation in regulating sex differences in myofibroblast activation and subsequent aortic valve stenosis progression. Our results underscore the importance of considering sex as a biological variable to understand the molecular mechanisms of aortic valve stenosis and to help guide sex-based precision therapies.
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Affiliation(s)
- Brian A. Aguado
- Department of Chemical and Biological Engineering, University of Colorado Boulder, CO 80303, USA
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Cierra J. Walker
- Materials Science and Engineering Program, University of Colorado Boulder, CO 80309, USA
- Department of Biochemistry, University of Colorado Boulder, CO 80303, USA
| | - Joseph C. Grim
- Department of Chemical and Biological Engineering, University of Colorado Boulder, CO 80303, USA
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
| | - Megan E. Schroeder
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
- Materials Science and Engineering Program, University of Colorado Boulder, CO 80309, USA
| | - Dilara Batan
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
- Department of Biochemistry, University of Colorado Boulder, CO 80303, USA
| | - Brandon J. Vogt
- Department of Chemical and Biological Engineering, University of Colorado Boulder, CO 80303, USA
- Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Sanford Consortium for Regenerative Medicine, La Jolla, CA 92037, USA
| | - Andrea Gonzalez Rodriguez
- Department of Chemical and Biological Engineering, University of Colorado Boulder, CO 80303, USA
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
| | - Jessica A. Schwisow
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Karen S. Moulton
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Robert M. Weiss
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242
| | - Donald D. Heistad
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242
| | - Leslie A. Leinwand
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
- Department of Molecular, Cellular, and Developmental Biology, University of Colorado Boulder, CO 80309, USA
| | - Kristi S. Anseth
- Department of Chemical and Biological Engineering, University of Colorado Boulder, CO 80303, USA
- BioFrontiers Institute, University of Colorado Boulder, CO 80309, USA
- Materials Science and Engineering Program, University of Colorado Boulder, CO 80309, USA
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9
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Han RI, Hu CW, Loose DS, Yang L, Li L, Connell JP, Reardon MJ, Lawrie GM, Qutub AA, Morrisett JD, Grande-Allen KJ. Differential proteome profile, biological pathways, and network relationships of osteogenic proteins in calcified human aortic valves. Heart Vessels 2022; 37:347-358. [PMID: 34727208 PMCID: PMC10960607 DOI: 10.1007/s00380-021-01975-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 10/22/2021] [Indexed: 11/30/2022]
Abstract
Calcific aortic valve disease (CAVD) is the most common heart valve disease requiring intervention. Most research on CAVD has focused on inflammation, ossification, and cellular phenotype transformation. To gain a broader picture into the wide range of cellular and molecular mechanisms involved in this disease, we compared the total protein profiles between calcified and non-calcified areas from 5 human valves resected during surgery. The 1413 positively identified proteins were filtered down to 248 proteins present in both calcified and non-calcified segments of at least 3 of the 5 valves, which were then analyzed using Ingenuity Pathway Analysis. Concurrently, the top 40 differentially abundant proteins were grouped according to their biological functions and shown in interactive networks. Finally, the abundance of selected osteogenic proteins (osteopontin, osteonectin, osteocalcin, osteoprotegerin, and RANK) was quantified using ELISA and/or immunohistochemistry. The top pathways identified were complement system, acute phase response signaling, metabolism, LXR/RXR and FXR/RXR activation, actin cytoskeleton, mineral binding, nucleic acid interaction, structural extracellular matrix (ECM), and angiogenesis. There was a greater abundance of osteopontin, osteonectin, osteocalcin, osteoprotegerin, and RANK in the calcified regions than the non-calcified ones. The osteogenic proteins also formed key connections between the biological signaling pathways in the network model. In conclusion, this proteomic analysis demonstrated the involvement of multiple signaling pathways in CAVD. The interconnectedness of these pathways provides new insights for the treatment of this disease.
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Affiliation(s)
- Richard I Han
- Department of Bioengineering, Rice University, 6100 Main Street, MS-142, Houston, TX, 77030, USA
- Division of Atherosclerosis and Vascular Medicine, Departments of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Chenyue W Hu
- Department of Bioengineering, Rice University, 6100 Main Street, MS-142, Houston, TX, 77030, USA
| | - David S Loose
- Department of Integrative Biology and Pharmacology, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Li Yang
- Department of Pathology, University of Washington, Seattle, WA, USA
| | - Li Li
- Clinical and Translational Proteomics Service Center, University of Texas Health Sciences at Houston, Houston, TX, USA
| | - Jennifer P Connell
- Department of Bioengineering, Rice University, 6100 Main Street, MS-142, Houston, TX, 77030, USA
| | - Michael J Reardon
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Gerald M Lawrie
- Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Amina A Qutub
- Department of Biomedical Engineering, University of Texas at San Antonio, San Antonio, TX, USA
| | - Joel D Morrisett
- Division of Atherosclerosis and Vascular Medicine, Departments of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - K Jane Grande-Allen
- Department of Bioengineering, Rice University, 6100 Main Street, MS-142, Houston, TX, 77030, USA.
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10
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Ferrari S, Pesce M. The Complex Interplay of Inflammation, Metabolism, Epigenetics, and Sex in Calcific Disease of the Aortic Valve. Front Cardiovasc Med 2022; 8:791646. [PMID: 35071359 PMCID: PMC8770423 DOI: 10.3389/fcvm.2021.791646] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/30/2021] [Indexed: 12/20/2022] Open
Abstract
Calcification of the aortic valve is one of the most rapidly increasing pathologies in the aging population worldwide. Traditionally associated to cardiovascular risk conditions, this pathology is still relatively unaddressed on a molecular/cellular standpoint and there are no available treatments to retard its progression unless valve substitution. In this review, we will describe some of the most involved inflammatory players, the metabolic changes that may be responsible of epigenetic modifications and the gender-related differences in the onset of the disease. A better understanding of these aspects and their integration into a unique pathophysiology context is relevant to improve current therapies and patients management.
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Affiliation(s)
- Silvia Ferrari
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Maurizio Pesce
- Unità di Ingegneria Tissutale Cardiovascolare, Centro Cardiologico Monzino, IRCCS, Milan, Italy
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11
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Pacheco C, Mullen KA, Coutinho T, Jaffer S, Parry M, Van Spall HG, Clavel MA, Edwards JD, Sedlak T, Norris CM, Dhukai A, Grewal J, Mulvagh SL. THE CANADIAN WOMEN’S HEART HEALTH ALLIANCE ATLAS ON THE EPIDEMIOLOGY, DIAGNOSIS, AND MANAGEMENT OF CARDIOVASCULAR DISEASE IN WOMEN -- CHAPTER 5: SEX- AND GENDER-UNIQUE MANIFESTATIONS OF CARDIOVASCULAR DISEASE. CJC Open 2021; 4:243-262. [PMID: 35386135 PMCID: PMC8978072 DOI: 10.1016/j.cjco.2021.11.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022] Open
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12
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Walker CJ, Schroeder ME, Aguado BA, Anseth KS, Leinwand LA. Matters of the heart: Cellular sex differences. J Mol Cell Cardiol 2021; 160:42-55. [PMID: 34166708 PMCID: PMC8571046 DOI: 10.1016/j.yjmcc.2021.04.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/12/2021] [Accepted: 04/24/2021] [Indexed: 02/06/2023]
Abstract
Nearly all cardiovascular diseases show sexual dimorphisms in prevalence, presentation, and outcomes. Until recently, most clinical trials were carried out in males, and many animal studies either failed to identify the sex of the animals or combined data obtained from males and females. Cellular sex in the heart is relatively understudied and many studies fail to report the sex of the cells used for in vitro experiments. Moreover, in the small number of studies in which sex is reported, most of those studies use male cells. The observation that cells from males and females are inherently different is becoming increasingly clear - either due to acquired differences from hormones and other factors or due to intrinsic differences in genotype (XX or XY). Because of the likely contribution of cellular sex differences in cardiac health and disease, here, we explore differences in mammalian male and female cells in the heart, including the less-studied non-myocyte cell populations. We discuss how the heart's microenvironment impacts male and female cellular phenotypes and vice versa, including how secretory profiles are dependent on cellular sex, and how hormones contribute to sexually dimorphic phenotypes and cellular functions. Intracellular mechanisms that contribute to sex differences, including gene expression and epigenetic remodeling, are also described. Recent single-cell sequencing studies have revealed unexpected sex differences in the composition of cell types in the heart which we discuss. Finally, future recommendations for considering cellular sex differences in the design of bioengineered in vitro disease models of the heart are provided.
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Affiliation(s)
- Cierra J Walker
- Materials Science and Engineering Program, University of Colorado, Boulder, CO 80303, United States of America; Interdisciplinary Quantitative Biology, University of Colorado, Boulder, CO 80303, United States of America; BioFrontiers Institute, University of Colorado, Boulder, CO 80303, United States of America
| | - Megan E Schroeder
- Chemical and Biological Engineering Department, University of Colorado, Boulder, CO 80303, United States of America; BioFrontiers Institute, University of Colorado, Boulder, CO 80303, United States of America
| | - Brian A Aguado
- Chemical and Biological Engineering Department, University of Colorado, Boulder, CO 80303, United States of America; BioFrontiers Institute, University of Colorado, Boulder, CO 80303, United States of America
| | - Kristi S Anseth
- Chemical and Biological Engineering Department, University of Colorado, Boulder, CO 80303, United States of America; BioFrontiers Institute, University of Colorado, Boulder, CO 80303, United States of America
| | - Leslie A Leinwand
- BioFrontiers Institute, University of Colorado, Boulder, CO 80303, United States of America; Molecular, Cellular, and Developmental Biology, University of Colorado, Boulder, CO 80309, United States of America.
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13
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Gonzalez Rodriguez A, Schroeder ME, Grim JC, Walker CJ, Speckl KF, Weiss RM, Anseth KS. Tumor necrosis factor-α promotes and exacerbates calcification in heart valve myofibroblast populations. FASEB J 2021; 35:e21382. [PMID: 33554387 DOI: 10.1096/fj.202002013rr] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/04/2021] [Accepted: 01/06/2021] [Indexed: 12/16/2022]
Abstract
Pro-inflammatory cytokines play critical roles in regulating valvular interstitial cell (VIC) phenotypic changes that can cause heart valve fibrosis and calcification. Tumor necrosis factor alpha (TNF-α) is a cytokine known to influence VIC behavior and has been reported at high levels in calcified valves ex vivo. We sought to understand the specific effects of TNF-α on VIC phenotypes (eg, fibroblast, profibrotic activated myofibroblasts) and its link with heart valve disorders. We characterize human aortic valve tissue from patients with valve disorders and identify a high variability of fibrotic and calcific markers between tissues. These results motivated in vitro studies to explore the effects of TNF-α on defined VIC fibroblasts and profibrotic activated myofibroblasts, induced via FGF-2 and TGF-β1 treatment. Using 3D hydrogels to culture VICs, we measure the effect of TNF-α (0.1-10 ng/mL) on key markers of fibrosis (eg, αSMA, COL1A1) and calcification (eg, RUNX2, BMP2, and calcium deposits). We observe calcification in TNF-α-treated VIC activated myofibroblasts and identify the MAPK/ERK signaling cascade as a potential pathway for TNF-α mediated calcification. Conversely, VIC fibroblasts respond to TNF-α with decreased calcification. Treatment of VIC profibrotic activated myofibroblast populations with TNF-α leads to increased calcification. Our in vitro findings correlate with findings in diseased human valves and highlight the importance of understanding the effect of cytokines and signaling pathways on specific VIC phenotypes. Finally, we reveal MAPK/ERK as a potential pathway involved in VIC-mediated matrix calcification with TNF-α treatment, suggesting this pathway as a potential pharmaceutical target for aortic valve disease.
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Affiliation(s)
- Andrea Gonzalez Rodriguez
- Department of Chemical and Biological Engineering, University of Colorado Boulder, Boulder, CO, USA.,BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, USA
| | - Megan E Schroeder
- BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, USA.,Materials Science and Engineering Program, University of Colorado Boulder, Boulder, CO, USA
| | - Joseph C Grim
- Department of Chemical and Biological Engineering, University of Colorado Boulder, Boulder, CO, USA.,BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, USA
| | - Cierra J Walker
- BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, USA.,Materials Science and Engineering Program, University of Colorado Boulder, Boulder, CO, USA
| | - Kelly F Speckl
- Department of Chemical and Biological Engineering, University of Colorado Boulder, Boulder, CO, USA
| | - Robert M Weiss
- Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Kristi S Anseth
- Department of Chemical and Biological Engineering, University of Colorado Boulder, Boulder, CO, USA.,BioFrontiers Institute, University of Colorado Boulder, Boulder, CO, USA.,Materials Science and Engineering Program, University of Colorado Boulder, Boulder, CO, USA
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14
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Büttner P, Feistner L, Lurz P, Thiele H, Hutcheson JD, Schlotter F. Dissecting Calcific Aortic Valve Disease-The Role, Etiology, and Drivers of Valvular Fibrosis. Front Cardiovasc Med 2021; 8:660797. [PMID: 34041283 PMCID: PMC8143377 DOI: 10.3389/fcvm.2021.660797] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/08/2021] [Indexed: 12/15/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is a highly prevalent and progressive disorder that ultimately causes gradual narrowing of the left ventricular outflow orifice with ensuing devastating hemodynamic effects on the heart. Calcific mineral accumulation is the hallmark pathology defining this process; however, fibrotic extracellular matrix (ECM) remodeling that leads to extensive deposition of fibrous connective tissue and distortion of the valvular microarchitecture similarly has major biomechanical and functional consequences for heart valve function. Significant advances have been made to unravel the complex mechanisms that govern these active, cell-mediated processes, yet the interplay between fibrosis and calcification and the individual contribution to progressive extracellular matrix stiffening require further clarification. Specifically, we discuss (1) the valvular biomechanics and layered ECM composition, (2) patterns in the cellular contribution, temporal onset, and risk factors for valvular fibrosis, (3) imaging valvular fibrosis, (4) biomechanical implications of valvular fibrosis, and (5) molecular mechanisms promoting fibrotic tissue remodeling and the possibility of reverse remodeling. This review explores our current understanding of the cellular and molecular drivers of fibrogenesis and the pathophysiological role of fibrosis in CAVD.
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Affiliation(s)
- Petra Büttner
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Lukas Feistner
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Philipp Lurz
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Joshua D. Hutcheson
- Department of Biomedical Engineering, Florida International University, Miami, FL, United States
- Biomolecular Sciences Institute, Florida International University, Miami, FL, United States
| | - Florian Schlotter
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
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15
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Woodward HJ, Zhu D, Hadoke PWF, MacRae VE. Regulatory Role of Sex Hormones in Cardiovascular Calcification. Int J Mol Sci 2021; 22:4620. [PMID: 33924852 PMCID: PMC8125640 DOI: 10.3390/ijms22094620] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/20/2021] [Accepted: 04/26/2021] [Indexed: 02/06/2023] Open
Abstract
Sex differences in cardiovascular disease (CVD), including aortic stenosis, atherosclerosis and cardiovascular calcification, are well documented. High levels of testosterone, the primary male sex hormone, are associated with increased risk of cardiovascular calcification, whilst estrogen, the primary female sex hormone, is considered cardioprotective. Current understanding of sexual dimorphism in cardiovascular calcification is still very limited. This review assesses the evidence that the actions of sex hormones influence the development of cardiovascular calcification. We address the current question of whether sex hormones could play a role in the sexual dimorphism seen in cardiovascular calcification, by discussing potential mechanisms of actions of sex hormones and evidence in pre-clinical research. More advanced investigations and understanding of sex hormones in calcification could provide a better translational outcome for those suffering with cardiovascular calcification.
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Affiliation(s)
- Holly J. Woodward
- The Roslin Institute & R(D)SVS, University of Edinburgh, Easter Bush, Midlothian EH25 9RG, UK;
| | - Dongxing Zhu
- Guangzhou Institute of Cardiovascular Disease, Guangdong Key Laboratory of Vascular Diseases, State Key Laboratory of Respiratory Disease, the Second Affiliated Hospital, Guangzhou Medical University, Guangzhou 510260, China
| | - Patrick W. F. Hadoke
- University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK;
| | - Victoria E. MacRae
- The Roslin Institute & R(D)SVS, University of Edinburgh, Easter Bush, Midlothian EH25 9RG, UK;
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16
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Fleury MA, Clavel MA. Sex and Race Differences in the Pathophysiology, Diagnosis, Treatment, and Outcomes of Valvular Heart Diseases. Can J Cardiol 2021; 37:980-991. [PMID: 33581193 DOI: 10.1016/j.cjca.2021.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/20/2021] [Accepted: 02/03/2021] [Indexed: 12/22/2022] Open
Abstract
Valvular heart diseases have long been considered to be similar in men and women and across races/ethnicities. Recently, studies have demonstrated major differences between sexes. Unfortunately, studies on valvular heart diseases, as on other cardiovascular diseases, are mostly performed in Caucasian men or in cohorts with a vast majority of Caucasian men. Therefore, our knowledge on valvular diseases in women and non-Caucasians remains limited. Nevertheless, aortic stenosis has been shown to be almost as prevalent in women as in men, and less prevalent in African Americans. Men appear to have a more calcified aortic valve lesion, and women tend to have a more fibrosed one. Primary mitral regurgitation is more frequent in women who have more rheumatic and Barlow etiologies, whereas men have more fibroelastic deficiency and posterior leaflet prolapse/flail. Left ventricular remodelling due to valvular heart diseases is sex related in terms of geometry and probably also in composition of the tissue. Outcomes seem to be worse in women after surgical interventions and better than or equivalent to men after transcatheter ones. Regarding other valvular heart diseases, very few studies are available: Aortic regurgitation is more frequent in men, isolated tricuspid regurgitation more frequent in women. Rheumatic valve diseases are more frequent in women and are mostly represented by mitral and aortic stenoses. Many other sex/gender- and race/ethnic-specific studies are still needed in epidemiology, pathophysiology, presentation, management, and outcomes. This review aims to report the available data on sex differences and race specificities in valvular heart diseases, with a primary focus on aortic stenosis and mitral regurgitation.
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Affiliation(s)
- Marie-Ange Fleury
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute, Laval University, Québec City, Québec, Canada.
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17
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Schroeder ME, Gonzalez Rodriguez A, Speckl KF, Walker CJ, Midekssa FS, Grim JC, Weiss RM, Anseth KS. Collagen networks within 3D PEG hydrogels support valvular interstitial cell matrix mineralization. Acta Biomater 2021; 119:197-210. [PMID: 33181362 PMCID: PMC7738375 DOI: 10.1016/j.actbio.2020.11.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023]
Abstract
Enzymatically degradable hydrogels were designed for the 3D culture of valvular interstitial cells (VICs), and through the incorporation of various functionalities, we aimed to investigate the role of the tissue microenvironment in promoting the osteogenic properties of VICs and matrix mineralization. Specifically, porcine VICs were encapsulated in a poly(ethylene glycol) hydrogel crosslinked with a matrix metalloproteinase (MMP)-degradable crosslinker (KCGPQG↓IWGQCK) and formed via a thiol-ene photoclick reaction in the presence or absence of collagen type I to promote matrix mineralization. VIC-laden hydrogels were treated with osteogenic medium for up to 15 days, and the osteogenic response was characterized by the expression of RUNX2 as an early marker of an osteoblast-like phenotype, osteocalcin (OCN) as a marker of a mature osteoblast-like phenotype, and vimentin (VIM) as a marker of the fibroblast phenotype. In addition, matrix mineralization was characterized histologically with Von Kossa stain for calcium phosphate. Osteogenic response was further characterized biochemically with calcium assays, and physically via optical density measurements. When the osteogenic medium was supplemented with calcium chloride, OCN expression was upregulated and mineralization was discernable at 12 days of culture. Finally, this platform was used to screen various drug therapeutics that were assessed for their efficacy in preventing mineralization using optical density as a higher throughput readout. Collectively, these results suggest that matrix composition has a key role in supporting mineralization deposition within diseased valve tissue.
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Affiliation(s)
- Megan E Schroeder
- Materials Science and Engineering Program, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA; The BioFrontiers Institute, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA
| | - Andrea Gonzalez Rodriguez
- Department of Chemical and Biological Engineering, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA; The BioFrontiers Institute, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA
| | - Kelly F Speckl
- Department of Chemical and Biological Engineering, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA; The BioFrontiers Institute, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA
| | - Cierra J Walker
- Materials Science and Engineering Program, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA; The BioFrontiers Institute, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA
| | - Firaol S Midekssa
- Department of Chemical and Biological Engineering, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA
| | - Joseph C Grim
- Department of Chemical and Biological Engineering, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA; The BioFrontiers Institute, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA
| | - Robert M Weiss
- Department of Internal Medicine, University of Iowa, 200 Hawkins Dr, Iowa City, IA, 52242
| | - Kristi S Anseth
- Materials Science and Engineering Program, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA; Department of Chemical and Biological Engineering, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA; The BioFrontiers Institute, University of Colorado Boulder, 3415 Colorado Avenue, Boulder CO 80303, USA.
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18
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Summerhill VI, Moschetta D, Orekhov AN, Poggio P, Myasoedova VA. Sex-Specific Features of Calcific Aortic Valve Disease. Int J Mol Sci 2020; 21:ijms21165620. [PMID: 32781508 PMCID: PMC7460640 DOI: 10.3390/ijms21165620] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/21/2020] [Accepted: 07/31/2020] [Indexed: 01/09/2023] Open
Abstract
Calcific aortic valve disease (CAVD) is the most common valvular heart disease in developed countries predominantly affecting the elderly population therefore posing a large economic burden. It is a gradually progressive condition ranging from mild valve calcification and thickening, without the hemodynamic obstruction, to severe calcification impairing leaflet motion, known as aortic stenosis (AS). The progression of CAVD occurs over many years, and it is extremely variable among individuals. It is also associated with an increased risk of coronary events and mortality. The recent insights into the CAVD pathophysiology included an important role of sex. Accumulating evidence suggests that, in patients with CAVD, sex can determine important differences in the relationship between valvular calcification process, fibrosis, and aortic stenosis hemodynamic severity between men and women. Consequently, it has implications on the development of different valvular phenotypes, left ventricular hypertrophy, and cardiovascular outcomes in men and women. Along these lines, taking into account the sex-related differences in diagnosis, prognosis, and treatment outcomes is of profound importance. In this review, the sex-related differences in patients with CAVD, in terms of pathobiology, clinical phenotypes, and outcomes were discussed.
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Affiliation(s)
- Volha I. Summerhill
- Department of Basic Research, Institute for Atherosclerosis Research, Skolkovo Innovative Center, 121609 Moscow, Russia;
- Correspondence:
| | - Donato Moschetta
- Unit for the Study of Aortic, Valvular and Coronary Pathologies, Monzino Cardiology Center IRCCS, 20138 Milan, Italy; (D.M.); (P.P.); (V.A.M.)
- Department of Pharmacological and Biomolecular Sciences, The University of Milan, 20133 Milan, Italy
| | - Alexander N. Orekhov
- Department of Basic Research, Institute for Atherosclerosis Research, Skolkovo Innovative Center, 121609 Moscow, Russia;
- Laboratory of Angiopathology, Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, 125315 Moscow, Russia
| | - Paolo Poggio
- Unit for the Study of Aortic, Valvular and Coronary Pathologies, Monzino Cardiology Center IRCCS, 20138 Milan, Italy; (D.M.); (P.P.); (V.A.M.)
| | - Veronika A. Myasoedova
- Unit for the Study of Aortic, Valvular and Coronary Pathologies, Monzino Cardiology Center IRCCS, 20138 Milan, Italy; (D.M.); (P.P.); (V.A.M.)
- Laboratory of Angiopathology, Institute of General Pathology and Pathophysiology, Russian Academy of Medical Sciences, 125315 Moscow, Russia
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19
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Voisine M, Hervault M, Shen M, Boilard AJ, Filion B, Rosa M, Bossé Y, Mathieu P, Côté N, Clavel MA. Age, Sex, and Valve Phenotype Differences in Fibro-Calcific Remodeling of Calcified Aortic Valve. J Am Heart Assoc 2020; 9:e015610. [PMID: 32384012 PMCID: PMC7660864 DOI: 10.1161/jaha.119.015610] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background In calcific aortic valve disease on tricuspid aortic valves (TAVs), men have higher aortic valve calcification and less fibrosis than women. However, little is known in bicuspid aortic valves (BAV). We thus aimed to investigate the impact of age, sex, and valve phenotype (TAVs versus BAVs) on fibro‐calcific remodeling in calcific aortic valve disease. Methods and Results We included 2 cohorts: 411 patients who underwent multidetector computed tomography (37% women) for aortic valve calcification density assessment and 138 explanted aortic valves (histological cohort; 50% women). The cohorts were divided in younger (<60 years old) or older patients with BAV (≥60 years old), and TAV patients. In each group, women and men were matched. Women presented less aortic valve calcification density than men in each group of the multidetector computed tomography cohort (all P≤0.01). Moreover, in women, younger patients with BAV had the lowest aortic valve calcification density (both P=0.02). In multivariate analysis, aortic valve calcification density correlated with age (β estimate±standard error: 6.5±1.8; P=0.0004) and male sex (109.2±18.4; P<0.0001), and there was a trend with TAVs (41.5±23.0; P=0.07). Women presented a higher collagen content than men (77.8±10.8 versus 69.9±12.9%; P<0.001) in the entire cohort. In women, younger patients with BAV had denser connective tissue than TAV and older patients with BAV (both P≤0.05), while no difference was observed between men. Conclusions In calcific aortic valve disease, women had less calcification and more fibrotic remodeling than men, regardless of the phenotype of the valve or age of the patient. Moreover, younger women with BAVs had less valve calcification. Thus, mineralization/fibrosis of the aortic valve is likely to have sex/age‐specific mechanisms and be influenced by the valve morphology.
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Affiliation(s)
- Martine Voisine
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Maxime Hervault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Mylène Shen
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Anne-Julie Boilard
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Benoît Filion
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Mickael Rosa
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Yohan Bossé
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Patrick Mathieu
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Nancy Côté
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec/Québec Heart and Lung Institute Université Laval Québec City Québec Canada
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20
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Gourgas O, Khan K, Schwertani A, Cerruti M. Differences in mineral composition and morphology between men and women in aortic valve calcification. Acta Biomater 2020; 106:342-350. [PMID: 32092430 DOI: 10.1016/j.actbio.2020.02.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 01/31/2020] [Accepted: 02/18/2020] [Indexed: 01/02/2023]
Abstract
Aortic valve calcification leads to the deposition of calcium phosphate minerals in the extracellular matrix of the aortic valve leaflets. The mineral deposits can severely narrow the opening of the aortic valve, leading to aortic stenosis. There are no therapies to halt or slow down disease progression and the mechanisms governing aortic valve calcification are still poorly understood. Recently, several studies have shown that for the same aortic stenosis severity, women present significantly lower calcification loads than men. The cause of this sex-related difference is unknown. To understand this difference, we analyzed mineral deposits from surgically excised calcified human aortic valves with different material characterization techniques. We find profound differences in mineral composition and morphology between sexes, which strongly suggest that minerals form slower in women than in men and follow a different mineralization pathway. This finding paves the way for new approaches specifically geared towards men or women in the diagnosis and treatment of aortic valve calcification. STATEMENT OF SIGNIFICANCE: Aortic valve calcification is a health disorder with increasing prevalence and high morbidity and mortality. Currently there is no approved effective treatment; the only available therapeutic option is invasive valve replacement, to which not all patients are suited. The main reason for such lack of treatment options is our lack of understanding of the calcification mechanism. In this study, we show profound differences in mineral composition and morphology between sexes, suggesting that aortic valve calcification follows different mineralization pathways in men and women. These findings pave the way for new approaches specifically geared towards men or women in the diagnosis and treatment of aortic valve calcification.
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21
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Gee T, Farrar E, Wang Y, Wu B, Hsu K, Zhou B, Butcher J. NFκB (Nuclear Factor κ-Light-Chain Enhancer of Activated B Cells) Activity Regulates Cell-Type-Specific and Context-Specific Susceptibility to Calcification in the Aortic Valve. Arterioscler Thromb Vasc Biol 2020; 40:638-655. [PMID: 31893948 DOI: 10.1161/atvbaha.119.313248] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Although often studied independently, little is known about how aortic valve endothelial cells and valve interstitial cells interact collaborate to maintain tissue homeostasis or drive valve calcific pathogenesis. Inflammatory signaling is a recognized initiator of valve calcification, but the cell-type-specific downstream mechanisms have not been elucidated. In this study, we test how inflammatory signaling via NFκB (nuclear factor κ-light-chain enhancer of activated B cells) activity coordinates unique and shared mechanisms of valve endothelial cells and valve interstitial cells differentiation during calcific progression. Approach and Results: Activated NFκB was present throughout the calcific aortic valve disease (CAVD) process in both endothelial and interstitial cell populations in an established mouse model of hypercholesterolemia-induced CAVD and in human CAVD. NFκB activity induces endothelial to mesenchymal transformation in 3-dimensional cultured aortic valve endothelial cells and subsequent osteogenic calcification of transformed cells. Similarly, 3-dimensional cultured valve interstitial cells calcified via NFκB-mediated osteogenic differentiation. NFκB-mediated endothelial to mesenchymal transformation was directly demonstrated in vivo during CAVD via genetic lineage tracking. Genetic deletion of NFκB in either whole valves or valve endothelium only was sufficient to prevent valve-specific molecular and cellular mechanisms of CAVD in vivo despite the persistence of a CAVD inducing environment. CONCLUSIONS Our results identify NFκB signaling as an essential molecular regulator for both valve endothelial and interstitial participation in CAVD pathogenesis. Direct demonstration of valve endothelial cell endothelial to mesenchymal transformation transmigration in vivo during CAVD highlights a new cellular population for further investigation in CAVD morbidity. The efficacy of valve-specific NFκB modulation in inhibiting hypercholesterolemic CAVD suggests potential benefits of multicell type integrated investigation for biological therapeutic development and evaluation for CAVD.
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Affiliation(s)
- Terence Gee
- From the Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY (T.G., E.F., K.H., J.B.)
| | - Emily Farrar
- From the Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY (T.G., E.F., K.H., J.B.)
| | - Yidong Wang
- Department of Genetics, Pediatrics, and Medicine (Cardiology), Wilf Cardiovascular Research Institute, Albert Einstein College of Medicine, Bronx, NY (Y.W., B.W., B.Z.)
| | - Bingruo Wu
- Department of Genetics, Pediatrics, and Medicine (Cardiology), Wilf Cardiovascular Research Institute, Albert Einstein College of Medicine, Bronx, NY (Y.W., B.W., B.Z.)
| | - Kevin Hsu
- From the Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY (T.G., E.F., K.H., J.B.)
| | - Bin Zhou
- Department of Genetics, Pediatrics, and Medicine (Cardiology), Wilf Cardiovascular Research Institute, Albert Einstein College of Medicine, Bronx, NY (Y.W., B.W., B.Z.)
| | - Jonathan Butcher
- From the Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY (T.G., E.F., K.H., J.B.)
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Parra-Izquierdo I, Castaños-Mollor I, López J, Gómez C, San Román JA, Sánchez Crespo M, García-Rodríguez C. Lipopolysaccharide and interferon-γ team up to activate HIF-1α via STAT1 in normoxia and exhibit sex differences in human aortic valve interstitial cells. Biochim Biophys Acta Mol Basis Dis 2019; 1865:2168-2179. [PMID: 31034990 DOI: 10.1016/j.bbadis.2019.04.014] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/17/2019] [Accepted: 04/24/2019] [Indexed: 12/20/2022]
Abstract
In early stages of calcific aortic valve disease (CAVD), immune cells infiltrate into the valve leaflets and release cytokines such as interferon (IFN)-γ. IFN-γ has context-dependent direct effects, and also regulates other immune pathways. The purpose of this study was addressing the effects of IFN-γ on human aortic valve interstitial cells (AVICs), focusing on the pathogenic processes underlying CAVD. Strikingly, under normoxic conditions, IFN-γ induced hypoxia inducible factor (HIF)-1α expression, an effect strongly potentiated by the Toll-like receptor (TLR)-4 ligand lipopolysaccharide (LPS). Immunodetection studies confirmed the nuclear translocation of HIF-1α. Gene silencing showed that HIF-1α expression is dependent on signal transducer and activator of transcription (STAT)-1 expression. Consistent with HIF-1α induction, the secretion of the endothelial growth factor was detected by ELISA, and downregulation of the antiangiogenic factor chondromodulin-1 gene was observed by qPCR. Results also disclosed IFN-γ as a proinflammatory cytokine that cooperates with LPS to induce the expression of adhesion molecules, prostaglandin E2 and interleukins. Moreover, IFN-γ induced an osteogenic phenotype and promoted in vitro calcification that were markedly potentiated by LPS. Pharmacological experiments disclosed the involvement of Janus Kinases (JAK)/STATs as well as ERK/HIF-1α routes on the induction of calcification. Notably, IFN-γ receptor 1 expression, as well as ERK/HIF-1α activation, and the subsequent responses were more robust in male AVICs. This is the first report uncovering an immune and non-hypoxic activation of HIF-1α via STAT1 in AVIC. The aforementioned results and the sex-differential responses may be potentially relevant to better understand CAVD pathogenesis.
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Affiliation(s)
- Iván Parra-Izquierdo
- Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Valladolid, Spain
| | - Irene Castaños-Mollor
- Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Valladolid, Spain
| | - Javier López
- ICICOR, Hospital Clínico Universitario, Valladolid, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Cristina Gómez
- Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Valladolid, Spain
| | - J Alberto San Román
- ICICOR, Hospital Clínico Universitario, Valladolid, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Mariano Sánchez Crespo
- Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Valladolid, Spain
| | - Carmen García-Rodríguez
- Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Valladolid, Spain; CIBER de Enfermedades Cardiovasculares (CIBERCV), Spain.
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23
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Parra-Izquierdo I, Castaños-Mollor I, López J, Gómez C, San Román JA, Sánchez Crespo M, García-Rodríguez C. Calcification Induced by Type I Interferon in Human Aortic Valve Interstitial Cells Is Larger in Males and Blunted by a Janus Kinase Inhibitor. Arterioscler Thromb Vasc Biol 2019; 38:2148-2159. [PMID: 30026273 DOI: 10.1161/atvbaha.118.311504] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective- Calcific aortic valve disease is the most prevalent valvulopathy in Western countries. An unanticipated pathogenetic clue involving IFN (interferon) was disclosed by the finding of constitutive type I IFN activity associated with aortic valve calcification in children with the atypical Singleton-Merten syndrome. On this basis, the role of type I IFN on inflammation and calcification in human aortic valve interstitial cells (AVIC) was examined. Approach and Results- IFN-α was weakly proinflammatory but potentiated lipopolysaccharide-mediated activation of NF (nuclear factor)-κB and the ensuing induction of proinflammatory molecules in human AVIC. Stimulation with IFN-α and in combination with lipopolysaccharide promoted osteoblast-like differentiation characterized by increased osteoblastic gene expression, BMP (bone morphogenetic protein)-2 secretion, and ectopic phosphatase activity. Sex differences were observed. Likewise, IFN-α treatment of human AVICs in osteogenic medium resulted in increased formation of calcific nodules. Strikingly, IFN-α-mediated calcification was significantly higher in AVICs from males, and was blocked by tofacitinib, a JAK (Janus kinase) inhibitor, and by a BMP antagonist. A female-specific protective mechanism involving the activation of PI3K-Akt (protein kinase B) pathways and cell survival was disclosed. Females exhibited higher levels of BCL2 in valve cells and tissues and lower annexin V staining on cell stimulation. Conclusions- IFN-α acts as a proinflammatory and pro-osteogenic cytokine in AVICs, its effects being potentiated by lipopolysaccharide. Results also uncovered sex differences with lower responses in female AVICs and sex-specific mechanisms involving apoptosis. Data point to JAK/STAT (signal transducer and activator of transcription) system as a potential therapeutic target for calcific aortic valve disease.
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Affiliation(s)
- Iván Parra-Izquierdo
- From the Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Spain (I.P.-I., I.C.-M., C.G., M.S.C., C.G.-R.)
| | - Irene Castaños-Mollor
- From the Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Spain (I.P.-I., I.C.-M., C.G., M.S.C., C.G.-R.)
| | - Javier López
- ICICOR, Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain (J.L., J.A.S.R.).,CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.L., J.A.S.R., C.G.-R.)
| | - Cristina Gómez
- From the Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Spain (I.P.-I., I.C.-M., C.G., M.S.C., C.G.-R.)
| | - J Alberto San Román
- ICICOR, Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain (J.L., J.A.S.R.).,CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.L., J.A.S.R., C.G.-R.)
| | - Mariano Sánchez Crespo
- From the Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Spain (I.P.-I., I.C.-M., C.G., M.S.C., C.G.-R.)
| | - Carmen García-Rodríguez
- From the Instituto de Biología y Genética Molecular, CSIC-Universidad de Valladolid, Spain (I.P.-I., I.C.-M., C.G., M.S.C., C.G.-R.).,CIBER de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (J.L., J.A.S.R., C.G.-R.)
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24
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Affiliation(s)
- Ana M Porras
- From the Department of Biomedical Engineering (A.M.P., K.S.M.) and Department of Medicine (K.S.M.), University of Wisconsin-Madison; and Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina, Columbia (C.M.M.)
| | - Chloé M McCoy
- From the Department of Biomedical Engineering (A.M.P., K.S.M.) and Department of Medicine (K.S.M.), University of Wisconsin-Madison; and Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina, Columbia (C.M.M.)
| | - Kristyn S Masters
- From the Department of Biomedical Engineering (A.M.P., K.S.M.) and Department of Medicine (K.S.M.), University of Wisconsin-Madison; and Department of Emergency Medicine, Palmetto Health Richland, University of South Carolina, Columbia (C.M.M.).
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25
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Activation of human aortic valve interstitial cells by local stiffness involves YAP-dependent transcriptional signaling. Biomaterials 2018; 181:268-279. [DOI: 10.1016/j.biomaterials.2018.07.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 12/15/2022]
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26
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Hervault M, Clavel MA. Sex-related Differences in Calcific Aortic Valve Stenosis: Pathophysiology, Epidemiology, Etiology, Diagnosis, Presentation, and Outcomes. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2018. [DOI: 10.1080/24748706.2017.1420273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Maxime Hervault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
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27
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Clavel MA, Iung B, Pibarot P. A nationwide contemporary epidemiological portrait of valvular heart diseases. Heart 2017; 103:1660-1662. [DOI: 10.1136/heartjnl-2017-311472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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