Insights into aortic sclerosis and its relationship with coronary artery disease

Specific Multiomic Profiling in Aortic Stenosis in Bicuspid Aortic Valve Disease

INTRODUCTION AND PURPOSE

Bicuspid aortic valve (BAV) disease is associated with faster aortic valve degeneration and a high incidence of aortic stenosis (AS). In this study, we aimed to identify differences in the pathophysiology of AS between BAV and tricuspid aortic valve (TAV) patients in a multiomics study integrating metabolomics and transcriptomics as well as clinical data.

METHODS

Eighteen patients underwent aortic valve replacement due to severe aortic stenosis: 8 of them had a TAV, while 10 of them had a BAV. RNA sequencing (RNA-seq) and proton nuclear magnetic resonance spectroscopy (1H-NMR) were performed on these tissue samples to obtain the RNA profile and lipid and low-molecular-weight metabolites. These results combined with clinical data were posteriorly compared, and a multiomic profile specific to AS in BAV disease was obtained.

RESULTS

H-NMR results showed that BAV patients with AS had different metabolic profiles than TAV patients. RNA-seq also showed differential RNA expression between the groups. Functional analysis helped connect this RNA pattern to mitochondrial dysfunction. Integration of RNA-seq, 1H-NMR and clinical data helped create a multiomic profile that suggested that mitochondrial dysfunction and oxidative stress are key players in the pathophysiology of AS in BAV disease.

CONCLUSIONS

The pathophysiology of AS in BAV disease differs from patients with a TAV and has a specific RNA and metabolic profile. This profile was associated with mitochondrial dysfunction and increased oxidative stress.

The Role of Trace Elements in Cardiovascular Diseases

Essential trace elements play an important role in human physiology and are associated with various functions regulating cellular metabolism. Non-essential trace elements, on the other hand, often have well-documented toxicities that are dangerous for the initiation and development of diseases due to their widespread occurrence in the environment and their accumulation in living organisms. Non-essential trace elements are therefore regarded as serious environmental hazards that are harmful to health even in low concentrations. Many representatives of these elements are present as pollutants in our environment, and many people may be exposed to significant amounts of these substances over the course of their lives. Among the most common non-essential trace elements are heavy metals, which are also associated with acute poisoning in humans. When these elements accumulate in the body over years of chronic exposure, they often cause severe health damage in a variety of tissues and organs. In this review article, the role of selected essential and non-essential trace elements and their role in the development of exemplary pathophysiological processes in the cardiovascular system will be examined in more detail.

Impact of low-density lipoprotein cholesterol on progression of aortic valve sclerosis and stenosis

Background

Little research has been assessed atherosclerotic risk factors at various stages of calcific aortic valve disease. This study sought to determine risk factors of patients with aortic valve sclerosis (AVS) and mild to moderate aortic stenosis (AS).

Methods

The study included 1,007 patients diagnosed with AVS or mild to moderate AS according to echocardiographic criteria. Patients were identified as a rapid progression group if the annualized difference in peak aortic jet velocity (Vmax) between two echocardiographic examinations was >0.08 m/s/yr in AVS and >0.3 m/s/yr in AS, respectively. We used multivariable logistic regression analyses to assess the factors associated with rapid disease progression or progression to severe AS.

Results

Among 526 AVS patients, higher LDL-C level (odds ratio [OR] 1.22/per 25 mg/dl higher LDL-C, 95% confidence interval [CI] 1.05-1.43) was significantly associated with rapid disease progression. Compared to patients with LDL-C level <70 mg/dl, the adjusted OR for rapid progression were 1.32, 2.15, and 2.98 for those with LDL-C level of 70-95 mg/dl, 95-120 mg/dl, and ≥120 mg/dl, respectively. Among 481 mild to moderate AS patients, the baseline Vmax (OR 1.79/per 0.5 m/s higher Vmax, 95% CI 1.18-2.70) was associated with rapid progression. Compared to patients with Vmax 2.0-2.5 m/s, the adjusted OR for rapid progression were 2.47, 2.78, and 3.49 for those with Vmax of 2.5-3.0 m/s, 3.0-3.5 m/s, and 3.5-4.0 m/s, respectively. LDL-C and baseline Vmax values were independently associated with progression to severe AS.

Conclusion

Atherosclerotic risk factors such as LDL-C were significantly associated with the rapid progression in AVS and baseline Vmax was important in the stage of mild to moderate AS.

Prognostic role of tissue plasminogen activator in coronary artery disease with or without aortic valve sclerosis

AIMS

We sought to investigate the relationship between circulating tissue plasminogen activator (t-PA) level and long-term outcomes in stable coronary artery disease patients with or without aortic valve sclerosis (AVSc).

METHODS AND RESULTS

Serum levels of t-PA were determined in 347 consecutive stable angina patients with (n = 183) or without (n = 164) AVSc. Outcomes were prospectively recorded as planned clinic evaluations every 6 months up to 7 years. The primary endpoint was a composite of cardiovascular death and rehospitalization due to heart failure. The secondary endpoint included all-cause mortality, cardiovascular death, and rehospitalization due to heart failure. Serum t-PA was significantly higher in AVSc than in non-AVSc patients (2131.22 pg/mL vs. 1495.85 pg/mL, P < 0.001). For patients with AVSc, those with t-PA level above the median (>1840.68 pg/mL) were more likely to meet the primary and secondary endpoints (all P < 0.001). After adjusting for potential confounding factors, serum t-PA level remained significantly predictive for each endpoint in the Cox proportional hazard models. The prognostic value of t-PA was good, with an AUC-ROC of 0.753 (P < 0.001). The combination of t-PA with traditional risk factors improved the risk reclassification of AVSc patients, with a net reclassification index of 0.857 and an integrated discrimination improvement of 0.217 (all P < 0.001). However, for patients without AVSc, both primary and secondary endpoints were similar, irrespective of t-PA levels.

CONCLUSIONS

Elevated circulating t-PA confers an increased risk for poor long-term clinical outcomes in stable coronary artery disease patients with AVSc.

Role of follistatin-like 1 levels and functions in calcific aortic stenosis

Background

Calcific aortic valve disease (CAVD) is a progressive disease resulting in severe calcific aortic stenosis (AS), and there is increasing interest in the discovery of novel biomarkers to identify patients with potential future calcific AS at an early stage. This study aimed to determine whether follistatin-like 1 (FSTL1) is associated with calcific AS events and its exact role in aortic valve calcification.

Methods

A prospective observational cohort study involving 656 patients was performed to investigate the relationship between serum FSTL1 and calcific AS incidence during a follow-up of 5 years. Furthermore, we detected FSTL1 levels in valvular interstitial cells (VICs) from calcified valves and explored the effects of FSTL1 on VIC osteogenic differentiation in vitro as well as the signaling pathways involved.

Results

During a median follow-up of 5 years, lower FSTL1 levels were associated with a significantly higher risk of calcific AS events (log rank test, P = 0.007). In addition, Cox multivariable regression analyses verified the predictive value of FSTL1 after adjusting for both demographic features and laboratory confounders. Consistent with our results for serum, a lower concentration of FSTL1 was observed in calcified human valves (n = 11) and mainly colocalized with VICs. Recombinant human FSTL1 (rhFSTL1) stimulation inhibited calcium deposition, alkaline phosphatase (ALP) activity, and osteogenic gene expression partly through the downregulation of the ERK1/2 pathway.

Conclusion

Taken together, this study provides a strong rationale to consider FSTL1 as a potential therapeutic target for calcific AS.

Innate immune cells in the pathophysiology of calcific aortic valve disease: lessons to be learned from atherosclerotic cardiovascular disease?

Calcific aortic valve disease (CAVD) is the most common valvular disease in the developed world with currently no effective pharmacological treatment available. CAVD results from a complex, multifactorial process, in which valvular inflammation and fibro-calcific remodelling lead to valve thickening and cardiac outflow obstruction. The exact underlying pathophysiology of CAVD is still not fully understood, yet the development of CAVD shows many similarities with the pathophysiology of atherosclerotic cardiovascular disease (ASCVD), such as coronary artery disease. Innate immune cells play a crucial role in ASCVD and might also play a pivotal role in the development of CAVD. This review summarizes the current knowledge on the role of innate immune cells, both in the circulation and in the aortic valve, in the development of CAVD and the similarities and differences with ASCVD. Trained immunity and clonal haematopoiesis of indeterminate potential are proposed as novel immunological mechanisms that possibly contribute to the pathophysiology of CAVD and new possible treatment targets are discussed.

Prevalence of Aortic Valve Stenosis in Patients With ST-Segment Elevation Myocardial Infarction and Effect on Long-Term Outcome

Several studies have shown an association between aortic valve stenosis (AS), atherosclerosis and cardiovascular risk factors. These risk factors are frequently encountered in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to evaluate the prevalence and the prognostic implications of AS in patients presenting with STEMI. A total of 2041 patients (61 ± 12 years old, 76% male) admitted with STEMI and treated with primary percutaneous coronary intervention were included. Patients with previous myocardial infarction and previous aortic valve replacement were excluded. Echocardiography was performed at index admission. Patients were divided in 3 groups: 1) any grade of AS, 2) aortic valve sclerosis and 3) normal aortic valve. Any grade of AS was defined as an aortic valve area ≤2.0 cm². The primary endpoint was all-cause mortality. The prevalence of AS was 2.7% in the total population and it increased with age (1%, 3%, 7% and 16%, in the patients aged <65 years, 65 to 74 years, 75 to 84 years and ≥85 years, respectively). Patients with AS showed a significantly higher mortality rate when compared to the other two groups (p < 0.001) and AS was independently associated with all-cause mortality, with a HR of 1.81 (CI 95%: 1.02 to 3.22; p = 0.04). In conclusion, AS is not uncommon in patients with STEMI, and concomitant AS in patients with first STEMI is independently associated with all-cause mortality at long-term follow up.

Plasmatic PCSK9 Levels Are Associated with Very Fast Progression of Asymptomatic Degenerative Aortic Stenosis

The aim of this work was to study the association of potential biomarkers with fast aortic stenosis (AS) progression. Patients with moderate-to-severe AS were classified as very fast progressors (VFP) if exhibited an annualized change in peak velocity (aΔVmax) ≥0.45m/s/year and/or in aortic valve area (aΔAVA) ≥-0.2cm2/year. Respective cut-off values of ≥0.3m/s/year and ≥-0.1cm²/year defined fast progressors (FP), whereas the remaining patients were non-fast progressors (non-FP). Baseline markers of lipid metabolism, inflammation, and cardiac overload were determined. Two hundred and nine patients (97 non-FP, 38 FP, and 74 VFP) were included. PCSK9 levels were significantly associated with VFP (OR 1.014 [95%CI 1.005-1.024], for every 10 ng/mL), as were active smoking (OR 3.48) and body mass index (BMI, OR 1.09), with an AUC of 0.704 for the model. PCSK9 levels, active smoking, and BMI were associated with very fast AS progression in our series, suggesting that inflammation and calcification participate in disease progression.

Aortic Valve Sclerosis in High-Risk Coronary Artery Disease Patients

Background: Current knowledge regarding the relationship between aortic valve sclerosis (AVSc), cardiovascular risk factors, and mortality in patients with known coronary artery disease (CAD) is still unclear. The present study aimed at investigating the prevalence of AVSc as well as its association with long-term all-cause mortality in high-risk CAD patients that has never been explored in large cohorts thus far.

Methods and Results: In this retrospective and observational cohort study we enrolled high-risk CAD patients, hospitalized at Centro Cardiologico Monzino (CCM), Milan, Italy, between January 2006 and December 2016. The morphology and function of the aortic valve were assessed from the recorded echocardiographic images to evaluate the presence of AVSc, defined as a non-uniform thickening of the aortic leaflets with no consequences on hemodynamics. Data on 5-year all-cause mortality was retrieved from a Regional database. Of the 5,489 patients initially screened, 4,938 (mean age 67 ± 11 years, 3,954 [80%] men) were enrolled in the study. In the overall population, AVSc was detected in 2,138 (43%) patients. Multivariable LASSO regression revealed that age, female gender, diabetes mellitus, previous MI, and left ventricular ejection fraction were independently associated with AVSc. All-cause mortality (adjusted hazard ratio: 1.29, 95%CI: 1.05–1.58) was significantly higher in AVSc than in non-AVSc patients.

Conclusions: AVSc is frequently detected in high-risk CAD patients and is associated with long-term mortality. Our findings corroborate the hypothesis that AVSc is an underestimated marker of systemic cardiovascular risk. Thus, AVSc detection may be used to improve long-term risk stratification of high-risk CAD patients.

Trace elements in patients with aortic valve sclerosis

Background:

Aortic valve sclerosis (AVSc) is defined as the thickening and calcification of aortic valve cusps, in the absence of obstruction of ventricular outflow. AVSc is linked with a clear imbalance in some trace elements.

Aims:

The objective of this study was to investigate the relationship between AVSc and serum levels of iron (Fe), zinc (Zn), selenium (Se), and copper (Cu). Additionally, this research aimed to explore the clinical significance of human serum zinc, selenium, copper, and iron concentrations as a potential new biomarker for AVSc patients and to clarify the pathophysiological role in individuals at risk of developing AVSc.

Patients and methods:

The study included 40 subjects with AVSc (25% male and 75% female) who were compared with a healthy control group with the same gender ratio. AVSc was based on comprehensive echocardiographic assessments. Blood samples were taken and Zn and Cu concentrations were determined through the use of atomic absorption spectroscopy. Se was measured using an inductively coupled plasma mass spectrometry device and Fe was measured using a Beckman Coulter instrument.

Results:

There was a significant difference in the prevalence of diabetes, blood pressure levels, and body mass index between the patients and the healthy subjects (p < 0.05). The differences between the serum Fe, Se, and Cu levels of the AVSc patients and the healthy subjects (p > 0.05) were recorded. The serum Zn of AVSc patients when compared was significantly lower compared with that of the control group (p < 0.01).

Conclusion:

Patients with AVSc had an imbalance in some of the trace elements in their blood. The patient group’s valves had higher serum Cu levels and lower serum Se, Zn, and Fe concentrations compared with the healthy group’s valves. In the valve patients as compared, AVSc had a high prevalence of obesity, hypertension, and diabetes.

Effect of Left and Right Coronary Flow Waveforms on Aortic Sinus Hemodynamics and Leaflet Shear Stress: Correlation with Calcification Locations

Coronary flow induces hemodynamic alterations in the aortic sinus region. The objectives of this study are to: (1) investigate the differences among sinus hemodynamics and leaflet wall shear stresses engendered by the left versus right versus non-coronary flow and (2) correlate respective wall shear stresses with leaflet calcification in patients. A left heart simulator flow loop with a tunable coronary circuit provided physiological coronary flow waveforms corresponding to the left coronary cusp case (LCC), right coronary cusp case (RCC), and non-coronary cusp case (NCC). High spatio-temporal resolution particle image velocimetry was conducted to quantify leaflet wall shear stress and sinus vorticity fields and to measure aortic leaflet tip kinematics. Thirty-one patients with severe calcific aortic valve disease were segmented from CT data for the calcific volumes in their respective left, right, and non-coronary cusps. Leaflet tip position during systole shows the RCC has a wider leaflet opening compared to LCC and NCC. Velocity and vorticity fields combined with leaflet position data show that sinus vorticity is diminished (peak ~ 43 s-1) in the LCC while RCC and NCC maintain high vorticity (~ 1200 and ~ 950 s-1 respectively). WSS magnitudes greater than 0.3 Pa show 20 and 81% greater occurrences in the LCC and RCC respectively compared to NCC. Significant differences [X2 (2, n = 31) = 7.31, p = 0.0258] between the calcification levels in each cusp of the patient population. Coronary flow differences between LCC, RCC, and NCC show significant impact on leaflet kinematics and sinus flow hemodynamics. Clinical data correlations of the coronary flow cases indicate the left coronary cusp has a higher likelihood of calcification compared to the right.

Lipid levels linked to symptomatic aortic valve stenosis: evidence from Mendelian randomization?

Collapse

Clinical Relevance of Plasma Endogenous Tissue-Plasminogen Activator and Aortic Valve Sclerosis: Performance as a Diagnostic Biomarker

Background: Aortic valve sclerosis (AVSc), a common precursor to calcific aortic valve disease, may progress into advanced aortic stenosis with hemodynamic instability. However, plasma biomarkers of such a subclinical condition remain lacking. Since impaired fibrinolysis featuring dysregulated tissue plasminogen activator (t-PA) is involved in several cardiovascular diseases, we investigated whether endogenous t-PA was also associated with AVSc.

Methods: Plasma t-PA levels were measured in 295 consecutive patients undergoing standard echocardiography and Doppler flow imaging. Multiple logistic regression analyses were used to assess the association between t-PA and AVSc. Receiver operating characteristic curve analysis was performed for determining the diagnostic value of t-PA for AVSc. The performance of adding t-PA to clinical signatures of AVSc was evaluated. Concentration of t-PA was assessed in human sclerotic and non-sclerotic aortic valves by histology and immunohistochemistry analysis.

Results: Plasma t-PA was higher in patients with AVSc than in non-AVSc counterparts (median, 2063.10 vs. 1403.17 pg/mL, p < 0.01). C-statistics of plasma t-PA for discriminating AVSc was 0.698 (95%CI: 0.639–0.758). The performance of t-PA for identifying AVSc was better among male and non-hypertensive patients [C-statistics (95%CI): 0.712 (0.634–0.790) and 0.805 (0.693–0.916), respectively]. Combination of t-PA and clinical factors improved classification of the patients (category-free NRI: 0.452, p < 0.001; IDI: 0.020, p = 0.012). The concentration of t-PA was three times higher in sclerotic compared to non-sclerotic aortic valves.

Conclusion: Elevated circulating t-PA level confers an increased risk for AVSc. Further prospective studies with larger sample size are needed to examine if t-PA could serve as a diagnostic clinical marker for AVSc.

Prevalence and Predictors of Atherosclerotic Peripheral Arterial Obstructive Disease in Severe Heart Valve Diseases

Despite witnessing an upsurge in heart valve diseases (HVDs), the correlation between HVDs and atherosclerotic peripheral arterial obstructive disease (PAOD) remains unclear. This study aims to investigate the prevalence and predictors of PAOD in HVDs.In this study, a total of 245 consecutive patients were examined: 153 with severe aortic valve stenosis (AS), 66 with severe primary mitral valve regurgitation (MR), and 26 with severe pure native aortic valve regurgitation (AR). All patients underwent ultrasound scan of the carotid artery to ascertain the presence of internal carotid artery stenosis (ICAS). ICAS was defined as a peak systolic velocity ≥ 125 cm/second and/or ≥ 50% reduction in diameter. In addition, we measured the ankle-brachial index in each leg using a volume plethysmograph. A result of ≤ 0.9 was considered lower extremity artery disease (LEAD).The presence of ICAS was statistically more frequent in patients with severe AS than in patients with severe MR and AR (11.1% versus 1.5% versus 3.8%; P = 0.038). LEAD was present in patients with severe AS (17.6%) and MR (10.6%) but not in patients with severe AR (P = 0.037). The multivariate analysis revealed that the presence of severe AS (OR, 5.6 [1.3-24.9]; P = 0.023) was an independent predictor for ICAS, while history of coronary artery disease (OR, 4.8 [2.2-10.5]; P < 0.001) was an independent predictor for LEAD.The prevalence of PAOD varies depending on each valvular disease. Individual screening should be considered on the basis of atherosclerotic risk factors, especially for patients with severe AS.

Aortic valve microcalcification and cardiovascular risk: an exploratory study using sodium fluoride in high cardiovascular risk patients

18F-sodium fluoride (18F-NaF) has been used to access aortic stenosis in clinical research setting. It is known that its uptake is related with microcalcification. The purpose of this study was to assess the relationship between 18F-NaF uptake by the aortic valve and cardiovascular risk. Twenty-five patients with risk factors for cardiovascular disease, without known cardiovascular disease or aortic stenosis underwent PET-CT with 18F-NaF. Cardiovascular risk was assessed through the ASCVD (Atherosclerotic Cardiovascular Disease) risk calculator. Aortic valve 18F-NaF (AoVCUL) uptake was evaluated through the corrected uptake per lesion (CUL = max SUV - mean blood-pool SUV). Calcium score was obtained through cardiac CT. The patients present a mean age of 63.90 ± 8.60 years and 56% males. The mean ASCVD was of 28.76 ± 18.96 (M 25, IQR 38.50). The mean aortic valve calcium score (AoVCaSc) was of 53.24 ± 164.38 (M 6; IQR 29.75) and the AoVCUL was of 0.50 ± 0.10 (M 0.52, IQR 0.15). The patients were classified according to the ASCVD: patients with a risk greater or equal than the 50th percentile of the ASCVD risk and patients with a risk lower than the 50th percentile. The AoVCUL was evaluated in both groups: AoVCUL = 0.56 ± 0.10 vs 0.42 ± 0.15, p = 0.02; AoVCaSc was of 0 in 11 patients (44%) and those with an ASCVD greater or equal than the 50th percentile had a mean AoVCaSc of 8.00 ± 13.80, and those with an ASCVD risk lower than the 50th percentile had a mean AoVCaSc of 95.00 ± 223.45; p = 0.09. In this study microcalcification, evaluated through 18F-NaF on PET-CT, was related with cardiovascular risk. Although the score of calcium seems to be higher in higher cardiovascular risk patients, no significant difference was found between groups.

Ischemia and reperfusion injury following cardioplegic arrest is attenuated by age and testosterone deficiency in male but not female mice

BACKGROUND

Cardiovascular disease increases with age in both sexes. Treatment can require cardiac surgery, where the hearts are pre-treated with protective cardioplegic solution before ischemia and reperfusion (I/R). While endogenous estrogen is beneficial in I/R, whether testosterone is involved is uncertain and whether age modifies responses to I/R is unclear. We investigated sex- and age-specific differences in I/R injury in the hearts pre-treated with clinically relevant cardioplegic solution.

METHODS

The hearts were isolated from young (6-9 months) and old (20-28 months) mice of both sexes and perfused (Langendorff) with Krebs-Henseleit buffer (15 min, 37 °C), followed by St. Thomas' two cardioplegia (6 min, 6-7 °C), global ischemia (90 min, 23-24 °C), and reperfusion (30 min, 37 °C). The hearts were perfused with triphenyltetrazolium chloride to quantify infarct area. Testosterone's role was investigated in gonadectomized (GDX, 6-9 months) male mice; serum testosterone and estradiol were measured with ELISA assays.

RESULTS

Left ventricular developed pressure (LVDP) recovered to 67.3 ± 7.4% in the old compared to 21.8 ± 9.2% in the young male hearts (p < 0.05). Similar results were seen for rates of pressure development (+dP/dt) and decay (-dP/dt). Infarct areas were smaller in the old male hearts (16.6 ± 1.6%) than in the younger hearts (55.8 ± 1.2%, p < 0.05). By contrast, the hearts from young and old females exhibited a similar post-ischemic functional recovery and no age-dependent difference in infarcts. There was a sex difference in the young group, where ventricular function (LVDP, +dP/dt, -dP/dt) recovered better and infarcts were smaller in females than males. Estradiol levels were highest in young females. Testosterone was high in young males but low in females and old males, which suggested beneficial effects of low testosterone. Indeed, the hearts from GDX males exhibited much better recovery of LVDP in reperfusion than that from intact males (values were 64.4 ± 7.5 % vs. 21.8 ± 9.2%; p < 0.05). The GDX hearts also had smaller infarcts than the hearts from intact males (p < 0.05).

CONCLUSIONS

Although age had no effect on susceptibility to I/R injury after cardioplegic arrest in females, it actually protected against injury in older males. Our findings indicate that low testosterone may be protective against I/R injury following cardioplegic arrest in older males.

Impact of Oxidative Stress and Protein S-Glutathionylation in Aortic Valve Sclerosis Patients with Overt Atherosclerosis

Aortic valve sclerosis (AVSc) is characterized by non-uniform thickening of the leaflets without hemodynamic changes. Endothelial dysfunction, also caused by dysregulation of glutathione homeostasis expressed as ratio between its reduced (GSH) and its oxidised form (GSSG), could represent one of the pathogenic triggers of AVSc. We prospectively enrolled 58 patients with overt atherosclerosis and requiring coronary artery bypass grafting (CABG). The incidence of AVSc in the studied population was 50%. The two groups (No-AVSc and AVSc) had similar clinical characteristics. Pre-operatively, AVSc group showed significantly lower GSH/GSSG ratio than No-AVSc group (p = 0.02). Asymmetric dimethylarginine (ADMA) concentration was significantly higher in AVSc patients compared to No-AVSc patients (p < 0.0001). Explanted sclerotic aortic valves presented a significantly increased protein glutathionylation (Pr-SSG) than No-AVSc ones (p = 0.01). In vitro, inhibition of glutathione reductase caused β-actin glutathionylation, activation of histone 2AX, upregulation of α2 smooth muscle actin (ACTA2), downregulation of platelet and endothelial cell adhesion molecule 1 (PECAM1) and cadherin 5 (CDH5). In this study, we showed for the first time that the dysregulation of glutathione homeostasis is associated with AVSc. We found that Pr-SSG is increased in AVSc leaflets and it could lead to EndMT via DNA damage. Further studies are warranted to elucidate the causal role of Pr-SSG in aortic valve degeneration.

Association of Aortic Valve Sclerosis and Clinical Factors in Patients With Acute Myocardial Infarction

BACKGROUND

Since aortic valve sclerosis (AVS) and coronary artery disease (CAD) share similar cardiovascular risk factors, we hypothesized that the clinical profile of patients with acute myocardial infarction (AMI) would be worse in the presence of AVS. The aim of this study was to investigate the association between AVS and clinical factors in patients with AMI.

METHODS

Three hundred and fifteen patients with AMI were consecutively enrolled in the study. Echocardiography was used to assess the aortic valve morphology and left ventricular function. The extent and severity of CAD were assessed by Gensini score and the number of obstructed vessels. The patients were divided into 2 groups according to presence or absence of AVS.

RESULTS

The overall number of patients with AVS was 132 (41.9%). Patients with AVS were older (69.5 ± 11 vs. 59.5 ± 12 years, P < 0.00001). They also had a higher prevalence of hypertension (61% vs. 45%, P = 0.006), prior CAD (33% vs. 23%, P = 0.041), prior AMI (20% vs. 11%, P = 0.019) and a higher percentage were female (32% vs. 19%, P = 0.007) compared with AMI patients without AVS. There was no significant difference between the 2 groups with respect to the Gensini score (P = 0.372). Prior AMI was associated with AVS on age-adjusted logistic regression analyses. A multivariate analysis showed an independent association between the AVS and prior AMI and age (P < 0.0000001, P = 0.022, respectively).

CONCLUSIONS

Our results showed that the presence of AVS is associated with AMI recurrence.

Cardiovascular morbidity and mortality in patients with aortic valve sclerosis: A systematic review and meta-analysis

AIMS

The association between aortic valve sclerosis (AVSc) and cardiovascular (CV) events is not consistent among different studies. We have performed a meta-analysis evaluating the association between AVSc and fatal and/or non-fatal CV and cerebrovascular events.

METHODS AND RESULTS

A systematic search was performed in the electronic databases (PubMed, Web of Science, Scopus, EMBASE). Studies evaluating coronary artery disease (CAD), stroke and CV mortality in AVSc patients and controls were included. Differences among cases and controls were expressed as Odds Ratio (OR) with pertinent 95% Confidence Intervals (CI). Thirty-one studies on 10,537 AVSc patients and 25,005 controls were included in the final analysis. The absolute risk of CAD was 45.8% (95% CI: 32.9-59.3) in AVSc patients and 29.4% (95% CI: 21.8-38.5) in controls with an OR of 2.02 (95% CI: 1.67-2.44) and an attributable risk of 35.8%. Moreover, stroke was reported in 11.8% (95% CI: 4.4-27.7) of AVSc patients and 7.9% (95% CI: 2.5-22.7) of controls (OR: 1.41, 95% CI: 1.16-1.71) with an attributable risk of 33.0%. CV mortality was 6.2% (95% CI: 2.7-13.5) in AVSc patients and 2.0% (95% CI: 0.5-7.9) in controls (OR: 2.70, 95% CI: 1.45-5.01), with an attributable risk of 67.7%. Results were confirmed when pooling together ORs for CAD, stroke and CV mortality obtained by means of multivariate analysis.

CONCLUSIONS

AVSc is associated with CAD, stroke and CV mortality. Taken together, these data suggest that patients with AVSc may benefit from a stricter CV risk monitoring and that AVSc screening may be included in the frame of CV risk stratification protocols.

Aging-Induced Biological Changes and Cardiovascular Diseases

Aging is characterized by functional decline in homeostatic regulation and vital cellular events. This process can be linked with the development of cardiovascular diseases (CVDs). In this review, we discussed aging-induced biological alterations that are associated with CVDs through the following aspects: (i) structural, biochemical, and functional modifications; (ii) autonomic nervous system (ANS) dysregulation; (iii) epigenetic alterations; and (iv) atherosclerosis and stroke development. Aging-mediated structural and biochemical modifications coupled with gradual loss of ANS regulation, vascular stiffening, and deposition of collagen and calcium often disrupt cardiovascular system homeostasis. The structural and biochemical adjustments have been consistently implicated in the progressive increase in mechanical burden and functional breakdown of the heart and vessels. In addition, cardiomyocyte loss in this process often reduces adaptive capacity and cardiovascular function. The accumulation of epigenetic changes also plays important roles in the development of CVDs. In summary, the understanding of the aging-mediated changes remains promising towards effective diagnosis, discovery of new drug targets, and development of new therapies for the treatment of CVDs.

Procedural challenge of coronary catheterization for ST-segment elevation myocardial infarction in patient who underwent transcatheter aortic valve replacement using the CoreValveTM

A 73-year-old man with severe aortic valve stenosis successfully underwent transcatheter aortic valve replacement (TAVR) using CoreValve^TM (29 mm, Medtronic Inc., Minneapolis, MN, USA). Four years after the TAVR, he was hospitalized due to anterior ST-segment elevation myocardial infarction. Despite the need for prompt restoration of coronary flow in the infarct-related artery, the implanted CoreValve^TM profoundly restricted the manipulation of diagnostic catheters during the coronary angiography. In particular, (I) guidewire easily migrated into the space between CoreValve^TM and aorta vessel wall; (II) the nickel-titanium frame of CoreValve^TM limited the space to manipulate catheters, making difficult to advance Judkins left (JL) 4, Judkins right (JR) 4 and Amplatz left 1 into coronary cusps; and (III) selecting specific spot within frame was required for cannulation. Left and right coronary arteries were barely engaged by JL3.5 and modified JR4, respectively. Percutaneous coronary intervention (PCI) for culprit lesion in the left-anterior descending artery was successfully completed by 6-French JL3.5 (Britetip^TM, Cordis, Milpitas, CA, USA) with drug-eluting stent implantation. Meticulous strategies and understanding of the prosthetic valve geometry are warranted to conduct PCI in patients who underwent TAVR.

Differences in Cardiovascular Aging in Men and Women

Cardiovascular diseases increase dramatically with age in both men and women. While it is clear that advanced age allows more time for individuals to be exposed to risk factors in general, there is strong evidence that age itself is a major independent risk factor for cardiovascular disease. Indeed, there are distinct age-dependent cellular, structural, and functional changes in both the heart and blood vessels, even in individuals with no clinical evidence of cardiovascular disease. Studies in older humans and in animal models of aging indicate that this age-related remodeling is maladaptive. An emerging view is that the heart and blood vessels accumulate cellular and subcellular deficits with age and these deficits increase susceptibility to disease in older individuals. Aspects of this age-dependent remodeling of the heart and blood vessels differ between the sexes. There is also new evidence that these maladaptive changes are more prominent in older animals and humans with a high degree of frailty. These observations may help explain why men and women are susceptible to different cardiovascular diseases as they age and why frail older adults are most often affected by these diseases.

Associations of Mitral and Aortic Valve Calcifications with Complex Aortic Atheroma in Patients with Embolic Stroke of Undetermined Source

BACKGROUND

This study investigated the associations of mitral and aortic valve calcification with complex aortic atheroma among patients with embolic stroke of undetermined source.

METHODS

We included 52 consecutive patients (mean age 58.1 years; 75.0% male) with embolic stroke of undetermined source. Mitral annular calcification, aortic annular calcification, and aortic valve sclerosis were assessed by transthoracic echocardiography. Complex aortic atheroma was assessed by transesophageal echocardiography and was defined as plaque protruding greater than or equal to 4 mm into the lumen or with ulcerated or mobile components.

RESULTS

Ten patients (19.2%) had complex aortic atheroma. Patients with and without complex aortic atheroma showed significant differences in terms of hypertension (80.0% versus 38.1%, P = .017), dyslipidemia (90.0% versus 31.0%, P <.01), chronic kidney disease (60.0% versus 14.3%, P <.01), previous coronary artery disease (30.0% versus 4.8%, P = .013), prior stroke (40.0% versus 7.1%, P <.01), left atrial dimension (4.0 cm versus 3.6 cm, P = .023), aortic valve sclerosis (80.0% versus 26.2%, P <.01), aortic valve calcification (aortic annular calcification or aortic valve sclerosis) (80.0% versus 26.0%, P <.01), and left-sided valve calcification (mitral annular calcification or aortic annular calcification or aortic valve sclerosis) (80.0% versus 28.6%, P <.01). In multivariate analysis, left-sided valve calcification was independently associated with complex aortic atheroma (odds ratio 4.1, 95% confidence interval 1.3-26.1, P = .049).

CONCLUSIONS

Mitral or aortic valve calcification detected by transthoracic echocardiography can be a useful marker for predicting complex aortic atheroma in patients with embolic stroke of undetermined source.

Aortic valve sclerosis is associated with the extent of coronaryartery disease in stable coronary artery disease

BACKGROUND/AIM

Aortic valve sclerosis (AVS) is characterized by lipid deposition and calcific infiltration on the edge of aortic leaflets without significant restriction of motion. The SYNTAX Score (SS) is an important method for evaluating coronary artery disease (CAD). Many studies showed that there is an important relation between the SS and undesired cardiac outcomes. In our study, we investigated the correlation between the SS and AVS by including both ACS and stable CAD cases.

MATERIALS AND METHODS

We enrolled 543 patients with CAD who underwent coronary angiography into this cross-sectional study between September 2013 and September 2014.

RESULTS

The study population was divided into two groups according to SS values above and below 22. Diabetes mellitus (DM) incidence was greater in the group with high SS values (26.3% vs. 19.2%, P = 0.052.). Left ventricular ejection fraction (LVEF) and glomerular filtration rate were lower. Low-density lipoprotein cholesterol and triglyceride levels were lower while platelet counts were higher. In multivariate analysis, for the stable coronary artery group AVS existence, platelet count, LVEF value, and chronic obstructive pulmonary disease were found as independent predictors.

CONCLUSION

Our study results demonstrated that AVS is significantly associated with the complexity of CAD, especially in patients with stable CAD. This study provides new information regarding the role of AVS in CAD complexity.

Prevalence of valvular heart diseases and associated risk factors in Han, Uygur and Kazak population in Xinjiang, China

Background

Valvular heart diseases (VHD) is very common in clinical practice and has became the subject of growing attention in the field of cardiovascular medicine. Our aim was to assess the prevalence and correlates of VHD in the general population in Xinjiang, China.

Methods

Using a 4-stage stratified cluster random sampling method, a total of 14618 participants were recruited in the Cardiovascular Risk Survey (CRS) study. The participants’ personal information, medical history were assessed by questionnaire. VHD was diagnosed by transthoracic echocardiography. We carried out the statistical analysis utilizing SPSS Statistics version 19.0.

Results

In the total study group, VHD was observed in 1397 (9.65%) individuals. The prevalence rates of VHD in Han, Uygur and Kazak group are 13.51%, 2.71% and 12.29% respectively. The prevalence rates of VHD increased strikingly with age (all P < 0.001). The results of multinomial regression analysis indicated that VHD were related to age in Han group, to age smoking and hypertension in Uygur group, to age and hypertension in Kazak group.

Conclusion

Our research provides a unique prevalence rate of VHD in Xinjiang natural population. The result suggests that VHD are notably common in this population (9.65%) and increase with age. There exists significant difference of prevalence rate between ethnics. The main risk factors of VHD are age, hypertension and smoking. Valvular heart diseases should be regarded as a serious and growing public-health problem.

Enzymatically Modified Low-Density Lipoprotein Is Present in All Stages of Aortic Valve Sclerosis: Implications for Pathogenesis of the Disease

Background

We have demonstrated previously that enzymatically degraded low‐density lipoprotein (eLDL) is an essential causative component for the initiation of atherosclerosis. Here, we investigated the different stages of human aortic valve sclerosis for the presence of eLDL and effectors of the innate immune system, as well as the interaction of eLDL with isolated valvular interstitial cells/myofibroblasts to discover possible pathways leading to aortic valve sclerosis.

Methods and Results

Human aortic valvular tissue was obtained from 68 patients undergoing valve replacement surgery. Patients were classified into 3 groups (mild, moderate, or severe aortic valve sclerosis), and clinical data for statistical analysis were gathered from all patients. Immunohistochemical staining demonstrated extensive extracellular deposits of eLDL throughout all grades of aortic valve sclerosis. Complementary analysis of lipid composition revealed higher concentrations of the decisive components of eLDL (ie, unesterified cholesterol and linoleic acid) compared with internal control tissues. Further, the complement component C3d and terminal complement complexes colocalized with eLDL compatible with the proposal that subendothelially deposited eLDL is enzymatically transformed into a complement activator at early stages of valvular cusp lesion development. Gene expression profiles of proteases and complement components corroborated by immunohistochemistry demonstrated an upregulation of the protease cathepsin D (a possible candidate for LDL degradation to eLDL) and the complement inhibitor CD55. Surprisingly, substantial C‐reactive protein expression was not observed before grade 2 aortic valve sclerosis as investigated with microarray analysis, reverse transcription–polymerase chain reaction analysis, and immunohistochemistry. Finally, we demonstrated cellular uptake of eLDL by valvular interstitial cells/myofibroblasts.

Conclusions

The present study is a startup of a hypothesis on the pathogenesis of aortic valve sclerosis declaring extracellular lipoprotein modification, subsequent complement activation, and cellular uptake by valvular interstitial cells/myofibroblasts as integral players.

IL-10 genetic polymorphisms were associated with valvular calcification in Han, Uygur and Kazak populations in Xinjiang, China

OBJECTIVE

Valvular calcification occurs via ongoing endothelial injury associated with inflammation. IL-10 is an anti-inflammatory cytokine and 75% of the variation in IL-10 production is genetically determined. However, the relationship between genetic polymorphisms of IL-10 and valvular calcification has not been studied. The objective of this study was to investigate the association between valvular calcification and IL-10 genetic polymorphisms in the Han, Uygur and Kazak populations in China.

PATIENTS AND METHODS

All of the participants were selected from subjects participating in the Cardiovascular Risk Survey (CRS) study. The single nucleotide polymorphisms (SNPs) rs1800871 and rs1800872 of the IL-10 gene were genotyped using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Three independent case-control studies involving the Han population, the Uygur population and the Kazak population were used in the analysis.

RESULTS

For the Han and Kazak populations, rs1800871 was found to be associated with valvular calcification in the recessive model, and the difference remained statistically significant following multivariate adjustment (p<0.001, p=0.031, respectively). For the Han, Uygur and Kazak populations, rs1800872 was found to be associated with valvular calcification in the dominant model, and the difference remained statistically significant following multivariate adjustment (p<0.001, p=0.009, and p=0.023,respectively).

CONCLUSION

Both rs1800871 and rs1800872 of the IL-10 gene are associated with valvular calcification in the Han and Kazak populations in China. Rs1800872 is also associated with valvular calcification in the Uygur population.