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Al-Bayati A, Alrifai A, Darmoch F, Alkhaimy H, Fanari Z. Transcatheter aortic valve replacement outcomes in patients with high gradient versus low ejection fraction low gradient severe aortic stenosis: A meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00606-7. [PMID: 39089911 DOI: 10.1016/j.carrev.2024.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 06/23/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The outcome of Low Flow-Low Gradient (LF-LG) severe aortic stenosis (AS) patients who underwent Transcatheter Aortic Valve Replacement (TAVR) procedure is not well defined. We conducted a systematic review of the literature to compare the outcomes of TAVR in LF-LG AS patients to the more traditional high gradient (HG) aortic stenosis. METHODS We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We are presenting the data using risk ratios (95 % confidence intervals) and measuring heterogeneity using Higgins' I2 index. RESULTS Our analysis included 4380 patients with 3425 HG patients and 955 LF-LG patients from 6 cohort (5 retrospective and 1 prospective) studies. When compared to LFLG; TAVR was associated with significantly lower 30 days mortality in HG patients (5.1 % vs 7.4 %; relative risk [RR]: 0.55; 95 % confidence interval [CI]: 0.35 to 0.86; p < 0.01). Similar findings were also observed in 12-month cardiovascular (CV) mortality (5.5 % vs. 10.4 %; RR: 0.47; 95 % CI: 0.38 to 0.60; p < 0.01 and 12-month all-cause mortality (15.9 % vs 20.9 %; RR: 0.70; 95 % CI: 0.49 to 1.00; p < 0.05). There was no significant difference in myocardial infarction (MI) after TAVR between HG and LF-LG at 30 days (0.16 % vs. 0.95 %; p < 0.09) or 12 months (0.43 % vs. 0.95 %; p = 0.20). Similarly, there was no difference in stroke rates at 30 days (2.9 % vs. 2.86 %) or at 12 months (3.6 % vs. 3.06 %). CONCLUSIONS AND RELEVANCE Patients with LF-LG severe AS who underwent TAVR had worse 1-year all-cause mortality, 30-day all-cause, and 1-year CV mortality when compared to TAVR in HG severe AS. There was no difference in MI or stroke rates. Therefore, with heart team discussion and informed patient decision regarding the risk and benefit, TAVR would still offer better outcomes in LFLG AS compared to conservative medical management.
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Affiliation(s)
| | | | - Fahed Darmoch
- Northside Hospital Cardiovascular Institute, Cumming, GA, USA
| | - Haytham Alkhaimy
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Zaher Fanari
- University of California San Francisco, Fresno, CA, USA.
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Jain H, Goyal A, Khan AT, Khan NU, Jain J, Chopra S, Sulaiman SA, Reddy MM, Patel K, Khullar K, Daoud M, Sohail AH. Insights into calcific aortic valve stenosis: a comprehensive overview of the disease and advancing treatment strategies. Ann Med Surg (Lond) 2024; 86:3577-3590. [PMID: 38846838 PMCID: PMC11152847 DOI: 10.1097/ms9.0000000000002106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 04/14/2024] [Indexed: 06/09/2024] Open
Abstract
Aortic valve stenosis is a disease characterized by thickening and narrowing of the aortic valve (AV), most commonly due to calcification, which leads to left ventricular outflow obstruction called calcific aortic valve disease (CAVD). CAVD presents as a progressive clinical syndrome with cardiorespiratory symptoms, often with rapid deterioration. The modern-day pathophysiology of CAVD involves a complex interplay of genetic factors, chronic inflammation, lipid deposition, and valve calcification, with early CAVD stages resembling atherosclerosis. Various imaging modalities have been used to evaluate CAVD, with a recent trend of using advanced imaging to measure numerous AV parameters, such as peak jet velocity. Significant improvements in mortality have been achieved with transcatheter AV repair, but numerous therapeutics and modalities are being researched to delay the progression of CAVD. This article aims to provide a comprehensive review of CAVD, explore recent developments, and provide insights into future treatments with various novel modalities.
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Affiliation(s)
- Hritvik Jain
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur
| | - Aman Goyal
- Department of Internal Medicine, Seth Gordhandas Sunderdas (GS) Medical College and King Edward Memorial (KEM) Hospital, Mumbai
| | | | - Noor U. Khan
- Department of Public Health, Health Services Academy, Islamabad, Pakistan
| | - Jyoti Jain
- Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur
| | - Shrey Chopra
- Department of Internal Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi
| | | | | | - Kush Patel
- Department of Internal Medicine, Baroda Medical College, Gujarat
| | - Kaarvi Khullar
- Department of Internal Medicine, Government Medical College and Hospital, Gondia, Maharashtra, India
| | - Mohamed Daoud
- Department of Internal Medicine, Bogomolets National Medical University, Kyiv, Ukraine
| | - Amir H. Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuquerque, New Mexico, USA
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3
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Lin R, Zhu Y, Chen W, Wang Z, Wang Y, Du J. Identification of Circulating Inflammatory Proteins Associated with Calcific Aortic Valve Stenosis by Multiplex Analysis. Cardiovasc Toxicol 2024; 24:499-512. [PMID: 38589550 DOI: 10.1007/s12012-024-09854-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 03/29/2024] [Indexed: 04/10/2024]
Abstract
Calcific aortic valve stenosis (CAVS) is characterized by increasing inflammation and progressive calcification in the aortic valve leaflets and is a major cause of death in the aging population. This study aimed to identify the inflammatory proteins involved in CAVS and provide potential therapeutic targets. We investigated the observational and causal associations of 92 inflammatory proteins, which were measured using affinity-based proteomic assays. Firstly, the case-control cohort identified differential proteins associated with the occurrence and progression of CAVS. Subsequently, we delved into exploring the causal impacts of these associated proteins through Mendelian randomization. This involved utilizing genetic instruments derived from cis-protein quantitative loci identified in genome-wide association studies, encompassing a cohort of over 400,000 individuals. Finally, we investigated the gene transcription and protein expression levels of inflammatory proteins by single-cell and immunohistochemistry analysis. Multivariate logistic regression and spearman's correlation analysis showed that five proteins showed a significant positive correlation with disease severity. Mendelian randomization showed that elevated levels of two proteins, namely, matrix metallopeptidase-1 (MMP1) and sirtuin 2 (SIRT2), were associated with an increased risk of CAVS. Immunohistochemistry and single-cell transcriptomes showed that expression levels of MMP1 and SIRT2 at the tissue and cell levels were significantly higher in calcified valves than in non-calcified control valves. These findings indicate that MMP1 and SIRT2 are causally related to CAVS and open up the possibility for identifying novel therapeutic targets.
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Affiliation(s)
- Rui Lin
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yuexin Zhu
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Weiyao Chen
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Zhiao Wang
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yuan Wang
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China.
| | - Jie Du
- The Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Anzhen Road, Chaoyang District, Beijing, 100029, China.
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4
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Haruyama N, Nakayama M, Yamada S, Tanaka S, Hiyamuta H, Taniguchi M, Tokumoto M, Tsuruya K, Kitazono T, Nakano T. History of fragility fracture is associated with cardiovascular mortality in hemodialysis patients: the Q-Cohort study. J Bone Miner Metab 2024; 42:253-263. [PMID: 38509305 DOI: 10.1007/s00774-024-01501-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/08/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION In patients undergoing dialysis, major bone fracture is associated with a high risk of mortality, including death of cardiovascular (CV) origin. In the present study, we aimed to determine whether a history of fragility fracture is a predictor of CV death in patients undergoing hemodialysis with long-term follow-up. MATERIALS AND METHODS In total, 3499 patients undergoing hemodialysis were analyzed for 10 years. We evaluated the history of fragility fracture in each patient at enrollment. The primary outcome was CV death. A Cox proportional hazard model and a competing risk approach were applied to determine the association between a history of fragility fracture and CV death. RESULTS A total of 346 patients had a history of fragility fracture at enrollment. During a median follow-up of 8.8 years, 1730 (49.4%) patients died. Among them, 621 patients experienced CV death. Multivariable Cox analyses after adjustment for confounding variables showed that a history of fragility fracture was associated with CV death (hazard ratio, 1.47; 95% confidence interval, 1.16-1.85). In the Fine-Gray regression model, a history of fragility fracture was an independent risk factor for CV death (subdistribution hazard ratio, 1.36; 95% confidence interval, 1.07-1.72). CONCLUSION In a large cohort of patients undergoing hemodialysis, a history of fragility fracture was an independent predictor of CV death.
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Affiliation(s)
- Naoki Haruyama
- Division of Nephrology, Department of Internal Medicine, NHO Kyushu Medical Center, Fukuoka, Japan
| | - Masaru Nakayama
- Division of Nephrology, Department of Internal Medicine, NHO Kyushu Medical Center, Fukuoka, Japan
| | - Shunsuke Yamada
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigeru Tanaka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroto Hiyamuta
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | | | - Masanori Tokumoto
- Division of Nephrology and Dialysis Center, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, Kashihara, Nara, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Zhu Z, Liu Z, Zhang D, Li L, Pei J, Cai L. Models for calcific aortic valve disease in vivo and in vitro. CELL REGENERATION (LONDON, ENGLAND) 2024; 13:6. [PMID: 38424219 PMCID: PMC10904700 DOI: 10.1186/s13619-024-00189-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024]
Abstract
Calcific Aortic Valve Disease (CAVD) is prevalent among the elderly as the most common valvular heart disease. Currently, no pharmaceutical interventions can effectively reverse or prevent CAVD, making valve replacement the primary therapeutic recourse. Extensive research spanning decades has contributed to the establishment of animal and in vitro cell models, which facilitates a deeper understanding of the pathophysiological progression and underlying mechanisms of CAVD. In this review, we provide a comprehensive summary and analysis of the strengths and limitations associated with commonly employed models for the study of valve calcification. We specifically emphasize the advancements in three-dimensional culture technologies, which replicate the structural complexity of the valve. Furthermore, we delve into prospective recommendations for advancing in vivo and in vitro model studies of CAVD.
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Affiliation(s)
- Zijin Zhu
- State Key Laboratory of Biocatalysis and Enzyme Engineering, School of Life Science, National & Local Joint Engineering Research Center of High-Throughput Drug Screening Technology, Hubei University, Wuhan, 430062, China
| | - Zhirong Liu
- State Key Laboratory of Biocatalysis and Enzyme Engineering, School of Life Science, National & Local Joint Engineering Research Center of High-Throughput Drug Screening Technology, Hubei University, Wuhan, 430062, China
| | - Donghui Zhang
- State Key Laboratory of Biocatalysis and Enzyme Engineering, School of Life Science, National & Local Joint Engineering Research Center of High-Throughput Drug Screening Technology, Hubei University, Wuhan, 430062, China
| | - Li Li
- State Key Laboratory of Biocatalysis and Enzyme Engineering, School of Life Science, National & Local Joint Engineering Research Center of High-Throughput Drug Screening Technology, Hubei University, Wuhan, 430062, China.
| | - Jianqiu Pei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Beijing Key Laboratory of Metabolic Disorders Related Cardiovascular Disease, Capital Medical University, Beijing, 100069, China.
| | - Lin Cai
- State Key Laboratory of Biocatalysis and Enzyme Engineering, School of Life Science, National & Local Joint Engineering Research Center of High-Throughput Drug Screening Technology, Hubei University, Wuhan, 430062, China.
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Wal P, Rathore S, Aziz N, Singh YK, Gupta A. Aortic stenosis: a review on acquired pathogenesis and ominous combination with diabetes mellitus. Egypt Heart J 2023; 75:26. [PMID: 37027109 PMCID: PMC10082141 DOI: 10.1186/s43044-023-00345-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 03/08/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Aortic stenosis (AS) is a progressive disease, with no pharmacological treatment. The prevalence of diabetes mellitus (DM) among AS patients is higher than in the general population. DM significantly increases the risk of AS development and progression from mild to severe. The interplay between AS and DM's mechanism is not entirely known yet. MAIN BODY The increased accumulation of advanced glycation end products (AGEs) was linked to increased valvular oxidative stress, inflammation, expression of coagulation factors, and signs of calcification, according to an analysis of aortic stenotic valves. It is interesting to note that in diabetic AS patients, valvular inflammation did not correlate with serum glucose levels but rather only with long-term glycemic management markers like glycated haemoglobin and fructosamine. Transcatheter aortic valve replacement, which has been shown to be safer than surgical aortic valve replacement, is advantageous for AS patients who also have concurrent diabetes. Additionally, novel anti-diabetic medications have been proposed to lower the risk of AS development in DM patients, including sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonist that target reduction of AGEs-mediated oxidative stress. CONCLUSIONS There are little data on the effects of hyperglycemia on valvular calcification, but understanding the interactions between them is essential to develop a successful treatment strategy to stop or at least slow the progression of AS in DM patients. There is a link among AS and DM and that DM negatively impacts the quality of life and longevity of AS patients. The sole successful treatment, despite ongoing efforts to find new therapeutic modalities, involves aortic valve replacement. More research is required to find methods that can slow the advancement of these conditions, enhancing the prognosis and course of people with AS and DM.
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Affiliation(s)
- Pranay Wal
- Pranveer Singh Institute of Technology (Pharmacy), Bhauti, Kanpur, UP, 209305, India.
| | - Shruti Rathore
- LCIT School of Pharmacy, Bilaspur, Chhattisgarh, 495220, India
| | - Namra Aziz
- Pranveer Singh Institute of Technology (Pharmacy), Bhauti, Kanpur, UP, 209305, India
| | - Yash Kumar Singh
- Pranveer Singh Institute of Technology (Pharmacy), Bhauti, Kanpur, UP, 209305, India
| | - Arpit Gupta
- Pranveer Singh Institute of Technology (Pharmacy), Bhauti, Kanpur, UP, 209305, India
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7
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Saeedi-Boroujeni A, Purrahman D, Shojaeian A, Poniatowski ŁA, Rafiee F, Mahmoudian-Sani MR. Progranulin (PGRN) as a regulator of inflammation and a critical factor in the immunopathogenesis of cardiovascular diseases. J Inflamm (Lond) 2023; 20:1. [PMID: 36658641 PMCID: PMC9851114 DOI: 10.1186/s12950-023-00327-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/15/2023] [Indexed: 01/20/2023] Open
Abstract
Immune dysregulation has been identified as a critical cause of the most common types of cardiovascular diseases (CVDs). Notably, the innate and adaptive immune responses under physiological conditions are typically regulated with high sensitivity to avoid the exacerbation of inflammation, but any dysregulation can probably be associated with CVDs. In this respect, progranulin (PGRN) serves as one of the main components of the regulation of inflammatory processes, which significantly contributes to the immunopathogenesis of such disorders. PGRN has been introduced among the secreted growth factors as one related to wound healing, inflammation, and human embryonic development, as well as a wide variety of autoimmune diseases. The relationship between the serum PGRN and TNF-α ratio with the spontaneous bacterial peritonitis constitute one of the independent predictors of these conditions. The full-length PGRN can thus effectively reduce the calcification of valve interstitial cells, and the granulin precursor (GRN), among the degradation products of PGRN, can be beneficial. Moreover, it was observed that, PGRN protects the heart against ischemia-reperfusion injury. Above all, PGRN also provides protection in the initial phase following myocardial ischemia-reperfusion injury. The protective impact of PGRN on this may be associated with the early activation of the PI3K/Akt signaling pathway. PGRN also acts as a protective factor in hyperhomocysteinemia, probably by down-regulating the wingless-related integration site Wnt/β-catenin signaling pathway. Many studies have further demonstrated that SARS-CoV-2 (COVID-19) has dramatically increased the risks of CVDs due to inflammation, so PGRN has drawn much more attention among scholars. Lysosomes play a pivotal role in the inflammation process, and PGRN is one of the key regulators in their functioning, which contributes to the immunomodulatory mechanism in the pathogenesis of CVDs. Therefore, investigation of PGRN actions can help find new prospects in the treatment of CVDs. This review aims to summarize the role of PGRN in the immunopathogenesis of CVD, with an emphasis on its treatment.
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Affiliation(s)
- Ali Saeedi-Boroujeni
- Department of Microbiology, School of Medicine, Abadan University of Medical Sciences, Abadan, Iran
| | - Daryush Purrahman
- grid.411230.50000 0000 9296 6873Thalassemia and Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Shojaeian
- grid.411950.80000 0004 0611 9280Research Center for Molecular Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Łukasz A. Poniatowski
- grid.491786.50000 0001 0211 9062Department of Neurosurgery, Dietrich-Bonhoeffer-Klinikum, Neubrandenburg, Germany
| | - Fatemeh Rafiee
- grid.469309.10000 0004 0612 8427Zanjan Metabolic Diseases Research Center, Zanjan University of Medical Science, Zanjan, Iran
| | - Mohammad-Reza Mahmoudian-Sani
- grid.411230.50000 0000 9296 6873Thalassemia and Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran ,grid.411230.50000 0000 9296 6873Clinical Research Development Unit, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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8
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Curini L, Pesce M. Shockwaves delivery for aortic valve therapy-Realistic perspective for clinical translation? Front Cardiovasc Med 2023; 10:1160833. [PMID: 37113704 PMCID: PMC10128859 DOI: 10.3389/fcvm.2023.1160833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/23/2023] [Indexed: 04/29/2023] Open
Abstract
Calcific aortic valve disease (CAVD) is the most frequent valvular heart disorder, and the one with the highest impact and burden in the elderly population. While the quality and standardization of the current aortic valve replacements has reached unprecedented levels with the commercialization of minimally-invasive implants and the design of procedures for valve repair, the need of supplementary therapies able to block or retard the course of the pathology before patients need the intervention is still awaited. In this contribution, we will discuss the emerging opportunity to set up devices to mechanically rupture the calcium deposits accumulating in the aortic valve and restore, at least in part, the pliability and the mechanical function of the calcified leaflets. Starting from the evidences gained by mechanical decalcification of coronary arteries in interventional cardiology procedures, a practice already in the clinical setting, we will discuss the advantages and the potential drawbacks of valve lithotripsy devices and their potential applicability in the clinical scenario.
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9
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Gorton AJ, Keshavamurthy S, Saha SP. Diagnosis and Management of Aortic Valvular Disease in the Elderly. Int J Angiol 2022; 31:232-243. [PMID: 36588869 PMCID: PMC9803555 DOI: 10.1055/s-0042-1759527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations for prompt diagnosis and efficacious treatment. The current paradigm for aortic valve disease is based on surgical or interventional therapy. In this review, we discuss the approach to diagnosing aortic valvular disease and the different options for treatment based on the most recent evidence.
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Affiliation(s)
- Andrew J. Gorton
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Suresh Keshavamurthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Sibu P. Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
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10
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Zhao Z, Meng Z, Song G, Wang C, Shi S, Zhao J, Zhang H, Wang M, Niu G, Zhou Z, Wang J, Wu Y. The effects of levosimendan in patients undergoing transcatheter aortic valve replacement- a retrospective analysis. Front Pharmacol 2022; 13:969088. [PMID: 36408223 PMCID: PMC9669067 DOI: 10.3389/fphar.2022.969088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Aortic stenosis (AS) increases left ventricular afterload, leading to cardiac damage and heart failure (HF). Transcatheter aortic valve replacement (TAVR) is an effective therapy for AS. No inotropic agents including levosimendan have been evaluated in patients undergoing TAVR. Methods: A total of 285 patients underwent TAVR between 2014 and 2019; 210 were included in the matched analysis and 105 received 0.1 μg/kg body weight/min levosimendan immediately after the prosthesis had been successfully implanted. Medical history, laboratory tests, and echocardiography results were analyzed. Endpoints including 2-year all-cause mortality, stroke, or HF-related hospitalization, and a combination of the above were analyzed by Cox proportional hazard models. Results: The levosimendan group had no difference in 2-year mortality compared with the control group (hazard ratio [HR]: 0.603, 95% confidence interval [CI]: 0.197-1.844; p = 0.375). However, levosimendan reduced stroke or HF-related hospitalization (HR: 0.346; 95% CI: 0.135-0.884; p = 0.027) and the combined endpoint (HR: 0.459, 95% CI: 0.215-0.980; p = 0.044). After adjusting for multiple variants, levosimendan still reduced stroke or HF-related hospitalization (HR: 0.346, 95% CI: 0.134-0.944; p = 0.038). Conclusion: Prophylactic levosimendan administration immediately after valve implantation in patients undergoing TAVR can reduce stroke or HF-related hospitalization but does not lower all-cause mortality.
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Affiliation(s)
- Zhenyan Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhen Meng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- Department of Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Guangyuan Song
- Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Chunrong Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sheng Shi
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hongliang Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Moyang Wang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Guannan Niu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zheng Zhou
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jianhui Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yongjian Wu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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11
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Walker CJ, Batan D, Bishop CT, Ramirez D, Aguado BA, Schroeder ME, Crocini C, Schwisow J, Moulton K, Macdougall L, Weiss RM, Allen MA, Dowell R, Leinwand LA, Anseth KS. Extracellular matrix stiffness controls cardiac valve myofibroblast activation through epigenetic remodeling. Bioeng Transl Med 2022; 7:e10394. [PMID: 36176599 PMCID: PMC9472021 DOI: 10.1002/btm2.10394] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/11/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022] Open
Abstract
Aortic valve stenosis (AVS) is a progressive fibrotic disease that is caused by thickening and stiffening of valve leaflets. At the cellular level, quiescent valve interstitial cells (qVICs) activate to myofibroblasts (aVICs) that persist within the valve tissue. Given the persistence of myofibroblasts in AVS, epigenetic mechanisms have been implicated. Here, we studied changes that occur in VICs during myofibroblast activation by using a hydrogel matrix to recapitulate different stiffnesses in the valve leaflet during fibrosis. We first compared the chromatin landscape of qVICs cultured on soft hydrogels and aVICs cultured on stiff hydrogels, representing the native and diseased phenotypes respectively. Using assay for transposase-accessible chromatin sequencing (ATAC-Seq), we found that open chromatin regions in aVICs were enriched for transcription factor binding motifs associated with mechanosensing pathways compared to qVICs. Next, we used RNA-Seq to show that the open chromatin regions in aVICs correlated with pro-fibrotic gene expression, as aVICs expressed higher levels of contractile fiber genes, including myofibroblast markers such as alpha smooth muscle actin (αSMA), compared to qVICs. In contrast, chromatin remodeling genes were downregulated in aVICs compared to qVICs, indicating qVICs may be protected from myofibroblast activation through epigenetic mechanisms. Small molecule inhibition of one of these remodelers, CREB Binding Protein (CREBBP), prevented qVICs from activating to aVICs. Notably, CREBBP is more abundant in valves from healthy patients compared to fibrotic valves. Our findings reveal the role of mechanical regulation in chromatin remodeling during VIC activation and quiescence and highlight one potential therapeutic target for treating AVS.
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Affiliation(s)
- Cierra J. Walker
- Materials Science and Engineering ProgramUniversity of Colorado BoulderBoulderColoradoUSA
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
| | - Dilara Batan
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Biochemistry DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Carrie T. Bishop
- Chemical and Biological Engineering DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Daniel Ramirez
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Molecular, Cellular, and Developmental Biology DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Brian A. Aguado
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Chemical and Biological Engineering DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Megan E. Schroeder
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Chemical and Biological Engineering DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Claudia Crocini
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Molecular, Cellular, and Developmental Biology DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Jessica Schwisow
- Division of CardiologyUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Karen Moulton
- Division of CardiologyUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Laura Macdougall
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Chemical and Biological Engineering DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Robert M. Weiss
- Department of Internal MedicineUniversity of IowaIowa CityIowaUSA
| | - Mary A. Allen
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Molecular, Cellular, and Developmental Biology DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Robin Dowell
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Molecular, Cellular, and Developmental Biology DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Leslie A. Leinwand
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Molecular, Cellular, and Developmental Biology DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
| | - Kristi S. Anseth
- BioFrontiers Institute, University of Colorado BoulderBoulderColoradoUSA
- Chemical and Biological Engineering DepartmentUniversity of Colorado BoulderBoulderColoradoUSA
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12
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Li XZ, Xiong ZC, Zhang SL, Hao QY, Gao M, Wang JF, Gao JW, Liu PM. Potential ferroptosis key genes in calcific aortic valve disease. Front Cardiovasc Med 2022; 9:916841. [PMID: 36003913 PMCID: PMC9395208 DOI: 10.3389/fcvm.2022.916841] [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: 04/11/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is a highly prevalent condition that comprises a disease continuum, ranging from microscopic changes to profound fibro-calcific leaflet remodeling, culminating in aortic stenosis, heart failure, and ultimately premature death. Ferroptosis has been hypothesized to contribute to the pathogenesis of CAVD. We aimed to study the association between ferroptosis genes and CAVD and reveal the potential roles of ferroptosis in CAVD. CAVD-related differentially expressed genes (DEGs) were identified via bioinformatic analysis of Datasets GSE51472 and GSE12644 obtained from Gene Expression Omnibus. A ferroptosis dataset containing 259 genes was obtained from the Ferroptosis Database. We then intersected with CAVD-related DEGs to identify the ferroptosis DEGs. Subsequently, protein–protein interaction networks and functional enrichment analyses were performed for ferroptosis DEGs. Then, we used miRWalk3.0 to predict the target pivotal microRNAs. An in vitro model of CAVD was constructed using human aortic valve interstitial cells. The qRT-PCR and western blotting methods were used to validate the ferroptosis DEGs identified by the microarray data. A total of 21 ferroptosis DEGs in CAVD containing 12 upregulated and nine downregulated genes were identified. The results of the Gene Set Enrichment Analysis (GSEA) and analysis of the KEGG pathway by WebGestalt indicated that the ferroptosis DEGs were enriched in six signaling pathways among which NAFLD (including IL-6, BID, and PRKAA2 genes) and HIF-1 (including IL-6, HIF-1, and HMOX1 genes) signaling pathways were also verified by DAVID and/or Metascape. Finally, the in vitro results showed that the mRNA and protein expression levels of IL-6, HIF-1α, HMOX1, and BID were higher, while the levels of PRKAA2 were lower in the Pi-treated group than those in the control group. However, the addition of ferrostatin-1 (a selective ferroptosis inhibitor) significantly reversed the above changes. Therefore, IL-6, HIF-1α, HMOX1, BID, and PRKAA2 are potential key genes closely associated with ferroptosis in CAVD. Further work is required to explore the underlying ferroptosis-related molecular mechanisms and provide possible therapeutic targets for CAVD.
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Affiliation(s)
- Xiong-Zhi Li
- Department of Cardiology, Guangzhou Key Laboratory on the Molecular Mechanisms of Major Cardiovascular Disease, Guangdong Provincial Key Laboratory of Arrhythmia and Electrophysiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zhuo-Chao Xiong
- Department of Cardiology, Guangzhou Key Laboratory on the Molecular Mechanisms of Major Cardiovascular Disease, Guangdong Provincial Key Laboratory of Arrhythmia and Electrophysiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shao-Ling Zhang
- Department of Endocrinology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qing-Yun Hao
- Department of Cardiology, Guangzhou Key Laboratory on the Molecular Mechanisms of Major Cardiovascular Disease, Guangdong Provincial Key Laboratory of Arrhythmia and Electrophysiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ming Gao
- Department of Radiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jing-Feng Wang
- Department of Cardiology, Guangzhou Key Laboratory on the Molecular Mechanisms of Major Cardiovascular Disease, Guangdong Provincial Key Laboratory of Arrhythmia and Electrophysiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jing-Wei Gao
- Department of Cardiology, Guangzhou Key Laboratory on the Molecular Mechanisms of Major Cardiovascular Disease, Guangdong Provincial Key Laboratory of Arrhythmia and Electrophysiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- *Correspondence: Jing-Wei Gao
| | - Pin-Ming Liu
- Department of Cardiology, Guangzhou Key Laboratory on the Molecular Mechanisms of Major Cardiovascular Disease, Guangdong Provincial Key Laboratory of Arrhythmia and Electrophysiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Pin-Ming Liu
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13
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Greenberg HZE, Zhao G, Shah AM, Zhang M. Role of oxidative stress in calcific aortic valve disease and its therapeutic implications. Cardiovasc Res 2022; 118:1433-1451. [PMID: 33881501 PMCID: PMC9074995 DOI: 10.1093/cvr/cvab142] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/19/2021] [Indexed: 12/12/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is the end result of active cellular processes that lead to the progressive fibrosis and calcification of aortic valve leaflets. In western populations, CAVD is a significant cause of cardiovascular morbidity and mortality, and in the absence of effective drugs, it will likely represent an increasing disease burden as populations age. As there are currently no pharmacological therapies available for preventing, treating, or slowing the development of CAVD, understanding the mechanisms underlying the initiation and progression of the disease is important for identifying novel therapeutic targets. Recent evidence has emerged of an important causative role for reactive oxygen species (ROS)-mediated oxidative stress in the pathophysiology of CAVD, inducing the differentiation of valve interstitial cells into myofibroblasts and then osteoblasts. In this review, we focus on the roles and sources of ROS driving CAVD and consider their potential as novel therapeutic targets for this debilitating condition.
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Affiliation(s)
- Harry Z E Greenberg
- Department of Cardiology, Cardiovascular Division, King's College London British Heart Foundation Centre of Research Excellence, James Black Centre, 125 Coldharbour Lane, London SE5 9NU, UK
| | - Guoan Zhao
- Department of Cardiology, The First Affiliated Hospital of Xinxiang Medical University, Heart Center of Xinxiang Medical University, Henan, China
| | - Ajay M Shah
- Department of Cardiology, Cardiovascular Division, King's College London British Heart Foundation Centre of Research Excellence, James Black Centre, 125 Coldharbour Lane, London SE5 9NU, UK
| | - Min Zhang
- Department of Cardiology, Cardiovascular Division, King's College London British Heart Foundation Centre of Research Excellence, James Black Centre, 125 Coldharbour Lane, London SE5 9NU, UK
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14
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Wisneski AD, Wang Y, Cutugno S, Pasta S, Stroh A, Yao J, Nguyen TC, Mahadevan VS, Guccione JM. Left Ventricle Biomechanics of Low-Flow, Low-Gradient Aortic Stenosis: A Patient-Specific Computational Model. Front Physiol 2022; 13:848011. [PMID: 35464089 PMCID: PMC9019780 DOI: 10.3389/fphys.2022.848011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
This study aimed to create an imaging-derived patient-specific computational model of low-flow, low-gradient (LFLG) aortic stenosis (AS) to obtain biomechanics data about the left ventricle. LFLG AS is now a commonly recognized sub-type of aortic stenosis. There remains much controversy over its management, and investigation into ventricular biomechanics may elucidate pathophysiology and better identify patients for valve replacement. ECG-gated cardiac computed tomography images from a patient with LFLG AS were obtained to provide patient-specific geometry for the computational model. Surfaces of the left atrium, left ventricle (LV), and outflow track were segmented. A previously validated multi-scale, multi-physics computational human heart model was adapted to the patient-specific geometry, yielding a model consisting of 91,000 solid elements. This model was coupled to a virtual circulatory system and calibrated to clinically measured parameters from echocardiography and cardiac catheterization data. The simulation replicated key physiologic parameters within 10% of their clinically measured values. Global LV systolic myocardial stress was 7.1 ± 1.8 kPa. Mean stress of the basal, middle, and apical segments were 7.7 ± 1.8 kPa, 9.1 ± 3.8 kPa, and 6.4 ± 0.4 kPa, respectively. This is the first patient-specific computational model of LFLG AS based on clinical imaging. Low myocardial stress correlated with low ejection fraction and eccentric LV remodeling. Further studies are needed to understand how alterations in LV biomechanics correlates with clinical outcomes of AS.
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Affiliation(s)
- Andrew D. Wisneski
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Yunjie Wang
- Thornton Tomassetti Life Sciences, Santa Clara, CA, United States
| | - Salvatore Cutugno
- Department of Engineering, Viale Dell Scienze, Universita degli Studi di Palermo, Palermo, Italy
| | - Salvatore Pasta
- Department of Engineering, Viale Dell Scienze, Universita degli Studi di Palermo, Palermo, Italy
| | - Ashley Stroh
- CATIA, Dassault Systèmes, Wichita, KS, United States
| | - Jiang Yao
- Simulia, Dassault Systèmes Simulia, Johnston, RI, United States
| | - Tom C. Nguyen
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Vaikom S. Mahadevan
- Division of Cardiology, University of California, San Francisco, San Francisco, CA, United States
| | - Julius M. Guccione
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
- *Correspondence: Julius M. Guccione,
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15
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Myasoedova VA, Conte M, Valerio V, Moschetta D, Massaiu I, Petraglia L, Leosco D, Poggio P, Parisi V. Red Flags, Prognostic Impact, and Management of Patients With Cardiac Amyloidosis and Aortic Valve Stenosis: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:858281. [PMID: 35355593 PMCID: PMC8959832 DOI: 10.3389/fmed.2022.858281] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 02/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Cardiac amyloidosis (CA) has been recently recognized as a condition frequently associated with aortic stenosis (AS). The aim of this study was to evaluate: the main characteristics of patients with AS with and without CA, the impact of CA on patients with AS mortality, and the effect of different treatment strategies on outcomes of patients with AS with concomitant CA. Materials and Methods A detailed search related to CA in patients with AS and outcomes was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seventeen studies enrolling 1,988 subjects (1,658 AS alone and 330 AS with CA) were included in the qualitative and quantitative analysis of main patients with AS characteristics with and without CA, difference in mortality, and treatment strategy. Results The prevalence of CA resulted in a mean of 15.4% and it was even higher in patients with AS over 80 years old (18.2%). Patients with the dual diagnosis were more often males, had lower body mass index (BMI), were more prone to have low flow, low gradient with reduced left ventricular ejection fraction AS phenotype, had higher E/A and E/e', and greater interventricular septum hypertrophy. Lower Sokolow–Lyon index, higher QRS duration, higher prevalence of right bundle branch block, higher levels of N-terminal pro-brain natriuretic peptide, and high-sensitivity troponin T were significantly associated with CA in patients with AS. Higher overall mortality in the 178 patients with AS + CA in comparison to 1,220 patients with AS alone was observed [odds ratio (OR) 2.25, p = 0.004]. Meta-regression analysis showed that younger age and diabetes were associated with overall mortality in patients with CS with CA (Z-value −3.0, p = 0.003 and Z-value 2.5, p = 0.013, respectively). Finally, patients who underwent surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) had a similar overall mortality risk, but lower than medication-treated only patients. Conclusion Results from our meta-analysis suggest that several specific clinical, electrocardiographic, and echocardiographic features can be considered “red flags” of CA in patients with AS. CA negatively affects the outcome of patients with AS. Patients with concomitant CA and AS benefit from SAVR or TAVI.
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Affiliation(s)
- Veronika A Myasoedova
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Maddalena Conte
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, Naples, Italy.,Casa di Cura San Michele, Maddaloni, Italy
| | - Vincenza Valerio
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Donato Moschetta
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Dipartimento di Scienze farmacologiche e biomolecolari, Università degli Studi di Milano, Milano, Italy
| | - Ilaria Massaiu
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy.,Developmental Biology of the Immune System, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Laura Petraglia
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Dario Leosco
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, Naples, Italy
| | - Paolo Poggio
- Centro Cardiologico Monzino Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Valentina Parisi
- Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, Naples, Italy
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16
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Cortese B, Sanchez-Jimenez E, Ielasi A, Biccirè F, Budassi S, Prati F, Gelpi G. Balloon aortic valvuloplasty review: the revenge during COVID-19 outbreak? Minerva Cardiol Angiol 2022; 70:572-580. [PMID: 35332746 DOI: 10.23736/s2724-5683.22.05997-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aortic stenosis is a highly prevalent cardiac valvular disease in adult population and increases with age. After symptoms onset in severe aortic stenosis, the prognosis begins to decline; however, new studies demonstrate an increased risk of death in patients with moderate disease. Although majority of patients with severe aortic stenosis are treated electively with surgical or transcatheter aortic valve replacement, not all patients are candidates for the interventions. Balloon aortic valvuloplasty can be used successfully as a bridge to definitive treatment or as palliative therapy in patients who are not candidates for either procedure. In this paper, we discuss and justify the current indications and contraindications for balloon aortic valvuloplasty. Additionally, the step-by-step procedure technique and most frequent complications are described. Moreover, we present the safety and feasibility of balloon aortic valvuloplasty in 33 consecutive patients on a waiting list for transcatheter aortic valve replacement at 3 expert Italian centers during the first and second waves of COVID-19, when clinical priorities focused on hospitalized patients with pneumonia. The procedural success in this cohort of patients was achieved in 31 patients (94%). Out of the 33 patients enrolled, 15 underwent TAVR within 5 ± 2 months from the valvuloplasty, and at 6-month follow-up a total of 2 patients died for end-stage heart failure.
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Affiliation(s)
- Bernardo Cortese
- Interventional cardiology department, Clinica Polispecialistica San Carlo, Milano, Italy - .,Fondazione Ricerca e Innovazione Cardiovascolare, Milano, Italy -
| | - Erick Sanchez-Jimenez
- Interventional cardiology department, Clinica Polispecialistica San Carlo, Milano, Italy
| | - Alfonso Ielasi
- Interventional cardiology department, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Flavio Biccirè
- Interventional cardiology department, Ospedale San Giovanni Addolorata, Roma, Italy
| | - Simone Budassi
- Interventional cardiology department, Ospedale San Giovanni Addolorata, Roma, Italy
| | - Francesco Prati
- Interventional cardiology department, Ospedale San Giovanni Addolorata, Roma, Italy
| | - Guido Gelpi
- Fondazione Ricerca e Innovazione Cardiovascolare, Milano, Italy.,Interventional cardiology department, ASST-Fatebenefratelli-Sacco, Milano, Italy
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17
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Xiong T, Han S, Pu L, Zhang TC, Zhan X, Fu T, Dai YH, Li YX. Bioinformatics and Machine Learning Methods to Identify FN1 as a Novel Biomarker of Aortic Valve Calcification. Front Cardiovasc Med 2022; 9:832591. [PMID: 35295271 PMCID: PMC8918776 DOI: 10.3389/fcvm.2022.832591] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/28/2022] [Indexed: 12/14/2022] Open
Abstract
AimThe purpose of this study was to identify potential diagnostic markers for aortic valve calcification (AVC) and to investigate the function of immune cell infiltration in this disease.MethodsThe AVC data sets were obtained from the Gene Expression Omnibus. The identification of differentially expressed genes (DEGs) and the performance of functional correlation analysis were carried out using the R software. To explore hub genes related to AVC, a protein–protein interaction network was created. Diagnostic markers for AVC were then screened and verified using the least absolute shrinkage and selection operator, logistic regression, support vector machine-recursive feature elimination algorithms, and hub genes. The infiltration of immune cells into AVC tissues was evaluated using CIBERSORT, and the correlation between diagnostic markers and infiltrating immune cells was analyzed. Finally, the Connectivity Map database was used to forecast the candidate small molecule drugs that might be used as prospective medications to treat AVC.ResultsA total of 337 DEGs were screened. The DEGs that were discovered were mostly related with atherosclerosis and arteriosclerotic cardiovascular disease, according to the analyses. Gene sets involved in the chemokine signaling pathway and cytokine–cytokine receptor interaction were differently active in AVC compared with control. As the diagnostic marker for AVC, fibronectin 1 (FN1) (area the curve = 0.958) was discovered. Immune cell infiltration analysis revealed that the AVC process may be mediated by naïve B cells, memory B cells, plasma cells, activated natural killer cells, monocytes, and macrophages M0. Additionally, FN1 expression was associated with memory B cells, M0 macrophages, activated mast cells, resting mast cells, monocytes, and activated natural killer cells. AVC may be reversed with the use of yohimbic acid, the most promising small molecule discovered so far.ConclusionFN1 can be used as a diagnostic marker for AVC. It has been shown that immune cell infiltration is important in the onset and progression of AVC, which may benefit in the improvement of AVC diagnosis and treatment.
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Affiliation(s)
- Tao Xiong
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Shen Han
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Lei Pu
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Tian-Chen Zhang
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Xu Zhan
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Fu
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Ying-Hai Dai
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
| | - Ya-Xiong Li
- Cardiovascular Surgery, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Yan'an Affiliated Hospital of Kunming Medical University, Kunming Medical University, Kunming, China
- *Correspondence: Ya-Xiong Li ;
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18
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Camarzana A, Annweiler C, Pinaud F, Abi-Khalil W, Rouleau F, Duval G, Prunier F, Furber A, Biere L. Prognostic value of a comprehensive geriatric assessment for predicting one-year mortality in presumably frail patients with symptomatic aortic stenosis. Arch Med Sci 2022; 18:1446-1452. [PMID: 36457965 PMCID: PMC9710260 DOI: 10.5114/aoms/109391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/16/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Despite suffering a severe aortic stenosis, some patients are denied either surgical or transcatheter aortic valve implantation (TAVI) therapy because of a frail condition. We aimed to identify whether a comprehensive geriatric assessment (CGA) might be useful to predict the prognosis of presumably frail patients with severe aortic stenosis. MATERIAL AND METHODS Between March 2011 and July 2016, 818 patients were consecutively and prospectively enrolled. 161 had a CGA and were considered for analysis. Considering combined CGA and heart team recommendations, 102 TAVI procedures were performed (TAVI group) and 59 patients constituted the no-TAVI group. The primary endpoint was all-cause mortality at 1 year. RESULTS There was no difference between the TAVI and the no-TAVI groups considering morphometric data, cardiovascular risk factors or symptoms. The no-TAVI group had higher surgical risk (logistic EuroSCORE1 33.4 ±17.8 vs. 22.7 ±14.9; p < 0.001) and more moderate renal insufficiency (82% vs. 57%; p = 0.001). One-year mortality was 16% in the TAVI group and 46% in the no-TAVI group (p < 0.001). Multivariate analysis revealed that history of pulmonary edema, moderate renal failure, and not having a TAVI were associated with 1-year mortality. There was an interaction between the Five-Times-Sit-to-Stand-Test (FTSST) and the effect of TAVI on mortality (p = 0.049), as FTSST was the only predictor for 1-year mortality in the no-TAVI group (HR = 0.18, 95% CI: 0.04-0.76; p = 0.019). CONCLUSIONS One-year mortality was higher in geriatric-assessed frail patients who did not undergo TAVI. FTSST, which assesses patients' mobility, was the only prognostic marker for 1-year mortality, on top of the usual medical parameters.
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Affiliation(s)
| | - Cédric Annweiler
- Department of Geriatric Medicine, University Memory Center, Research Center on Autonomy and Longevity, University Hospital, Angers, France; UPRES EA 4638, University of Angers, Angers, France
| | - Frédéric Pinaud
- Department of Cardiac Surgery, University Hospital of Angers, Angers, France
| | - Wissam Abi-Khalil
- Institut Mitovasc, University of Angers, UMR CNRS 6015-INSERMU1083, Angers, France
| | - Frédéric Rouleau
- Institut Mitovasc, University of Angers, UMR CNRS 6015-INSERMU1083, Angers, France
| | - Guillaume Duval
- Department of Geriatric Medicine, University Memory Center, Research Center on Autonomy and Longevity, University Hospital, Angers, France; UPRES EA 4638, University of Angers, Angers, France
| | - Fabrice Prunier
- Institut Mitovasc, University of Angers, UMR CNRS 6015-INSERMU1083, Angers, France
| | - Alain Furber
- Institut Mitovasc, University of Angers, UMR CNRS 6015-INSERMU1083, Angers, France
| | - Loïc Biere
- Institut Mitovasc, University of Angers, UMR CNRS 6015-INSERMU1083, Angers, France
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19
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Wu M, Gu P, Cao Q, Gong A, Tan W, Hong D. Antihypertensive treatment and risk factors for syncope in asymptomatic aortic stenosis patients with hypertension. Clin Exp Hypertens 2021; 44:191-197. [PMID: 34872422 DOI: 10.1080/10641963.2021.1883047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Evidence for treating hypertension in patients with asymptomatic aortic valve stenosis(AS) is scarce. OBJECTIVES Given the paucity of data on the relationship between syncope and antihypertensive treatment in aortic stenosis. This study sought to investigate this association in patients admitted to our hospital. METHODS A total of 158 patients with asymptomatic moderate or severe aortic stenosis were analyzed. Follow-up was conducted by clinic visit, telephone contact, or review of electronic medical records. Outcomes were syncope. RESULTS Hypertension were documented in 90 of the 158 patients with moderate or severe AS, and 77 of them received antihypertensive medications. During an average 28 months follow-up period, the occurrence of syncope was observed in 13 patients. Among them, 8 were in antihypertensive group (n = 77) and 5 in normotensive group (n = 68). There was no significant difference in incidence of syncope between the two groups. Patients with treated hypertension and syncope had a lower stroke volume index (SVi), a higher valve arterial impedance (ZVA), a smaller SAC than those without. Kaplan-Meier analysis showed that there was no significant difference in syncope cumulative incidence between antihypertensive group and normotensive group (log rank P = .478). Multivariate cox regression analysis showed that both ZVA (hazard ratio:19.006, 95% confidence interval: 4.664 to77.448;P = .002) and LVMI (hazard ratio:1.484, 95% confidence interval: 1.427 to 5.157;P = .016) were associated with development of syncope, whereas hypertension were not related independently to syncope (hazard ratio:0.935, 95% confidence interval: 0.786 to3.173; P = .869). CONCLUSIONS In patients with moderate or severe AS, concomitant hypertension, and antihypertensive treatment didn't increase the occurrence of syncope, whereas higher ZVA was independently associated with greater risk of syncope.
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Affiliation(s)
- Meihua Wu
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Ping Gu
- Echocardiography Laboratory, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Qianqiang Cao
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Aibin Gong
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Wenliang Tan
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
| | - Dezhi Hong
- Department of Cardiovascular Medicine, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Jiangxi, China
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20
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Ott C, Pappritz K, Hegemann N, John C, Jeuthe S, McAlpine CS, Iwamoto Y, Lauryn JH, Klages J, Klopfleisch R, Van Linthout S, Swirski F, Nahrendorf M, Kintscher U, Grune T, Kuebler WM, Grune J. Spontaneous Degenerative Aortic Valve Disease in New Zealand Obese Mice. J Am Heart Assoc 2021; 10:e023131. [PMID: 34779224 PMCID: PMC9075397 DOI: 10.1161/jaha.121.023131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Degenerative aortic valve (AoV) disease and resulting aortic stenosis are major clinical health problems. Murine models of valve disease are rare, resulting in a translational knowledge gap on underlying mechanisms, functional consequences, and potential therapies. Naïve New Zealand obese (NZO) mice were recently found to have a dramatic decline of left ventricular (LV) function at early age. Therefore, we aimed to identify the underlying cause of reduced LV function in NZO mice. Methods and Results Cardiac function and pulmonary hemodynamics of NZO and age-matched C57BL/6J mice were monitored by serial echocardiographic examinations. AoVs in NZO mice demonstrated extensive thickening, asymmetric aortic leaflet formation, and cartilaginous transformation of the valvular stroma. Doppler echocardiography of the aorta revealed increased peak velocity profiles, holodiastolic flow reversal, and dilatation of the ascending aorta, consistent with aortic stenosis and regurgitation. Compensated LV hypertrophy deteriorated to decompensated LV failure and remodeling, as indicated by increased LV mass, interstitial fibrosis, and inflammatory cell infiltration. Elevated LV pressures in NZO mice were associated with lung congestion and cor pulmonale, evident as right ventricular dilatation, decreased right ventricular function, and increased mean right ventricular systolic pressure, indicative for the development of pulmonary hypertension and ultimately right ventricular failure. Conclusions NZO mice demonstrate as a novel murine model to spontaneously develop degenerative AoV disease, aortic stenosis, and the associated end organ damages of both ventricles and the lung. Closely mimicking the clinical scenario of degenerative AoV disease, the model may facilitate a better mechanistic understanding and testing of novel treatment strategies in degenerative AoV disease.
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Affiliation(s)
- Christiane Ott
- Department of Molecular Toxicology German Institute of Human Nutrition Potsdam-Rehbruecke Germany.,German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany
| | - Kathleen Pappritz
- German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,Berlin Institute of Health Center for Regenerative Therapies and Berlin-Brandenburg Center for Regenerative Therapies Charité-Universitätsmedizin BerlinCampus Virchow Klinikum Berlin Germany
| | - Niklas Hegemann
- German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,Institute of Physiology Charité-Universitätsmedizin Berlin Berlin Germany
| | - Cathleen John
- Department of Molecular Toxicology German Institute of Human Nutrition Potsdam-Rehbruecke Germany.,German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany
| | - Sarah Jeuthe
- German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,Department of Medicine/Cardiology Deutsches Herzzentrum Berlin Berlin Germany.,Max-Delbrück Center for Molecular Medicine in the Helmholtz Association Berlin Germany
| | - Cameron S McAlpine
- Center for Systems Biology Massachusetts General Hospital and Harvard Medical School Boston MA
| | - Yoshiko Iwamoto
- Center for Systems Biology Massachusetts General Hospital and Harvard Medical School Boston MA
| | - Jonathan H Lauryn
- German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,Institute of Physiology Charité-Universitätsmedizin Berlin Berlin Germany
| | - Jan Klages
- Department of Anesthesiology Deutsches Herzzentrum Berlin Berlin Germany
| | - Robert Klopfleisch
- Department of Veterinary Pathology Freie Universität Berlin Berlin Germany
| | - Sophie Van Linthout
- German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,Berlin Institute of Health Center for Regenerative Therapies and Berlin-Brandenburg Center for Regenerative Therapies Charité-Universitätsmedizin BerlinCampus Virchow Klinikum Berlin Germany.,Department of Cardiology Charité-Universitätsmedizin BerlinCampus Virchow Klinikum Berlin Germany
| | - Fil Swirski
- Center for Systems Biology Massachusetts General Hospital and Harvard Medical School Boston MA
| | - Matthias Nahrendorf
- Center for Systems Biology Massachusetts General Hospital and Harvard Medical School Boston MA
| | - Ulrich Kintscher
- German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,Center for Cardiovascular Research/Institute of Pharmacology Charité-Universitätsmedizin Berlin Berlin Germany
| | - Tilman Grune
- Department of Molecular Toxicology German Institute of Human Nutrition Potsdam-Rehbruecke Germany.,German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,German Center for Diabetes Research München-Neuherberg Germany.,Institute of Nutritional Science University of Potsdam Nuthetal Germany
| | - Wolfgang M Kuebler
- German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,Institute of Physiology Charité-Universitätsmedizin Berlin Berlin Germany.,Departments of Surgery and Physiology University of Toronto and Keenan Research Centre for Biomedical Science of St. Michael's Toronto Canada
| | - Jana Grune
- German Centre for Cardiovascular Research (partner site Berlin) Berlin Germany.,Institute of Physiology Charité-Universitätsmedizin Berlin Berlin Germany.,Center for Systems Biology Massachusetts General Hospital and Harvard Medical School Boston MA.,Center for Cardiovascular Research/Institute of Pharmacology Charité-Universitätsmedizin Berlin Berlin Germany
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21
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Shimozono K, Fukumoto Y. Effectiveness and Safety of Tolvaptan in Patients with Aortic Stenosis. Kurume Med J 2021; 67:11-16. [PMID: 34840201 DOI: 10.2739/kurumemedj.ms671001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Heart failure in severe aortic stenosis (AS) before aortic valve has a poor prognosis with high risk. Although the overuse of loop diuretics may induce hypovolemia, cardiac output reduction, and critical hypotension in severe AS, tolvaptan is characterized by its ability to help maintain hemodynamics and seems to be appropriate for use in heart failure caused by AS. Therefore, we retrospectively examined the effects and safety of tolvaptan use in patients with heart failure caused by severe AS. METHODS AND RESULTS Ten patients with heart failure caused by severe AS were enrolled. Tolvaptan administration did not cause blood pressure decrease significantly, whereas urine volume increased significantly from 896±318 to 1322±502 mL/day (P<0.05). Although there was no statistical significance, functional classes tended to be improved. Blood tests indicated no worsening of kidney function and N-terminal pro-brain natriuretic peptide levels after the use of tolvaptan. Echocardiography also showed no hypovolemia and no worsening of aortic valve flow (18.3±3.8 to 15.5±5.5 cm/s, n.s). CONCLUSIONS Tolvaptan use in AS patients with heart failure is effective and safe before aortic valve intervention.
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Affiliation(s)
- Koutatsu Shimozono
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
| | - Yoshihiro Fukumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine
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22
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Zebhi B, Lazkani M, Bark D. Calcific Aortic Stenosis-A Review on Acquired Mechanisms of the Disease and Treatments. Front Cardiovasc Med 2021; 8:734175. [PMID: 34604358 PMCID: PMC8486019 DOI: 10.3389/fcvm.2021.734175] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/18/2021] [Indexed: 11/13/2022] Open
Abstract
Calcific aortic stenosis is a progressive disease that has become more prevalent in recent decades. Despite advances in research to uncover underlying biomechanisms, and development of new generations of prosthetic valves and replacement techniques, management of calcific aortic stenosis still comes with unresolved complications. In this review, we highlight underlying molecular mechanisms of acquired aortic stenosis calcification in relation to hemodynamics, complications related to the disease, diagnostic methods, and evolving treatment practices for calcific aortic stenosis.
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Affiliation(s)
- Banafsheh Zebhi
- Department of Mechanical Engineering, Colorado State University, Fort Collins, CO, United States
| | - Mohamad Lazkani
- Medical Center of the Rockies, University of Colorado Health, Loveland, CO, United States
| | - David Bark
- Department of Pediatrics, Washington University in Saint Louis, Saint Louis, MO, United States.,Department of Biomedical Engineering, Washington University in Saint Louis, Saint Louis, MO, United States
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23
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Chen J, Li W, Xiang M. Burden of valvular heart disease, 1990-2017: Results from the Global Burden of Disease Study 2017. J Glob Health 2021; 10:020404. [PMID: 33110570 PMCID: PMC7568921 DOI: 10.7189/jogh.10.020404] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Valvular heart disease (VHD) is expected to cause an increase in public-health problems in the coming years, especially in elderly populations. We aim to estimate the incidence, mortality, and burden of VHD, by age, from 1990 to 2017 in 195 countries and territories. Methods We estimated the incidence, mortality, and burden of VHD based on the Global Burden of Disease Study 2017. All metrics are presented with their 95% uncertainty intervals (UIs). The Socio-demographic Index was used to identify whether developmental status correlates with health outcomes. Results The global incidence of rheumatic heart disease (RHD) decreased by 8.67% between 1990 and 2017, while that of non-rheumatic VHD (NRVHD) increased by 45.10%. There was a 54.00% decrease in age-standardized death rate (ASDR) for RHD, but a small and non-significant decrease (-3.00%) in the ASDR for NRVHD. The global age-standardized disability-adjusted life years (DALY) rate of RHD decreased by 53.52%, while there was a 12.62% reduction in the age-standardized DALY rate of NRVHD. Conclusions The burden from different VHDs demonstrated a diverse change at a global level between 1990 and 2017. Although RHD burden has an obvious means of mitigation, a substantially high incidence of NRVHD was observed over this time period, especially in the elderly, which may lead to high health care costs and signify the potential for even higher costs in the future.
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Affiliation(s)
- Jian Chen
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine. Key Lab of Cardiovascular Disease of Zhejiang Province, Hangzhou, China
| | - Wudi Li
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine. Key Lab of Cardiovascular Disease of Zhejiang Province, Hangzhou, China
| | - Meixiang Xiang
- Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine. Key Lab of Cardiovascular Disease of Zhejiang Province, Hangzhou, China
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24
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Jablonska P, Kutryb‐Zajac B, Mierzejewska P, Jasztal A, Bocian B, Lango R, Rogowski J, Chlopicki S, Smolenski RT, Slominska EM. The new insight into extracellular NAD + degradation-the contribution of CD38 and CD73 in calcific aortic valve disease. J Cell Mol Med 2021; 25:5884-5898. [PMID: 34142751 PMCID: PMC8256368 DOI: 10.1111/jcmm.15912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/03/2020] [Accepted: 08/21/2020] [Indexed: 12/26/2022] Open
Abstract
Nicotinamide adenine dinucleotide (NAD+ ) is crucial for cell energy metabolism and many signalling processes. Recently, we proved the role of ecto-enzymes in controlling adenine nucleotide-dependent pathways during calcific aortic valve disease (CAVD). This study aimed to investigate extracellular hydrolysis of NAD+ and mononucleotide nicotinamide (NMN) in aortic valves and aorta fragments of CAVD patients and on the inner aortic surface of ecto-5'-nucleotidase knockout mice (CD73-/-). Human non-stenotic valves (n = 10) actively converted NAD+ and NMN via both CD73 and NAD+ -glycohydrolase (CD38) according to our analysis with RP-HPLC and immunofluorescence. In stenotic valves (n = 50), due to reduced CD73 activity, NAD+ was degraded predominantly by CD38 and additionally by ALP and eNPP1. CAVD patients had significantly higher hydrolytic rates of NAD+ (0.81 ± 0.07 vs 0.56 ± 0.10) and NMN (1.12 ± 0.10 vs 0.71 ± 0.08 nmol/min/cm2 ) compared with controls. CD38 was also primarily engaged in human vascular NAD+ metabolism. Studies using specific ecto-enzyme inhibitors and CD73-/- mice confirmed that CD73 is not the only enzyme involved in NAD+ and NMN hydrolysis and that CD38 had a significant contribution to these pathways. Modifications of extracellular NAD+ and NMN metabolism in aortic valve cells may be particularly important in valve pathology and could be a potential therapeutic target.
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Affiliation(s)
| | | | | | - Agnieszka Jasztal
- Jagiellonian Center for Experimental TherapeuticsJagiellonian UniversityKrakowPoland
| | - Barbara Bocian
- Department of Cardiac & Vascular SurgeryMedical University of GdanskGdanskPoland
| | - Romuald Lango
- Department of Cardiac AnaesthesiologyMedical University of GdanskGdanskPoland
| | - Jan Rogowski
- Department of Cardiac & Vascular SurgeryMedical University of GdanskGdanskPoland
| | - Stefan Chlopicki
- Jagiellonian Center for Experimental TherapeuticsJagiellonian UniversityKrakowPoland
| | | | - Ewa M. Slominska
- Department of BiochemistryMedical University of GdanskGdanskPoland
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25
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Song X, Saito N, Morimoto T, Taniguchi T, Shiomi H, Ando K, Nagao K, Kanamori N, Murata K, Kitai T, Kawase Y, Izumi C, Miyake M, Mitsuoka H, Kato M, Hirano Y, Matsuda S, Inada T, Murakami T, Takeuchi Y, Yamane K, Toyofuku M, Ishii M, Minamino-Muta E, Kato T, Yoshikawa Y, Inoko M, Ikeda T, Ishii K, Hotta K, Higashitani N, Kato Y, Inuzuka Y, Maeda C, Jinnai T, Morikami Y, Minatoya K, Kimura T. Long-Term Impact of Diabetes Mellitus on Initially Conservatively Managed Patients With Severe Aortic Stenosis. Circ J 2021; 85:1083-1092. [PMID: 33208572 DOI: 10.1253/circj.cj-20-0681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although diabetes mellitus (DM) is a common comorbidity of aortic stenosis (AS), clinical evidence about the long-term effect of DM on patients with AS is insufficient.Methods and Results:Data were acquired from CURRENT AS, a large Japanese multicenter registry that enrolled 3,815 patients with severe AS. Patients without initial valve replacement were defined as the conservative group; among them, 621 (23.4%) had DM, whereas 1997 did not. The DM group was further divided into 2 groups according to insulin treatment (insulin-treated DM, n=130; non-insulin treated DM, n=491). The primary outcome was a composite of aortic valve (AV)-related death and heart failure (HF) hospitalization. Secondary outcomes were AV-related death, HF hospitalization, all-cause death, cardiovascular death, sudden death, and surgical or transcatheter AV replacement during follow up. As a result, DM was associated with higher risk for the primary outcome (52.8% vs. 42.9%, P<0.001), with a statistically significant adjusted hazard ratio (HR 1.33, 95% confidence interval: 1.14-1.56, P<0.001). All secondary outcomes were not significantly different between DM and non-DM patients after adjusting for confounding factors, except for HF hospitalization. Insulin use was not associated with higher incidence of primary or secondary outcome. CONCLUSIONS In initially conservatively managed patients with AS, DM was independently associated with higher risk for a composite of AV-related death or HF hospitalization; however, insulin use was not associated with poor outcomes.
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Affiliation(s)
- Xiaoyang Song
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Naritatsu Saito
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | | | - Hiroki Shiomi
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Kazuya Nagao
- Division of Cardiology, Cardiovascular Center, Osaka Red Cross Hospital
| | | | | | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Yuichi Kawase
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | | | | | - Hirokazu Mitsuoka
- Division of Cardiology, Nara Hospital, Kindai University Faculty of Medicine
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital
| | - Yutaka Hirano
- Department of Cardiology, Kindai University Hospital
| | - Shintaro Matsuda
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tsukasa Inada
- Division of Cardiology, Cardiovascular Center, Osaka Red Cross Hospital
| | | | | | | | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Mitsuru Ishii
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Eri Minamino-Muta
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Takao Kato
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Yusuke Yoshikawa
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | | | - Kozo Hotta
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | | | | | - Chiyo Maeda
- Department of Cardiology, Hamamatsu Rosai Hospital
| | | | | | - Kenji Minatoya
- the Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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26
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Ngiam JN, Chew NWS, Pramotedham T, Tan BYQ, Sim HW, Ruan W, Sia CH, Kong WKF, Yeo TC, Poh KK. Low Relative Valve Load is Associated With Paradoxical Low-Flow Aortic Stenosis Despite Preserved Left Ventricular Ejection Fraction and Adverse Clinical Outcomes. Heart Lung Circ 2021; 31:128-135. [PMID: 34116941 DOI: 10.1016/j.hlc.2021.05.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/03/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Paradoxical low-flow (LF) severe aortic stenosis (AS) despite preserved left ventricular (LV) ejection fraction (LVEF) has been shown to be distinct from normal-flow (NF) AS, with a poorer prognosis. Relative valve load (RVL) is a novel echocardiographic haemodynamic index based on the ratio of transaortic mean pressure gradient to the global valvulo-arterial impedance (Zva) in order to estimate the contribution of the valvular afterload to the global LV load. We aimed to determine the usefulness of RVL in LF AS versus NF AS. METHOD A total of 450 consecutive patients with medically managed severe AS (aortic valve area <1.0 cm2) with preserved LVEF (>50%) were studied. Patients were divided into LF (stroke volume index <35 mL/m2) or NF, and high RVL or low RVL. Baseline clinical and echocardiographic profiles, as well as clinical outcomes, were compared. RESULTS There were 149 (33.1%) patients with LF. Despite higher global impedance in LF (Zva 6.3±2.4 vs 3.9±0.9 mmHg/mL/m2; p<0.001) compared with NF, the RVL in LF AS was significantly lower (5.4±2.7 vs 9.8±5.1 mL/m2; p<0.001). On multivariable analysis, low RVL (≤7.51) remained independently associated with poor clinical outcomes on Cox regression (hazard ratio, 1.31; 95% confidence interval, 1.03-1.68), with 53.2% sensitivity and 70.3% specificity. This was comparable to other prognostic indices in AS. Kaplan-Meier curves demonstrated that low RVL was associated with increased mortality. CONCLUSIONS Increased systemic arterial afterload may be important in the pathophysiology of LF AS. Low RVL was an independent predictor of poor clinical outcomes in medically managed severe AS. There may be a greater role in the attenuation of systemic arterial afterload in AS to improve outcomes.
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Affiliation(s)
- Jinghao N Ngiam
- Department of Medicine, National University Health System, Singapore
| | - Nicholas W S Chew
- Department of Medicine, National University Health System, Singapore
| | | | - Benjamin Y Q Tan
- Department of Medicine, National University Health System, Singapore
| | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore
| | - Wen Ruan
- National Heart Centre Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - William K F Kong
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, National University Health System, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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27
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Wang D, Xiong T, Yu W, Liu B, Wang J, Xiao K, She Q. Predicting the Key Genes Involved in Aortic Valve Calcification Through Integrated Bioinformatics Analysis. Front Genet 2021; 12:650213. [PMID: 34046056 PMCID: PMC8144713 DOI: 10.3389/fgene.2021.650213] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Valvular heart disease is obtaining growing attention in the cardiovascular field and it is believed that calcific aortic valve disease (CAVD) is the most common valvular heart disease (VHD) in the world. CAVD does not have a fully effective treatment to delay its progression and the specific molecular mechanism of aortic valve calcification remains unclear. Materials and Methods: We obtained the gene expression datasets GSE12644 and GSE51472 from the public comprehensive free database GEO. Then, a series of bioinformatics methods, such as GO and KEGG analysis, STING online tool, Cytoscape software, were used to identify differentially expressed genes in CAVD and healthy controls, construct a PPI network, and then identify key genes. In addition, immune infiltration analysis was used via CIBERSORT to observe the expression of various immune cells in CAVD. Results: A total of 144 differential expression genes were identified in the CAVD samples in comparison with the control samples, including 49 up-regulated genes and 95 down-regulated genes. GO analysis of DEGs were most observably enriched in the immune response, signal transduction, inflammatory response, proteolysis, innate immune response, and apoptotic process. The KEGG analysis revealed that the enrichment of DEGs in CAVD were remarkably observed in the chemokine signaling pathway, cytokine-cytokine receptor interaction, and PI3K-Akt signaling pathway. Chemokines CXCL13, CCL19, CCL8, CXCL8, CXCL16, MMP9, CCL18, CXCL5, VCAM1, and PPBP were identified as the hub genes of CAVD. It was macrophages that accounted for the maximal proportion among these immune cells. The expression of macrophages M0, B cells memory, and Plasma cells were higher in the CAVD valves than in healthy valves, however, the expression of B cells naïve, NK cells activated, and macrophages M2 were lower. Conclusion: We detected that chemokines CXCL13, CXCL8, CXCL16, and CXCL5, and CCL19, CCL8, and CCL18 are the most important markers of aortic valve disease. The regulatory macrophages M0, plasma cells, B cells memory, B cells naïve, NK cells activated, and macrophages M2 are probably related to the occurrence and the advancement of aortic valve stenosis. These identified chemokines and these immune cells may interact with a subtle adjustment relationship in the development of calcification in CAVD.
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Affiliation(s)
- Dinghui Wang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tianhua Xiong
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenlong Yu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Wang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kaihu Xiao
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiang She
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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28
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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29
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Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review. Curr Probl Cardiol 2021; 46:100843. [PMID: 33994024 DOI: 10.1016/j.cpcardiol.2021.100843] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/08/2021] [Indexed: 12/31/2022]
Abstract
Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 555] [Impact Index Per Article: 185.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 837] [Impact Index Per Article: 279.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Tandon I, Johns S, Woessner A, Perez J, Cross D, Ozkizilcik A, Muldoon TJ, Vallurupalli S, Padala M, Quinn KP, Balachandran K. Label-free optical biomarkers detect early calcific aortic valve disease in a wild-type mouse model. BMC Cardiovasc Disord 2020; 20:521. [PMID: 33308143 PMCID: PMC7731510 DOI: 10.1186/s12872-020-01776-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/08/2020] [Indexed: 12/31/2022] Open
Abstract
Background Calcific aortic valve disease (CAVD) pathophysiology is a complex, multistage process, usually diagnosed at advanced stages after significant anatomical and hemodynamic changes in the valve. Early detection of disease progression is thus pivotal in the development of prevention and mitigation strategies. In this study, we developed a diet-based, non-genetically modified mouse model for early CAVD progression, and explored the utility of two-photon excited fluorescence (TPEF) microscopy for early detection of CAVD progression. TPEF imaging provides label-free, non-invasive, quantitative metrics with the potential to correlate with multiple stages of CAVD pathophysiology including calcium deposition, collagen remodeling and osteogenic differentiation. Methods Twenty-week old C57BL/6J mice were fed either a control or pro-calcific diet for 16 weeks and monitored via echocardiography, histology, immunohistochemistry, and quantitative polarized light imaging. Additionally, TPEF imaging was used to quantify tissue autofluorescence (A) at 755 nm, 810 nm and 860 nm excitation, to calculate TPEF 755–860 ratio (A860/525/(A755/460 + A860/525)) and TPEF Collagen-Calcium ratio (A810/525/(A810/460 + A810/525)) in the murine valves. In a separate experiment, animals were fed the above diets till 28 weeks to assess for later-stage calcification. Results Pro-calcific mice showed evidence of lipid deposition at 4 weeks and calcification at 16 weeks at the valve commissures. The valves of pro-calcific mice also showed positive expression for markers of osteogenic differentiation, myofibroblast activation, proliferation, inflammatory cytokines and collagen remodeling. Pro-calcific mice exhibited lower TPEF autofluorescence ratios, at locations coincident with calcification, that correlated with increased collagen disorganization and positive expression of osteogenic markers. Additionally, locations with lower TPEF autofluorescence ratios at 4 and 16 weeks exhibited increased calcification at later 28-week timepoints. Conclusions This study suggests the potential of TPEF autofluorescence metrics to serve as a label-free tool for early detection and monitoring of CAVD pathophysiology.
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Affiliation(s)
- Ishita Tandon
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA
| | - Shelby Johns
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA
| | - Alan Woessner
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA
| | - Jessica Perez
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA
| | - Delaney Cross
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA
| | - Asya Ozkizilcik
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA
| | - Timothy J Muldoon
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA
| | - Srikanth Vallurupalli
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Muralidhar Padala
- Division of Cardiothoracic Surgery, Joseph P. Whitehead Department of Surgery, Emory University, Atlanta, GA, 30322, USA
| | - Kyle P Quinn
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA
| | - Kartik Balachandran
- Department of Biomedical Engineering, University of Arkansas, 122 John A. White Jr. Engineering Hall, Fayetteville, AR, 72701, USA.
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Relevance of Functional Mitral Regurgitation in Aortic Valve Stenosis. Am J Cardiol 2020; 136:115-121. [PMID: 32941813 DOI: 10.1016/j.amjcard.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 01/03/2023]
Abstract
The clinical relevance of functional-mitral-regurgitation (FMR) in patients with aortic valve stenosis (AS) has been poorly studied using a quantitative approach. In addition, FMR prognostic value has mostly been analyzed after aortic valve replacement. Between 2010 and 2014 the echocardiograms of consecutive AS patients were retrospectively reviewed. Inclusion criteria were calcified aortic valve with transaortic-velocity >2.5 m/s and calculated mitral effective regurgitant orifice area (ERO) in the presence of mitral regurgitation. Organic mitral valve disease was an exclusion-criteria. Primary endpoint was heart failure or death under medical management. Secondary endpoint was heart failure or death. Eligible patients were 189, age 79 ± 8 years, 61% NYHA I/II, indexed aortic valve area (AVA) 0.55 ± 0.17 cm2/m2. Mitral ERO was 7.6 ± 4.2 mm2 (>10 mm2 in 30% of patients). Longitudinal function (by S'-TDI) was associated with mitral ERO independently of ejection fraction and ventricular volumes (p = 0.01). Mitral ERO greater than 10 mm2 (threshold identified by spline survival-modeling) was associated with severe symptoms (Odds ratio [OR] 3.1 [1.6 to 6.0]; p = 0.0006) and higher pulmonary-arterial-pressure (OR 3.0 [1.4 to 5.9]; p = 0.002). Follow-up was completed for 175 patients. After 4.7 [1.4 to 7.2] years, 87 (50%) patients underwent AVR, 66 (38%) had heart-failure, 64 (37%) died. No procedure on FMR was required. Mitral ERO was independently associated with primary and secondary endpoints both as continuous variable (Hazard ratio [HR] 1.15 [1.00 to 1.30]; p = 0.04 and HR 1.23 [1.05 to 1.43]; p = 0.01 per 5 mm2 ERO increase) or as ERO> versus ≤10 mm2. Adjustment for S'-TDI or subgroup-analysis did not affect results. The analysis by AVA revealed the incremental prognostic role of mitral ERO over AS severity. In conclusion, AS patients with concomitant FMR >10 mm2 holds a higher risk during medical follow-up. FMR quantitation, even for volumetrically modest regurgitation, provides incremental prognostic information over AS severity.
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Wisneski AD, Wang Y, Deuse T, Hill AC, Pasta S, Sack KL, Yao J, Guccione JM. Impact of Aortic Stenosis on Myofiber Stress: Translational Application of Left Ventricle-Aortic Coupling Simulation. Front Physiol 2020; 11:574211. [PMID: 33013489 PMCID: PMC7506067 DOI: 10.3389/fphys.2020.574211] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 08/19/2020] [Indexed: 12/19/2022] Open
Abstract
The severity of aortic stenosis (AS) has traditionally been graded by measuring hemodynamic parameters of transvalvular pressure gradient, ejection jet velocity, or estimating valve orifice area. Recent research has highlighted limitations of these criteria at effectively grading AS in presence of left ventricle (LV) dysfunction. We hypothesized that simulations coupling the aorta and LV could provide meaningful insight into myocardial biomechanical derangements that accompany AS. A realistic finite element model of the human heart with a coupled lumped-parameter circulatory system was used to simulate AS. Finite element analysis was performed with Abaqus FEA. An anisotropic hyperelastic model was assigned to LV passive properties, and a time-varying elastance function governed the LV active response. Global LV myofiber peak systolic stress (mean ± standard deviation) was 9.31 ± 10.33 kPa at baseline, 13.13 ± 10.29 kPa for moderate AS, and 16.18 ± 10.59 kPa for severe AS. Mean LV myofiber peak systolic strains were −22.40 ± 8.73%, −22.24 ± 8.91%, and −21.97 ± 9.18%, respectively. Stress was significantly elevated compared to baseline for moderate (p < 0.01) and severe AS (p < 0.001), and when compared to each other (p < 0.01). Ventricular regions that experienced the greatest systolic stress were (severe AS vs. baseline) basal inferior (39.87 vs. 30.02 kPa; p < 0.01), mid-anteroseptal (32.29 vs. 24.79 kPa; p < 0.001), and apex (27.99 vs. 23.52 kPa; p < 0.001). This data serves as a reference for future studies that will incorporate patient-specific ventricular geometries and material parameters, aiming to correlate LV biomechanics to AS severity.
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Affiliation(s)
- Andrew D Wisneski
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Yunjie Wang
- Thornton Tomassetti Lifesciences Division, Santa Clara, CA, United States
| | - Tobias Deuse
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Arthur C Hill
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Salvatore Pasta
- Department of Engineering, Universita degli Studi di Palermo, Palermo, Italy
| | - Kevin L Sack
- Cardiovascular Research Division, Medtronic Inc., Minneapolis, MN, United States
| | - Jiang Yao
- Dassault Systèmes Simulia, Johnston, RI, United States
| | - Julius M Guccione
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
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Éva Sikura K, Combi Z, Potor L, Szerafin T, Hendrik Z, Méhes G, Gergely P, Whiteman M, Beke L, Fürtös I, Balla G, Balla J. Hydrogen sulfide inhibits aortic valve calcification in heart via regulating RUNX2 by NF-κB, a link between inflammation and mineralization. J Adv Res 2020; 27:165-176. [PMID: 33318875 PMCID: PMC7728582 DOI: 10.1016/j.jare.2020.07.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/10/2020] [Accepted: 07/11/2020] [Indexed: 01/16/2023] Open
Abstract
Introduction Hydrogen sulfide (H2S) was revealed to inhibit aortic valve calcification and inflammation was implicated in the pathogenesis of calcific aortic valve disease (CAVD). Objectives We investigate whether H2S inhibits mineralization via abolishing inflammation. Methods and results Expression of pro-inflammatory cytokines, interleukin-1β (IL-1β) and tumor necrosis factor α (TNF-α) were increased in patients with CAVD and in calcified aortic valve of ApoE-/- mice. Administration of H2 2S releasing donor (4-methoxyphenyl piperidinylphosphinodithioc acid (AP72)) exhibited inhibition on both calcification and inflammation in aortic valve of apolipoprotein E knockout mice (ApoE-/-) mice is reflected by lowering IL-1β and TNF-α levels. Accordingly, AP72 prevented the accumulation of extracellular calcium deposition and decreased nuclear translocation of nuclear factor-κB (NF-κB) in human valvular interstitial cells (VIC). This was also accompanied by reduced cytokine response. Double-silencing of endogenous H2S producing enzymes, Cystathionine gamma-lyase (CSE) and Cystathionine beta-synthase (CBS) in VIC exerted enhanced mineralization and higher levels of IL-1β and TNF-α. Importantly, silencing NF-κB gene or its pharmacological inhibition prevented nuclear translocation of runt-related transcription factor 2 (Runx2) and subsequently the calcification of human VIC. Increased levels of NF-κB and Runx2 and their nuclear accumulation occurred in ApoE-/- mice with a high-fat diet. Administration of AP72 decreased the expression of NF-κB and prevented its nuclear translocation in VIC of ApoE-/- mice on a high-fat diet, and that was accompanied by a lowered pro-inflammatory cytokine level. Similarly, activation of Runx2 did not occur in VIC of ApoE-/- mice treated with H2S donor. Employing Stimulated Emission Depletion (STED) nanoscopy, a strong colocalization of NF-κB and Runx2 was detected during the progression of valvular calcification. Conclusions Hydrogen sulfide inhibits inflammation and calcification of aortic valve. Our study suggests that the regulation of Runx2 by hydrogen sulfide (CSE/CBS) occurs via NF-κB establishing a link between inflammation and mineralization in vascular calcification.
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Key Words
- AP72
- AP72, 4-methoxyphenyl piperidinylphosphinodithioc acid
- AS, stenotic aortic valve with calcification
- Aortic valve
- ApoE-/-, apolipoprotein E-deficient mice
- Apolipoprotein E knockout mice
- CAVD
- CAVD, calcific aortic valve disease
- CBS, Cystathionine beta-synthase
- CSE, Cystathionine gamma-lyase
- H2S
- HAV, healthy aortic valve from suicide patients
- IL-1β, interleukin-1β
- Inflammation
- NF-κB, nuclear factor-κB
- STED, Stimulated Emission Depletion Nanoscopy
- TNF-α, tumor necrosis factor α
- VIC, valvular interstitial cells
- cVIC, control healthy valve interstitial cells
- mHAV, healthy mouse aortic valve
- mVIC, mouse valvular interstitial cells
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Affiliation(s)
- Katalin Éva Sikura
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of Debrecen, 4012 Debrecen, Hungary.,HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
| | - Zsolt Combi
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of Debrecen, 4012 Debrecen, Hungary.,HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
| | - László Potor
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of Debrecen, 4012 Debrecen, Hungary.,HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
| | - Tamás Szerafin
- Department of Cardiac Surgery, Faculty of Medicine, University of Debrecen, 4012 Debrecen, Hungary
| | - Zoltán Hendrik
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of Debrecen, 4012 Debrecen, Hungary.,Department of Pathology, University of Debrecen, Faculty of Medicine, 4012 Debrecen, Hungary
| | - Gábor Méhes
- Department of Pathology, University of Debrecen, Faculty of Medicine, 4012 Debrecen, Hungary
| | - Péter Gergely
- Department of Forensic Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Matthew Whiteman
- University of Exeter Medical School, St. Luke's Campus, Magdalen Road, Exeter EX1 2LU, UK
| | - Lívia Beke
- Department of Pathology, University of Debrecen, Faculty of Medicine, 4012 Debrecen, Hungary
| | - Ibolya Fürtös
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of Debrecen, 4012 Debrecen, Hungary
| | - György Balla
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary.,Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4012 Debrecen, Hungary
| | - József Balla
- Division of Nephrology, Department of Medicine, Faculty of Medicine, University of Debrecen, 4012 Debrecen, Hungary.,HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
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Erdöl MA, Özbebek YE, Erbahçeci Timur IE, Ugurlu N, Bozkurt E. Effect of Transcatheter Aortic Valve Replacement on Retinal Layer Thickness Measured by Optical Coherence Tomography. Angiology 2020; 71:817-824. [PMID: 32672103 DOI: 10.1177/0003319720935294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transcatheter aortic valve replacement (TAVR) is associated with clinically significant cerebral microembolism and cognitive status changes. There are no data on the impact of TAVR on retinal layers. We assessed the influence of TAVR on the retinal nerve fiber layer, ganglion cell complex (GCC), and macular thickness (MT) measured by spectral domain optical coherence tomography (SD-OCT). Elderly patients (n = 50) with severe aortic stenosis undergoing TAVR were included in this study (mean age: 78.5 ± 6.9 years). Retinal nerve fiber layer, GCC, and MT were measured with SD-OCT by an ophthalmologist before and on the first day and in the first month after TAVR. The average MT was significantly increased on the first day after TAVR compared with the basal value (P = .04). Ganglion cell complex thickness was significantly thinner on the first day after TAVR than the basal value in the inner inferior quadrant and outer temporal quadrant of the left eye (P = .03 and .04, respectively). Postoperative changes observed on the first day compared with the preoperative period returned to basal values in the first month. In conclusion, TAVR did not cause permanent changes in retinal layers.
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Affiliation(s)
| | | | | | - Nagihan Ugurlu
- Department of Ophtalmology, 442146Yildirim Beyazit University, Ankara, Turkey
| | - Engin Bozkurt
- Department of Cardiology, 442146Yildirim Beyazit University, Ankara, Turkey
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Xie F, Li F, Li R, Liu Z, Shi J, Zhang C, Dong N. Inhibition of PP2A enhances the osteogenic differentiation of human aortic valvular interstitial cells via ERK and p38 MAPK pathways. Life Sci 2020; 257:118086. [PMID: 32679147 DOI: 10.1016/j.lfs.2020.118086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 12/28/2022]
Abstract
AIMS To investigate the role of PP2A in calcified aortic valve disease (CAVD). MATERIALS AND METHODS The expressions of PP2A subunits were detected by real-time polymerase chain reaction (RT-PCR) and western blot in aortic valves from patients with CAVD and normal controls, the activities of PP2A were analyzed by commercial assay kit at the same time. Aortic valve calcification of mice was evaluated through histological and echocardiographic analysis. ApoE-/- mice and ApoE-/- mice injected intraperitoneally with PP2A inhibitor LB100 were fed a high-cholesterol diet for 24 weeks. Immunofluorescent staining was used to locate the cell-type in which PP2A activity was decreased, the PP2A activity of valvular interstitial cells (VICs) treated with osteogenic induction medium was assessed by western blot and commercial assay kit. After changing the activity of VICs through pharmacologic and genetic intervention, the osteoblast differentiation and mineralization were assessed by western blot and Alizarin Red staining. Finally, the mechanism was clarified by using several specific inhibitors. KEY FINDINGS PP2A activity was decreased both in calcified aortic valves and human VICs under osteogenic induction. The PP2A inhibitor LB100 aggravated the aortic valve calcification of mice. Furthermore, PPP2CA overexpression inhibited osteogenic differentiation of VICs, whereas PPP2CA knockdown promoted the process. Further study revealed that the ERK/p38 MAPKs signaling pathways mediated the osteogenic differentiation of VICs induced by PP2A inactivation. SIGNIFICANCE This study demonstrated that PP2A plays an important role in CAVD pathophysiology, PP2A activation may provide a novel strategy for the pharmacological treatment of CAVD.
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Affiliation(s)
- Fei Xie
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Fei Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Rui Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zongtao Liu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jiawei Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Chao Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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Tandon I, Kolenc OI, Cross D, Vargas I, Johns S, Quinn KP, Balachandran K. Label-free metabolic biomarkers for assessing valve interstitial cell calcific progression. Sci Rep 2020; 10:10317. [PMID: 32587322 PMCID: PMC7316720 DOI: 10.1038/s41598-020-66960-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 05/29/2020] [Indexed: 12/13/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is the most common form of valve disease where the only available treatment strategy is surgical valve replacement. Technologies for the early detection of CAVD would benefit the development of prevention, mitigation and alternate therapeutic strategies. Two-photon excited fluorescence (TPEF) microscopy is a label-free, non-destructive imaging technique that has been shown to correlate with multiple markers for cellular differentiation and phenotypic changes in cancer and wound healing. Here we show how specific TPEF markers, namely, the optical redox ratio and mitochondrial fractal dimension, correlate with structural, functional and phenotypic changes occurring in the aortic valve interstitial cells (VICs) during osteogenic differentiation. The optical redox ratio, and fractal dimension of mitochondria were assessed and correlated with gene expression and nuclear morphology of VICs. The optical redox ratio decreased for VICs during early osteogenic differentiation and correlated with biological markers for CAVD progression. Fractal dimension correlated with structural and osteogenic markers as well as measures of nuclear morphology. Our study suggests that TPEF imaging markers, specifically the optical redox ratio and mitochondrial fractal dimension, can be potentially used as a tool for assessing early CAVD progression in vitro.
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Affiliation(s)
- Ishita Tandon
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, 72701, USA
| | - Olivia I Kolenc
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, 72701, USA
| | - Delaney Cross
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, 72701, USA
| | - Isaac Vargas
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, 72701, USA
| | - Shelby Johns
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, 72701, USA
| | - Kyle P Quinn
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, 72701, USA.
| | - Kartik Balachandran
- Department of Biomedical Engineering, University of Arkansas, Fayetteville, AR, 72701, USA.
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Persistent Left Ventricular Wall Thickening after Transcatheter Aortic Valve Replacement: A Hidden Cardiomyopathy. CASE 2020; 4:175-178. [PMID: 32577601 PMCID: PMC7303236 DOI: 10.1016/j.case.2020.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
ATTRwt is underdiagnosed, and sometimes coexists with AS. ATTRwt with AS tends to result in a poor prognosis after TAVR. Recognizing coexistent ATTRwt before TAVR is crucial. STE and cardiac scintigraphy are useful in diagnosing ATTRwt. Persistent wall thickening after TAVR suggests an occult ATTRwt.
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40
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Vadana M, Cecoltan S, Ciortan L, Macarie RD, Tucureanu MM, Mihaila AC, Droc I, Butoi E, Manduteanu I. Molecular mechanisms involved in high glucose-induced valve calcification in a 3D valve model with human valvular cells. J Cell Mol Med 2020; 24:6350-6361. [PMID: 32307869 PMCID: PMC7294117 DOI: 10.1111/jcmm.15277] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/05/2020] [Accepted: 03/26/2020] [Indexed: 12/31/2022] Open
Abstract
Calcific aortic valve disease (CAVD)—the most common valvular heart disease—is accelerated in diabetes and has no pharmacotherapy. Although it is known that early CAVD is associated with inflammation and osteogenesis, the molecular mechanisms involved in diabetes‐associated CAVD still need to be uncovered. In this context, we have developed a 3D construct based on gelatin populated with human valvular endothelial cells (VEC) and valvular interstitial cells (VIC) and evaluated the effect of high glucose (HG) concentration on osteogenic molecules expression and on calcification mechanisms. First, we characterized the 3D model and assessed VIC remodelling properties at different time‐points. Then, we exposed it to normal glucose (NG) or high glucose (HG) for 7, 14 and 21 days after which the cells were isolated, separated and investigated individually. Our results showed that encapsulated VIC actively remodel the hydrogel, as demonstrated by an increased expression of extracellular matrix (ECM) proteins and matrix metalloproteinases (MMPs). Moreover, exposure of the construct to HG triggered bone morphogenetic protein (BMP) and TGF‐β signalling pathways, up‐regulating expression of osteogenic molecules—BMP‐2/‐4, osteocalcin, osteopontin, SMADs and Runt‐related transcription factor (Runx‐2)—and increased calcium deposits in an osteogenic environment. These findings underline the potential of the developed 3D model as a suitable system to investigate the mechanisms of human CAVD and may help to better understand the calcification mechanisms in CAVD associated to diabetes.
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Affiliation(s)
- Mihaela Vadana
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu', Biopathology and Therapy of Inflammation, Bucharest, Romania
| | - Sergiu Cecoltan
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu', Biopathology and Therapy of Inflammation, Bucharest, Romania
| | - Letitia Ciortan
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu', Biopathology and Therapy of Inflammation, Bucharest, Romania
| | - Razvan D Macarie
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu', Biopathology and Therapy of Inflammation, Bucharest, Romania
| | - Monica M Tucureanu
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu', Biopathology and Therapy of Inflammation, Bucharest, Romania
| | - Andreea C Mihaila
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu', Biopathology and Therapy of Inflammation, Bucharest, Romania
| | - Ionel Droc
- Cardiovascular Surgery Department, Central Military Hospital, Bucharest, Romania
| | - Elena Butoi
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu', Biopathology and Therapy of Inflammation, Bucharest, Romania
| | - Ileana Manduteanu
- Institute of Cellular Biology and Pathology 'Nicolae Simionescu', Biopathology and Therapy of Inflammation, Bucharest, Romania
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Huang G, An L, Fan M, Zhang M, Chen B, Zhu M, Wu J, Liu Y, Wang Y, Huang Q, Shi Q, Weng Y. Potential role of full-length and nonfull-length progranulin in affecting aortic valve calcification. J Mol Cell Cardiol 2020; 141:93-104. [PMID: 32247641 DOI: 10.1016/j.yjmcc.2020.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/23/2020] [Accepted: 03/26/2020] [Indexed: 11/25/2022]
Abstract
Inflammation is implicated in the pathogenesis of calcific aortic valve disease (CAVD) which is a major contributor to cardiovascular mortality and lacks non-surgical treatment. The progranulin (PGRN) is an important immunomodulatory factor in a variety of inflammatory diseases, including rheumatoid arthritis, osteoarthritis, inflammatory bowel disease and pneumonia. However, its role in calcification of aortic valve remains unknown. We firstly found that PGRN was increased in calcified human aortic valve (AV) tissues. Interestingly, in addition to full-length PGRN (68KD), a much stronger band of approximately 45 KD was also significantly increased. The band of 45 KD (45-GRN), was present in wild type (WT) mouse MEFs and AV but absent in grn-/-MEFs, indicating that it was a specific degradation product derived from PGRN. 45-GRN was upregulated whereas PGRN was reduced in human valve interstitial cells (hVICs) under calcifying conditions which is induced by osteogenic medium (OM). In primary porcine VICs (pVICs), PGRN downregulated TNF-α and α-SMA which was accompanied by downregulation of RUNX2, OPN, OCN, alkaline phosphatase activity and calcium deposition, effects pointing to reduced inflammation, myofibroblastic and osteoblastic transition under calcifying conditions. We overexpressed a mimic of 45-GRN which contains p-G-F-B-A-C in pVICs. However, 45-GRN overexpression promoted OM-induced calcification through activating the Smad1/5/8, NF-κB and AKT signaling pathways. Inhibition of the three signaling pathways suppressed 45-GRN's effect on VICs phenotype transition. 45-GRN promoted TNF-α and expressed converse pathogenic signatures with PGRN during TNF-α stimulation. Collectively, this study provides new insight into the pathogenesis of CAVD, indicating that PGRN is a stratagem in mitigating valve fibrosis/osteoblastic differentiation, and also presenting 45-GRN as a potential target for the treatment of CAVD.
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Affiliation(s)
- Gaigai Huang
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Liqin An
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Mengtian Fan
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Menghao Zhang
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Bin Chen
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Mengying Zhu
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Jinghong Wu
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Yan Liu
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Yue Wang
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Qin Huang
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Qiong Shi
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China
| | - Yaguang Weng
- The M.O.E. Key Laboratory of Laboratory Medical Diagnostics, The College of Laboratory Medicine, Chongqing Medical University, Chongqing 400016, China.
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Li M, Ye ZC, Li CM, Zhao WB, Tang H, Liu X, Peng H, Lou TQ. The influence of cardiac valvular calcification on all-cause and cardiovascular mortality in maintenance hemodialysis patients. Int Urol Nephrol 2020; 52:943-951. [PMID: 32239335 DOI: 10.1007/s11255-020-02448-4] [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: 10/14/2019] [Accepted: 03/16/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the effect of cardiac valve calcification (CVC) on all-cause and cardiovascular mortality in maintenance hemodialysis (MHD) patients. METHODS A retrospective cohort study was conducted in 183 long-term hemodialysis patients with complete follow-up data from January 1, 2012, to December 30, 2015. The baseline data between CVC and non-CVC groups were compared. Kaplan-Meier method was used to analyze all-cause and cardiovascular mortality. The effect of CVC on prognosis was analyzed using the Cox proportional hazard regression model and subgroup analysis. RESULTS Among 183 patients under hemodialysis, 104 (56.8%) were males, with an average age of 56.1 ± 17.0 years and 68 (37.2%) were complicated with valvular calcification. The median follow-up period was 30.8 months. All-cause and cardiovascular mortality were 50% vs. 14.8% and 25% vs. 7.0% in the CVC and non-CVC groups, respectively (P < 0.05). Kaplan-Meier indicated that differences in all-cause and cardiovascular mortality were statistically significant between the two groups (P < 0.001). Cox regression analysis showed that CVC significantly increased all-cause (hazards ratio [HR] 2.161 [1.083-4.315]) and cardiovascular mortality (3.435 [1.222-9.651]) after adjusting for multiple factors. Meanwhile, CVC also increases the incidence of new-onset cardiovascular events. Subgroup analysis revealed that all-cause and cardiovascular mortality were significantly higher in patients with aortic valve calcification (AVC) than in patients with mitral valve calcification (MVC). Multivariate calibration showed that AVC increased the risk of cardiovascular death (HR 5.486 [1.802-16.702]) (P < 0.05), whereas MVC did not. By further comparing the echocardiographic data of the two groups, the incidence of LVH and pulmonary hypertension in the AVC group was significantly higher than that in the MVC group. CONCLUSION Valve calcification increases the risk of all-cause and cardiovascular mortality in MHD patients, also new-onset cardiovascular events, and aortic valve calcification contributes more to the risk of cardiovascular mortality.
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Affiliation(s)
- Ming Li
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600#, Guangzhou, 510630, People's Republic of China
| | - Zeng-Chun Ye
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600#, Guangzhou, 510630, People's Republic of China
| | - Can-Ming Li
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600#, Guangzhou, 510630, People's Republic of China
| | - Wen-Bo Zhao
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600#, Guangzhou, 510630, People's Republic of China
| | - Hua Tang
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600#, Guangzhou, 510630, People's Republic of China
| | - Xun Liu
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600#, Guangzhou, 510630, People's Republic of China
| | - Hui Peng
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600#, Guangzhou, 510630, People's Republic of China.
| | - Tan-Qi Lou
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Tianhe Road 600#, Guangzhou, 510630, People's Republic of China.
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The E, Yao Q, Zhang P, Zhai Y, Ao L, Fullerton DA, Meng X. Mechanistic Roles of Matrilin-2 and Klotho in Modulating the Inflammatory Activity of Human Aortic Valve Cells. Cells 2020; 9:cells9020385. [PMID: 32046115 PMCID: PMC7072362 DOI: 10.3390/cells9020385] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Calcific aortic valve disease (CAVD) is a chronic inflammatory disease. Soluble extracellular matrix (ECM) proteins can act as damage-associated molecular patterns and may induce valvular inflammation. Matrilin-2 is an ECM protein and has been found to elevate the pro-osteogenic activity in human aortic valve interstitial cells (AVICs). Klotho, an anti-aging protein, appears to have anti-inflammatory properties. The effect of matrilin-2 and Klotho on AVIC inflammatory responses remains unclear. METHODS AND RESULTS Isolated human AVICs were exposed to matrilin-2. Soluble matrilin-2 induced the production of ICAM-1, MCP-1, and IL-6. It also induced protein kinase R (PKR) activation via Toll-like receptor (TLR) 2 and 4. Pretreatment with PKR inhibitors inhibited NF-κB activation and inflammatory mediator production induced by matrilin-2. Further, recombinant Klotho suppressed PKR and NF-κB activation and markedly reduced the production of inflammatory mediators in human AVICs exposed to matrilin-2. CONCLUSIONS This study revealed that soluble matrilin-2 upregulates AVIC inflammatory activity via activation of the TLR-PKR-NF-κB pathway and that Klotho is potent to suppress AVIC inflammatory responses to a soluble ECM protein through inhibiting PKR. These novel findings indicate that soluble matrilin-2 may accelerate the progression of CAVD by inducing valvular inflammation and that Klotho has the potential to suppress valvular inflammation.
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Affiliation(s)
| | | | | | | | | | | | - Xianzhong Meng
- Correspondence: ; Tel.: +1-303-724-6303; Fax: +1-303-724-6330
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Loureiro-Ga M, Veiga C, Fdez-Manin G, Jimenez VA, Calvo-Iglesias F, Iñiguez A. A biomechanical model of the pathological aortic valve: simulation of aortic stenosis. Comput Methods Biomech Biomed Engin 2020; 23:303-311. [PMID: 31996041 DOI: 10.1080/10255842.2020.1720001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Aortic stenosis (AS) disease is a narrowing of the aortic valve (AV) opening which reduces blood flow from the heart causing several health complications. Although a lot of work has been done in AV simulations, most of the efforts have been conducted regarding healthy valves. In this article, a new three-dimensional patient-specific biomechanical model of the valve, based on a parametric formulation of the stenosis that permits the simulation of different degrees of pathology, is presented. The formulation is based on a double approach: the first one is done from the geometric point of view, reducing the effective ejection area of the AV by joining leaflets using a zipper effect to sew them; the second one, in terms of functionality, is based on the modification of AV tissue properties due to the effect of calcifications. Both healthy and stenotic valves were created using patient-specific data and results of the numerical simulation of the valve function are provided. Analysis of the results shows a variation in the first principal stress, geometric orifice area, and blood velocity which were validated against clinical data. Thus, the possibility to create a pipeline which allows the integration of patient-specific data from echocardiographic images and iFR studies to perform finite elements analysis is proved.
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Affiliation(s)
- Marcos Loureiro-Ga
- Applied Mathematics Department II - Telecommunications Engineering Faculty, Univeristiy of Vigo, Vigo, Spain.,Cardiology Department, Galicia Sur Health Research Institute (IIS Galicia Sur). SERGAS-UVIGO, Vigo, Spain
| | - Cesar Veiga
- Cardiology Department, Galicia Sur Health Research Institute (IIS Galicia Sur). SERGAS-UVIGO, Vigo, Spain
| | - Generosa Fdez-Manin
- Applied Mathematics Department II - Telecommunications Engineering Faculty, Univeristiy of Vigo, Vigo, Spain
| | - Victor Alfonso Jimenez
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (CHUVI), Alvaro Cunqueiro Hospital, SERGAS, Vigo, Spain
| | - Francisco Calvo-Iglesias
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (CHUVI), Alvaro Cunqueiro Hospital, SERGAS, Vigo, Spain
| | - Andres Iñiguez
- Cardiology Department, Complexo Hospitalario Universitario de Vigo (CHUVI), Alvaro Cunqueiro Hospital, SERGAS, Vigo, Spain
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Kostyunin AE, Ovcharenko EA, Barbarash OL. [The renin-angiotensin-aldosterone system as a potential target for therapy in patients with calcific aortic stenosis: a literature review]. ACTA ACUST UNITED AC 2019; 59:4-17. [PMID: 31884936 DOI: 10.18087/cardio.n328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/14/2019] [Indexed: 11/18/2022]
Abstract
Calcific aortic valve stenosis (CAVS) is a serious socio-economic problem in developed countries because this disease is the most common indication for aortic valve replacement. Currently, there are no methods for non-invasive treatment of CAVS. Nevertheless, it is assumed that effective drug therapy for CAVS can be developed on the basis of modulators of the renin-angiotensin-aldosterone system (RAAS), which is involved in the pathogenesis of this disease. The purpose of this paper is to compile and analyze current information on the role of RAAS in the CAVS pathophysiology. Recent data on the effectiveness of RAAS inhibition are reviewed.
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Affiliation(s)
- A E Kostyunin
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - E A Ovcharenko
- Research Institute for Complex Issues of Cardiovascular Diseases
| | - O L Barbarash
- Research Institute for Complex Issues of Cardiovascular Diseases
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Ellouze M, Mazine A, Carrier M, Bouchard D. Sutureless and Transcatheter Aortic Valve Replacement: When Rivals Become Allies. Semin Thorac Cardiovasc Surg 2019; 32:427-430. [PMID: 31330180 DOI: 10.1053/j.semtcvs.2019.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/06/2019] [Indexed: 11/11/2022]
Abstract
In recent years, sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve replacement (TAVR) have emerged as viable alternatives to standard surgical aortic valve replacement (AVR) in higher risk patients. We report 7 cases in which SU-AVR and TAVR were used as bailout procedures for each other. Between June 2011 and August 2018, 626 patients underwent SU-AVR with the Perceval S prosthesis, and 588 patients underwent TAVR at the Montreal Heart Institute. Herein, we report the cases of 7 patients who underwent both procedures within a short time frame: 3 patients who underwent SU-AVR with a Perceval prosthesis after a failed TAVR procedure, 3 patients who underwent TAVR after degeneration of a surgically implanted Perceval sutureless prosthesis, and 1 patient who was scheduled for multiple percutaneous interventions-including TAVR, right coronary angioplasty, atrial fibrillation ablation with left atrial appendage occlusion-who suffered a periprocedural complication requiring an emergent surgery, during which a Perceval sutureless prosthesis was deployed. All patients were discharged home alive. Two patients suffered a complete heart block requiring permanent pacemaker implantation. We demonstrate that SU-AVR with the Perceval S prosthesis and TAVR are complementary procedures within the therapeutic armamentarium to treat aortic valve disease in higher risk patients. Specifically, valve-in-valve TAVR is an attractive option in the setting of Perceval prosthesis degeneration, whereas SU-AVR is a useful bailout option in the context of periprocedural failure of a TAVR.
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Affiliation(s)
- Mariam Ellouze
- Department of Cardiac Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Québec, Canada
| | - Amine Mazine
- Department of Cardiac Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Québec, Canada
| | - Michel Carrier
- Department of Cardiac Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Québec, Canada
| | - Denis Bouchard
- Department of Cardiac Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Québec, Canada.
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Development of calcific aortic valve disease: Do we know enough for new clinical trials? J Mol Cell Cardiol 2019; 132:189-209. [PMID: 31136747 DOI: 10.1016/j.yjmcc.2019.05.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 05/11/2019] [Accepted: 05/19/2019] [Indexed: 12/19/2022]
Abstract
Calcific aortic valve disease (CAVD), previously thought to represent a passive degeneration of the valvular extracellular matrix (VECM), is now regarded as an intricate multistage disorder with sequential yet intertangled and interacting underlying processes. Endothelial dysfunction and injury, initiated by disturbed blood flow and metabolic disorders, lead to the deposition of low-density lipoprotein cholesterol in the VECM further provoking macrophage infiltration, oxidative stress, and release of pro-inflammatory cytokines. Such changes in the valvular homeostasis induce differentiation of normally quiescent valvular interstitial cells (VICs) into synthetically active myofibroblasts producing excessive quantities of the VECM and proteins responsible for its remodeling. As a result of constantly ongoing degradation and re-deposition, VECM becomes disorganised and rigid, additionally potentiating myofibroblastic differentiation of VICs and worsening adaptation of the valve to the blood flow. Moreover, disrupted and excessively vascularised VECM is susceptible to the dystrophic calcification caused by calcium and phosphate precipitating on damaged collagen fibers and concurrently accompanied by osteogenic differentiation of VICs. Being combined, passive calcification and biomineralisation synergistically induce ossification of the aortic valve ultimately resulting in its mechanical incompetence requiring surgical replacement. Unfortunately, multiple attempts have failed to find an efficient conservative treatment of CAVD; however, therapeutic regimens and clinical settings have also been far from the optimal. In this review, we focused on interactions and transitions between aforementioned mechanisms demarcating ascending stages of CAVD, suggesting a predisposing condition (bicuspid aortic valve) and drug combination (lipid-lowering drugs combined with angiotensin II antagonists and cytokine inhibitors) for the further testing in both preclinical and clinical trials.
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Levy-Neuman S, Meledin V, Gandelman G, Goland S, Zilberman L, Edri O, Shneider N, Abaeh N, Bdolah-Abram T, George J, Shimoni S. The Association Between Longitudinal Strain at Rest and Stress and Outcome in Asymptomatic Patients With Moderate and Severe Aortic Stenosis. J Am Soc Echocardiogr 2019; 32:722-729. [PMID: 30926404 DOI: 10.1016/j.echo.2019.01.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Calcific aortic stenosis (AS) is a progressive disease, and once moderate AS is present, the likelihood of symptom onset within 5 years is significant. The aim of this study was to determine the incremental value of global longitudinal strain (GLS) and basal longitudinal strain (BLS) at rest and during exercise on outcomes among asymptomatic patients' with moderate and severe AS. METHODS Seventy-five patients with isolated, asymptomatic AS and preserved left ventricular function were retrospectively enrolled and underwent symptom-limited exercise echocardiography. Clinical and echocardiographic data, including GLS and BLS at rest and during exercise, were assessed. Occurrence of AS-related cardiovascular events was recorded. RESULTS The mean age was 71 ± 10 years, and 63% were men. The mean aortic valve gradient was 30 ± 11 mm Hg, and the mean aortic valve area was 0.98 ± 0.21 cm2. Resting GLS and BLS were -16.5 ± 4% and -16.9 ± 3.6%, respectively. Exercise stress test results were positive in 27 patients (36%). Mean exercise GLS was -17.8 ± 3.5%, and mean exercise BLS was -17.9 ± 4%. During mean follow-up of 34.5 ± 3.5 months, cardiovascular events were observed in 45 patients. In multivariate analysis, aortic valve mean gradient (HR, 1.073; 95% CI, 1.032-1.115; P < .001) and peak exercise BLS (HR, 1.177; 95% CI, 1.07-1.295; P = .001) were associated with cardiac events during follow-up. CONCLUSIONS Reduced exercise BLS is associated with future cardiovascular events in patients' with asymptomatic AS, independently of clinical factors and conventional echocardiographic parameters. Detection of postexercise myocardial dysfunction in patients with asymptomatic AS with preserved left ventricular function can aid in risk assessment of these patients.
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Affiliation(s)
| | - Valery Meledin
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
| | - Gera Gandelman
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
| | - Sorel Goland
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel; Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Liaz Zilberman
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
| | - Orly Edri
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
| | | | - Naama Abaeh
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel
| | | | - Jacob George
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel; Hebrew University and Hadassah Medical School, Jerusalem, Israel
| | - Sara Shimoni
- The Heart Institute, Kaplan Medical Center, Rehovot, Israel; Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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Vuorio A, Watts GF, Kovanen PT. Lipoprotein(a) as a risk factor for calcific aortic valvulopathy in heterozygous familial hypercholesterolemia. Atherosclerosis 2019; 281:25-30. [DOI: 10.1016/j.atherosclerosis.2018.11.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/17/2018] [Accepted: 11/28/2018] [Indexed: 12/24/2022]
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Preoperative Evaluation of Aortic Stenosis Patient. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2018.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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