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Chen SY, Kong XQ, Zhang JJ. Pathological Mechanism and Treatment of Calcified Aortic Stenosis. Cardiol Rev 2024; 32:320-327. [PMID: 38848535 DOI: 10.1097/crd.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Calcified aortic stenosis (AS) is one of the most common valvular heart diseases worldwide, characterized by progressive fibrocalcific remodeling and thickening of the leaflets, which ultimately leads to obstruction of blood flow. Its pathobiology is an active and complicated process, involving endothelial cell dysfunction, lipoprotein deposition and oxidation, chronic inflammation, phenotypic transformation of valve interstitial cells, neovascularization, and intravalvular hemorrhage. To date, no targeted drug has been proven to slow down or prevent disease progression. Aortic valve replacement is still the optimal treatment of AS. This article reviews the etiology, diagnosis, and management of calcified aortic stenosis and proposes novel potential therapeutic targets.
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Affiliation(s)
- Si-Yu Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China, Nanjing 210006, China
| | - Xiang-Quan Kong
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China, Nanjing 210006, China
- Department of Cardiology, Nanjing Heart Centre, Nanjing, China
| | - Jun-Jie Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China, Nanjing 210006, China
- Department of Cardiology, Nanjing Heart Centre, Nanjing, China
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2
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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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Prapa M, Ho SY. Human Genetics of Semilunar Valve and Aortic Arch Anomalies. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1441:761-775. [PMID: 38884747 DOI: 10.1007/978-3-031-44087-8_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Lesions of the semilunar valve and the aortic arch can occur either in isolation or as part of well-described clinical syndromes. The polygenic cause of calcific aortic valve disease will be discussed including the key role of NOTCH1 mutations. In addition, the complex trait of bicuspid aortic valve disease will be outlined, both in sporadic/familial cases and in the context of associated syndromes, such as Alagille, Williams, and Kabuki syndromes. Aortic arch abnormalities particularly coarctation of the aorta and interrupted aortic arch, including their association with syndromes such as Turner and 22q11 deletion, respectively, are also discussed. Finally, the genetic basis of congenital pulmonary valve stenosis is summarized, with particular note to Ras-/mitogen-activated protein kinase (Ras/MAPK) pathway syndromes and other less common associations, such as Holt-Oram syndrome.
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Affiliation(s)
- Matina Prapa
- Department of Clinical Genetics, St George's University Hospitals NHS Foundation Trust, London, UK.
| | - Siew Yen Ho
- Cardiac Morphology, Royal Brompton & Harefield Hospitals, London, UK
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Luna-Zurita L, Flores-Garza BG, Grivas D, Siguero-Álvarez M, de la Pompa JL. Cooperative Response to Endocardial Notch Reveals Interaction With Hippo Pathway. Circ Res 2023; 133:1022-1039. [PMID: 37961886 PMCID: PMC10699509 DOI: 10.1161/circresaha.123.323474] [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: 08/02/2023] [Revised: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND The endocardium is a crucial signaling center for cardiac valve development and maturation. Genetic analysis has identified several human endocardial genes whose inactivation leads to bicuspid aortic valve formation and calcific aortic valve disease, but knowledge is very limited about the role played in valve development and disease by noncoding endocardial regulatory regions and upstream factors. METHODS We manipulated Notch signaling in mouse embryonic endocardial cells by short-term and long-term coculture with OP9 stromal cells expressing Notch ligands and inhibition of Notch activity. We examined the transcriptional profile and chromatin accessibility landscape for each condition, integrated transcriptomic, transcription factor occupancy, chromatin accessibility, and proteomic datasets. We generated in vitro and in vivo models with CRISPR-Cas9-edited deletions of various noncoding regulatory elements and validated their regulatory potential. RESULTS We identified primary and secondary transcriptional responses to Notch ligands in the mouse embryonic endocardium, and a NOTCH-dependent transcriptional signature in valve development and disease. By defining the changes in the chromatin accessibility landscape and integrating with the landscape in developing mouse endocardium and adult human valves, we identify potential noncoding regulatory elements, validated selected candidates, propose interacting cofactors, and define the timeframe of their regulatory activity. Additionally, we found cooperative transcriptional repression with Hippo pathway by inhibiting nuclear Yap (Yes-associated protein) activity in the endocardium during cardiac valve development. CONCLUSIONS Sequential Notch-dependent transcriptional regulation in the embryonic endocardium involves multiple factors. Notch activates certain noncoding elements through these factors and simultaneously suppresses elements that could hinder cardiac valve development and homeostasis. Biorxviv: https://www.biorxiv.org/content/10.1101/2023.03.23.533882v1.full.
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Affiliation(s)
- Luis Luna-Zurita
- Intercellular Signaling in Cardiovascular Development and Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
- Ciber CV, Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
| | - Brenda Giselle Flores-Garza
- Intercellular Signaling in Cardiovascular Development and Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
- Ciber CV, Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
| | - Dimitrios Grivas
- Intercellular Signaling in Cardiovascular Development and Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
- Ciber CV, Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
- Developmental Biology, Centre for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation Academy of Athens, Greece (D.G.)
| | - Marcos Siguero-Álvarez
- Intercellular Signaling in Cardiovascular Development and Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
- Ciber CV, Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
| | - José Luis de la Pompa
- Intercellular Signaling in Cardiovascular Development and Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
- Ciber CV, Madrid, Spain (L.L.-Z., B.G.F.-G., D.G., M.S.-A., J.L.d.l.P.)
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Liu H, Lu P, He S, Luo Y, Fang Y, Benkaci S, Wu B, Wang Y, Zhou B. β-Catenin regulates endocardial cushion growth by suppressing p21. Life Sci Alliance 2023; 6:e202302163. [PMID: 37385754 PMCID: PMC10310929 DOI: 10.26508/lsa.202302163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/01/2023] Open
Abstract
Endocardial cushion formation is essential for heart valve development and heart chamber separation. Abnormal endocardial cushion formation often causes congenital heart defects. β-Catenin is known to be essential for endocardial cushion formation; however, the underlying cellular and molecular mechanisms remain incompletely understood. Here, we show that endothelial-specific deletion of β-catenin in mice resulted in formation of hypoplastic endocardial cushions due to reduced cell proliferation and impaired cell migration. By using a β-catenin DM allele in which the transcriptional function of β-catenin is selectively disrupted, we further reveal that β-catenin regulated cell proliferation and migration through its transcriptional and non-transcriptional function, respectively. At the molecular level, loss of β-catenin resulted in increased expression of cell cycle inhibitor p21 in cushion endocardial and mesenchymal cells in vivo. In vitro rescue experiments with HUVECs and pig aortic valve interstitial cells confirmed that β-catenin promoted cell proliferation by suppressing p21. In addition, one savvy negative observation is that β-catenin was dispensable for endocardial-to-mesenchymal fate change. Taken together, our findings demonstrate that β-catenin is essential for cell proliferation and migration but dispensable for endocardial cells to gain mesenchymal fate during endocardial cushion formation. Mechanistically, β-catenin promotes cell proliferation by suppressing p21. These findings inform the potential role of β-catenin in the etiology of congenital heart defects.
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Affiliation(s)
- Huahua Liu
- Department of Cardiology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Pengfei Lu
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Shan He
- The Institute of Cardiovascular Sciences, School of Basic Medical Sciences, Xi'an Jiaotong University, Xi'an, China
| | - Yuru Luo
- The Institute of Cardiovascular Sciences, School of Basic Medical Sciences, Xi'an Jiaotong University, Xi'an, China
| | - Yuan Fang
- The Institute of Cardiovascular Sciences, School of Basic Medical Sciences, Xi'an Jiaotong University, Xi'an, China
| | - Sonia Benkaci
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Bingruo Wu
- Department of Genetics, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yidong Wang
- The Institute of Cardiovascular Sciences, School of Basic Medical Sciences; Department of Cardiology, First Affiliated Hospital; Key Laboratory of Environment and Genes Related to Diseases of Ministry of Education, Xi'an Jiaotong University, Xi'an, China
| | - Bin Zhou
- Departments of Genetics, Pediatrics (Pediatric Genetic Medicine), and Medicine (Cardiology), The Wilf Family Cardiovascular Research Institute, The Einstein Institute for Aging Research, Albert Einstein College of Medicine, Bronx, NY, USA
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Tessler I, Albuisson J, Piñeiro-Sabarís R, Verstraeten A, Kamber Kaya HE, Siguero-Álvarez M, Goudot G, MacGrogan D, Luyckx I, Shpitzen S, Levin G, Kelman G, Reshef N, Mananet H, Holdcraft J, Muehlschlegel JD, Peloso GM, Oppenheim O, Cheng C, Mazzella JM, Andelfinger G, Mital S, Eriksson P, Billon C, Heydarpour M, Dietz HC, Jeunemaitre X, Leitersdorf E, Sprinzak D, Blacklow SC, Body SC, Carmi S, Loeys B, de la Pompa JL, Gilon D, Messas E, Durst R. Novel Association of the NOTCH Pathway Regulator MIB1 Gene With the Development of Bicuspid Aortic Valve. JAMA Cardiol 2023; 8:721-731. [PMID: 37405741 PMCID: PMC10323766 DOI: 10.1001/jamacardio.2023.1469] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 04/21/2023] [Indexed: 07/06/2023]
Abstract
Importance Nonsyndromic bicuspid aortic valve (nsBAV) is the most common congenital heart valve malformation. BAV has a heritable component, yet only a few causative genes have been identified; understanding BAV genetics is a key point in developing personalized medicine. Objective To identify a new gene for nsBAV. Design, Setting, and Participants This was a comprehensive, multicenter, genetic association study based on candidate gene prioritization in a familial cohort followed by rare and common association studies in replication cohorts. Further validation was done using in vivo mice models. Study data were analyzed from October 2019 to October 2022. Three cohorts of patients with BAV were included in the study: (1) the discovery cohort was a large cohort of inherited cases from 29 pedigrees of French and Israeli origin; (2) the replication cohort 1 for rare variants included unrelated sporadic cases from various European ancestries; and (3) replication cohort 2 was a second validation cohort for common variants in unrelated sporadic cases from Europe and the US. Main Outcomes and Measures To identify a candidate gene for nsBAV through analysis of familial cases exome sequencing and gene prioritization tools. Replication cohort 1 was searched for rare and predicted deleterious variants and genetic association. Replication cohort 2 was used to investigate the association of common variants with BAV. Results A total of 938 patients with BAV were included in this study: 69 (7.4%) in the discovery cohort, 417 (44.5%) in replication cohort 1, and 452 (48.2%) in replication cohort 2. A novel human nsBAV gene, MINDBOMB1 homologue MIB1, was identified. MINDBOMB1 homologue (MIB1) is an E3-ubiquitin ligase essential for NOTCH-signal activation during heart development. In approximately 2% of nsBAV index cases from the discovery and replication 1 cohorts, rare MIB1 variants were detected, predicted to be damaging, and were significantly enriched compared with population-based controls (2% cases vs 0.9% controls; P = .03). In replication cohort 2, MIB1 risk haplotypes significantly associated with nsBAV were identified (permutation test, 1000 repeats; P = .02). Two genetically modified mice models carrying Mib1 variants identified in our cohort showed BAV on a NOTCH1-sensitized genetic background. Conclusions and Relevance This genetic association study identified the MIB1 gene as associated with nsBAV. This underscores the crucial role of the NOTCH pathway in the pathophysiology of BAV and its potential as a target for future diagnostic and therapeutic intervention.
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Affiliation(s)
- Idit Tessler
- Cardiology Department, Hadassah Medical Center, Jerusalem, Israel
- Sheba Medical Center, Ramat Gan, Israel
- Faculty of Medicine, the Hebrew University, Jerusalem, Israel
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Juliette Albuisson
- Genetics Department, Assistance Publique–Hȏpitaux de Paris, Hôpital Européen Georges Pompidou, National Referral Center for Rare Vascular Diseases, VASCERN MSA European Reference Center, Paris, France
- Université Paris Cité, INSERM, U970 PARCC, Paris, France
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer –UNICANCER, Dijon, France
- Genomic and Immunotherapy Medical Institute, Dijon, France
| | - Rebeca Piñeiro-Sabarís
- Intercellular Signaling in Cardiovascular Development & Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- Ciber de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Aline Verstraeten
- Center of Medical Genetics, University of Antwerp and Antwerp University Hospital, Edegem, Belgium
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hatem Elif Kamber Kaya
- Department of Biological Chemistry and Molecular Pharmacology, Blavatnik Institute, Harvard Medical School, Boston, Massachusetts
- Department of Cancer Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Marcos Siguero-Álvarez
- Intercellular Signaling in Cardiovascular Development & Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- Ciber de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Guillaume Goudot
- Université Paris Cité, INSERM, U970 PARCC, Paris, France
- Vascular Medicine Department, Assistance Publique–Hȏpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
- French Research Consortium RHU STOP-AS, Rouen, France
| | - Donal MacGrogan
- Intercellular Signaling in Cardiovascular Development & Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- Ciber de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Ilse Luyckx
- Center of Medical Genetics, University of Antwerp and Antwerp University Hospital, Edegem, Belgium
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Shoshana Shpitzen
- Cardiology Department, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, the Hebrew University, Jerusalem, Israel
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Galina Levin
- Cardiology Department, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, the Hebrew University, Jerusalem, Israel
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Guy Kelman
- Faculty of Medicine, the Hebrew University, Jerusalem, Israel
- The Jerusalem Center for Personalized Computational Medicine, Jerusalem, Israel
| | - Noga Reshef
- Faculty of Medicine, the Hebrew University, Jerusalem, Israel
- The Jerusalem Center for Personalized Computational Medicine, Jerusalem, Israel
| | - Hugo Mananet
- Platform of Transfer in Cancer Biology, Georges François Leclerc Cancer –UNICANCER, Dijon, France
- Genomic and Immunotherapy Medical Institute, Dijon, France
| | - Jake Holdcraft
- Department of Anesthesiology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Gina M. Peloso
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Olya Oppenheim
- School of Neurobiology, Biochemistry and Biophysics, George S. Wise Faculty of Life Science, Tel Aviv University, Tel Aviv, Israel
| | - Charles Cheng
- Université Paris Cité, INSERM, U970 PARCC, Paris, France
- Vascular Medicine Department, Assistance Publique–Hȏpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
- French Research Consortium RHU STOP-AS, Rouen, France
| | - Jean-Michael Mazzella
- Université Paris Cité, INSERM, U970 PARCC, Paris, France
- Vascular Medicine Department, Assistance Publique–Hȏpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Gregor Andelfinger
- Cardiovascular Genetics, Department of Pediatrics, CHU Sainte-Justine, Université de Montreal, Montreal, Quebec, Canada
| | - Seema Mital
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Per Eriksson
- Cardiovascular Medicine Unit, Center for Molecular Medicine, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Solna, Sweden
| | - Clarisse Billon
- Genetics Department, Assistance Publique–Hȏpitaux de Paris, Hôpital Européen Georges Pompidou, National Referral Center for Rare Vascular Diseases, VASCERN MSA European Reference Center, Paris, France
- Université Paris Cité, INSERM, U970 PARCC, Paris, France
| | - Mahyar Heydarpour
- Department of Medicine, Division of Endocrinology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harry C. Dietz
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xavier Jeunemaitre
- Université Paris Cité, INSERM, U970 PARCC, Paris, France
- Vascular Medicine Department, Assistance Publique–Hȏpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Eran Leitersdorf
- Cardiology Department, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, the Hebrew University, Jerusalem, Israel
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Sprinzak
- School of Neurobiology, Biochemistry and Biophysics, George S. Wise Faculty of Life Science, Tel Aviv University, Tel Aviv, Israel
| | - Stephen C. Blacklow
- Department of Biological Chemistry and Molecular Pharmacology, Blavatnik Institute, Harvard Medical School, Boston, Massachusetts
- Department of Cancer Biology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Simon C. Body
- Department of Anesthesiology, Boston University School of Medicine, Boston, Massachusetts
| | - Shai Carmi
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Bart Loeys
- Center of Medical Genetics, University of Antwerp and Antwerp University Hospital, Edegem, Belgium
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - José Luis de la Pompa
- Intercellular Signaling in Cardiovascular Development & Disease Laboratory, Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
- Ciber de Enfermedades Cardiovasculares, Instituto de Salud Carlos III, Madrid, Spain
| | - Dan Gilon
- Cardiology Department, Hadassah Medical Center, Jerusalem, Israel
| | - Emmanuel Messas
- Université Paris Cité, INSERM, U970 PARCC, Paris, France
- Vascular Medicine Department, Assistance Publique–Hȏpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
- French Research Consortium RHU STOP-AS, Rouen, France
| | - Ronen Durst
- Cardiology Department, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, the Hebrew University, Jerusalem, Israel
- Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
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Ackah RL, Yasuhara J, Garg V. Genetics of aortic valve disease. Curr Opin Cardiol 2023; 38:169-178. [PMID: 36789772 PMCID: PMC10079625 DOI: 10.1097/hco.0000000000001028] [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] [Indexed: 02/16/2023]
Abstract
PURPOSE OF REVIEW Aortic valve disease is a leading global cause of morbidity and mortality, posing an increasing burden on society. Advances in next-generation technologies and disease models over the last decade have further delineated the genetic and molecular factors that might be exploited in development of therapeutics for affected patients. This review describes several advances in the molecular and genetic understanding of AVD, focusing on bicuspid aortic valve (BAV) and calcific aortic valve disease (CAVD). RECENT FINDINGS Genomic studies have identified a myriad of genes implicated in the development of BAV, including NOTCH1 , SMAD6 and ADAMTS19 , along with members of the GATA and ROBO gene families. Similarly, several genes associated with the initiation and progression of CAVD, including NOTCH1 , LPA , PALMD , IL6 and FADS1/2 , serve as the launching point for emerging clinical trials. SUMMARY These new insights into the genetic contributors of AVD have offered new avenues for translational disease investigation, bridging molecular discoveries to emergent pharmacotherapeutic options. Future studies aimed at uncovering new genetic associations and further defining implicated molecular pathways are fuelling the new wave of drug discovery.
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Affiliation(s)
- Ruth L. Ackah
- Center for Cardiovascular Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, USA
- The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jun Yasuhara
- Center for Cardiovascular Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, USA
- The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Vidu Garg
- Center for Cardiovascular Research, Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, Ohio, USA
- The Heart Center, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
- Department of Molecular Genetics, The Ohio State University, Columbus, Ohio, USA
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8
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Jaouadi H, Jopling C, Bajolle F, Théron A, Faucherre A, Gerard H, Al Dybiat S, Ovaert C, Bonnet D, Avierinos JF, Zaffran S. Expanding the phenome and variome of the ROBO-SLIT pathway in congenital heart defects: toward improving the genetic testing yield of CHD. J Transl Med 2023; 21:160. [PMID: 36855159 PMCID: PMC9976407 DOI: 10.1186/s12967-023-03994-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/15/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Recent studies have shown the implication of the ROBO-SLIT pathway in heart development. Within this study, we aimed to further assess the implication of the ROBO and SLIT genes mainly in bicuspid aortic valve (BAV) and other human congenital heart defects (CHD). METHODS We have analyzed a cohort of singleton exome sequencing data comprising 40 adult BAV patients, 20 pediatric BAV patients generated by the Pediatric Cardiac Genomics Consortium, 10 pediatric cases with tetralogy of Fallot (ToF), and one case with coarctation of the aorta. A gene-centered analysis of data was performed. To further advance the interpretation of the variants, we intended to combine more than 5 prediction tools comprising the assessment of protein structure and stability. RESULTS A total of 24 variants were identified. Only 4 adult BAV patients (10%) had missense variants in the ROBO and SLIT genes. In contrast, 19 pediatric cases carried variants in ROBO or SLIT genes (61%). Three BAV patients with a severe phenotype were digenic. Segregation analysis was possible for two BAV patients. For the homozygous ROBO4: p.(Arg776Cys) variant, family segregation was consistent with an autosomal recessive pattern of inheritance. The ROBO4: c.3001 + 3G > A variant segregates with the affected family members. Interestingly, these variants were also found in two unrelated patients with ToF highlighting that the same variant in the ROBO4 gene may underlie different cardiac phenotypes affecting the outflow tract development. CONCLUSION Our results further reinforce the implication of the ROBO4 gene not only in BAV but also in ToF hence the importance of its inclusion in clinical genetic testing. The remaining ROBO and SLIT genes may be screened in patients with negative or inconclusive genetic tests.
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Affiliation(s)
- Hager Jaouadi
- Marseille Medical Genetics (MMG) U1251, Aix Marseille Université, INSERM, 13005, Marseille, France
| | - Chris Jopling
- Institute of Functional Genomics (IGF), University of Montpellier, CNRS, INSERM, LabEx ICST, Montpellier, France
| | - Fanny Bajolle
- Service de Cardiologie Congénitale Et Pédiatrique, Centre de Référence Malformations Cardiaques Congénitales Complexes - M3C, Hôpital Necker-Enfants Malades, APHP and Université Paris Cité, Paris, France
| | - Alexis Théron
- Marseille Medical Genetics (MMG) U1251, Aix Marseille Université, INSERM, 13005, Marseille, France
- Department of Cardiac Surgery, La Timone Hospital, AP-HM, Marseille, France
| | - Adèle Faucherre
- Institute of Functional Genomics (IGF), University of Montpellier, CNRS, INSERM, LabEx ICST, Montpellier, France
| | - Hilla Gerard
- Department of Cardiology, La Timone Hospital, AP-HM, Marseille, France
| | - Sarab Al Dybiat
- Department of Pediatric Cardiology, Timone Enfant Hospital, AP-HM, Marseille, France
| | - Caroline Ovaert
- Department of Pediatric Cardiology, Timone Enfant Hospital, AP-HM, Marseille, France
| | - Damien Bonnet
- Service de Cardiologie Congénitale Et Pédiatrique, Centre de Référence Malformations Cardiaques Congénitales Complexes - M3C, Hôpital Necker-Enfants Malades, APHP and Université Paris Cité, Paris, France
| | - Jean-François Avierinos
- Marseille Medical Genetics (MMG) U1251, Aix Marseille Université, INSERM, 13005, Marseille, France
- Department of Cardiology, La Timone Hospital, AP-HM, Marseille, France
| | - Stéphane Zaffran
- Marseille Medical Genetics (MMG) U1251, Aix Marseille Université, INSERM, 13005, Marseille, France.
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9
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Kobayashi M, Muneuchi J, Sugitani Y, Yamada A, Ezaki H, Watanabe M. Coronary anomalies associated with ventricular septal defect. Heart Vessels 2023; 38:255-264. [PMID: 35882655 DOI: 10.1007/s00380-022-02144-6] [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: 03/14/2022] [Accepted: 07/15/2022] [Indexed: 01/10/2023]
Abstract
Coronary anomalies encompass different conditions in terms of anomalous origin, coursing, and branching, which are occasionally associated with congenital heart disease. This study aimed to explore coronary anomalies associated with ventricular septal defect that was a stereotypical congenital heart disease. We retrospectively reviewed angiographic findings in patients with ventricular septal defect who required corrective surgery, and identified coronary abnormalities, including anomalous origin, coursing, and branching of coronary arteries based on angiography. We studied the prevalence and types of coronary anomalies among them. A total of 998 patients with ventricular septal defect was studied. Age and weight were 2.0 (2.1-15.2) months and 5.7 (4.1-8.7) kg, respectively. There were 115 patients (12%) with syndrome or genetic disorder, and 34 patients (3%) with extracardiac major organ anomalies. The overall prevalence of coronary anomalies was 6.2%. All coronary anomalies were anomalous origin and coursing, among 3 patients accompanied anomalous intrinsic coronary anatomy. Originating within aortic root above the Valsalva sinus was the most common coronary anomaly. Coronary anomalies were independently correlated with bicuspid aortic valve (odds ratio [OR]: 8.02, 95% confidence interval [CI]: 2.34-23.4) and persistent left superior caval vein (OR: 5.02, 95% CI: 1.93-11.7). We showed the possibility that minor cardiac variants, such as bicuspid aortic valve and persistent left superior caval vein, contribute to higher prevalence of coronary anomalies in patients with ventricular septal defect.
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Affiliation(s)
- Masaru Kobayashi
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-2, Kishionura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8507, Japan
| | - Jun Muneuchi
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-2, Kishionura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8507, Japan.
| | - Yuichiro Sugitani
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-2, Kishionura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8507, Japan
| | - Ayumu Yamada
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-2, Kishionura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8507, Japan
| | - Hiroki Ezaki
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-2, Kishionura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8507, Japan
| | - Mamie Watanabe
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-2, Kishionura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8507, Japan
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10
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Li G, Shen N, Deng H, Wang Y, Kong G, Shi J, Dong N, Deng C. Abnormal mechanical stress on bicuspid aortic valve induces valvular calcification and inhibits Notch1/NICD/Runx2 signal. PeerJ 2023; 11:e14950. [PMID: 36908813 PMCID: PMC9997191 DOI: 10.7717/peerj.14950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/03/2023] [Indexed: 03/08/2023] Open
Abstract
Background Bicuspid aortic valve (BAV) is a congenital cardiac deformity, increasing the risk of developing calcific aortic valve disease (CAVD). The disturbance of hemodynamics can induce valvular calcification, but the mechanism has not been fully identified. Methods We constructed a finite element model (FEM) of the aortic valve based on the computed tomography angiography (CTA) data from BAV patients and tricuspid aortic valve (TAV) individuals. We analyzed the hemodynamic properties based on our model and investigated the characteristics of mechanical stimuli on BAV. Further, we detected the expression of Notch, NICD and Runx2 in valve samples and identified the association between mechanical stress and the Notch1 signaling pathway. Results Finite element analysis showed that at diastole phase, the equivalent stress on the root of BAV was significantly higher than that on the TAV leaflet. Correspondingly, the expression of Notch1 and NICH decreased and the expression of Runx2 elevated significantly on large BAV leaflet belly, which is associated with equivalent stress on leaflet. Our findings indicated that the root of BAV suffered higher mechanical stress due to the abnormal hemodynamic environment, and the disturbance of the Notch1/NICD/Runx2 signaling pathway caused by mechanical stimuli contributed to valvular calcification.
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Affiliation(s)
- Guangzhou Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Na Shen
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huifang Deng
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yixuan Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gangcheng Kong
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiawei Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cheng Deng
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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11
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Angiopoietin-like 2 is essential to aortic valve development in mice. Commun Biol 2022; 5:1277. [PMID: 36414704 PMCID: PMC9681843 DOI: 10.1038/s42003-022-04243-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 11/09/2022] [Indexed: 11/24/2022] Open
Abstract
Aortic valve (AoV) abnormalities during embryogenesis are a major risk for the development of aortic valve stenosis (AVS) and cardiac events later in life. Here, we identify an unexpected role for Angiopoietin-like 2 (ANGPTL2), a pro-inflammatory protein secreted by senescent cells, in valvulogenesis. At late embryonic stage, mice knocked-down for Angptl2 (Angptl2-KD) exhibit a premature thickening of AoV leaflets associated with a dysregulation of the fine balance between cell apoptosis, senescence and proliferation during AoV remodeling and a decrease in the crucial Notch signalling. These structural and molecular abnormalities lead toward spontaneous AVS with elevated trans-aortic gradient in adult mice of both sexes. Consistently, ANGPTL2 expression is detected in human fetal semilunar valves and associated with pathways involved in cell cycle and senescence. Altogether, these findings suggest that Angptl2 is essential for valvulogenesis, and identify Angptl2-KD mice as an animal model to study spontaneous AVS, a disease with unmet medical need.
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12
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Clift CL, Saunders J, Drake RR, Angel PM. Perspectives on pediatric congenital aortic valve stenosis: Extracellular matrix proteins, post translational modifications, and proteomic strategies. Front Cardiovasc Med 2022; 9:1024049. [PMID: 36439995 PMCID: PMC9685993 DOI: 10.3389/fcvm.2022.1024049] [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: 08/20/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
In heart valve biology, organization of the extracellular matrix structure is directly correlated to valve function. This is especially true in cases of pediatric congenital aortic valve stenosis (pCAVS), in which extracellular matrix (ECM) dysregulation is a hallmark of the disease, eventually leading to left ventricular hypertrophy and heart failure. Therapeutic strategies are limited, especially in pediatric cases in which mechanical and tissue engineered valve replacements may not be a suitable option. By identifying mechanisms of translational and post-translational dysregulation of ECM in CAVS, potential drug targets can be identified, and better bioengineered solutions can be developed. In this review, we summarize current knowledge regarding ECM proteins and their post translational modifications (PTMs) during aortic valve development and disease and contributing factors to ECM dysregulation in CAVS. Additionally, we aim to draw parallels between other fibrotic disease and contributions to ECM post-translational modifications. Finally, we explore the current treatment options in pediatrics and identify how the field of proteomics has advanced in recent years, highlighting novel characterization methods of ECM and PTMs that may be used to identify potential therapeutic strategies relevant to pCAVS.
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Affiliation(s)
- Cassandra L. Clift
- Department of Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, United States
- Division of Cardiovascular Medicine, Center for Interdisciplinary Cardiovascular Sciences, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, United States
| | - Janet Saunders
- Department of Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, United States
| | - Richard R. Drake
- Department of Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, United States
| | - Peggi M. Angel
- Department of Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, United States
- *Correspondence: Peggi M. Angel,
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13
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Fatehi Hassanabad A, King MA, Di Martino E, Fedak PWM, Garcia J. Clinical implications of the biomechanics of bicuspid aortic valve and bicuspid aortopathy. Front Cardiovasc Med 2022; 9:922353. [PMID: 36035900 PMCID: PMC9411999 DOI: 10.3389/fcvm.2022.922353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 07/25/2022] [Indexed: 11/27/2022] Open
Abstract
Bicuspid aortic valve (BAV), which affects up to 2% of the general population, results from the abnormal fusion of the cusps of the aortic valve. Patients with BAV are at a higher risk for developing aortic dilatation, a condition known as bicuspid aortopathy, which is associated with potentially life-threatening sequelae such as aortic dissection and aortic rupture. Although BAV biomechanics have been shown to contribute to aortopathy, their precise impact is yet to be delineated. Herein, we present the latest literature related to BAV biomechanics. We present the most recent definitions and classifications for BAV. We also summarize the current evidence pertaining to the mechanisms that drive bicuspid aortopathy. We highlight how aberrant flow patterns can contribute to the development of aortic dilatation. Finally, we discuss the role cardiac magnetic resonance imaging can have in assessing and managing patient with BAV and bicuspid aortopathy.
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Affiliation(s)
- Ali Fatehi Hassanabad
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Melissa A. King
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Elena Di Martino
- Department of Civil Engineering, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada
- Centre for Bioengineering Research and Education, University of Calgary, Calgary, AB, Canada
| | - Paul W. M. Fedak
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Julio Garcia
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute, Calgary, AB, Canada
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- *Correspondence: Julio Garcia
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14
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Novelli M, Masini M, Vecoli C, Moscato S, Funel N, Pippa A, Mattii L, Ippolito C, Campani D, Neglia D, Masiello P. Dysregulated insulin secretion is associated with pancreatic β-cell hyperplasia and direct acinar-β-cell trans-differentiation in partially eNOS-deficient mice. Physiol Rep 2022; 10:e15425. [PMID: 35986504 PMCID: PMC9391603 DOI: 10.14814/phy2.15425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/11/2022] [Accepted: 07/23/2022] [Indexed: 06/15/2023] Open
Abstract
eNOS-deficient mice were previously shown to develop hypertension and metabolic alterations associated with insulin resistance either in standard dietary conditions (eNOS-/- homozygotes) or upon high-fat diet (HFD) (eNOS+/- heterozygotes). In the latter heterozygote model, the present study investigated the pancreatic morphological changes underlying the abnormal glycometabolic phenotype. C57BL6 wild type (WT) and eNOS+/- mice were fed with either chow or HFD for 16 weeks. After being longitudinally monitored for their metabolic state after 8 and 16 weeks of diet, mice were euthanized and fragments of pancreas were processed for histological, immuno-histochemical and ultrastructural analyses. HFD-fed WT and eNOS+/- mice developed progressive glucose intolerance and insulin resistance. Differently from WT animals, eNOS+/- mice showed a blunted insulin response to a glucose load, regardless of the diet regimen. Such dysregulation of insulin secretion was associated with pancreatic β-cell hyperplasia, as shown by larger islet fractional area and β-cell mass, and higher number of extra-islet β-cell clusters than in chow-fed WT animals. In addition, only in the pancreas of HFD-fed eNOS+/- mice, there was ultrastructural evidence of a number of hybrid acinar-β-cells, simultaneously containing zymogen and insulin granules, suggesting the occurrence of a direct exocrine-endocrine transdifferentiation process, plausibly triggered by metabolic stress associated to deficient endothelial NO production. As suggested by confocal immunofluorescence analysis of pancreatic histological sections, inhibition of Notch-1 signaling, likely due to a reduced NO availability, is proposed as a novel mechanism that could favor both β-cell hyperplasia and acinar-β-cell transdifferentiation in eNOS-deficient mice with impaired insulin response to a glucose load.
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Affiliation(s)
- Michela Novelli
- Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Matilde Masini
- Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Cecilia Vecoli
- Institute of Clinical PhysiologyNational Research Council (CNR)PisaItaly
| | - Stefania Moscato
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
- Interdepartmental Research Centre "Nutraceuticals and Food for Health"University of PisaPisaItaly
| | - Niccola Funel
- Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
| | - Anna Pippa
- Institute of Clinical PhysiologyNational Research Council (CNR)PisaItaly
| | - Letizia Mattii
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
- Interdepartmental Research Centre "Nutraceuticals and Food for Health"University of PisaPisaItaly
| | - Chiara Ippolito
- Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
| | - Daniela Campani
- Department of Surgical, Medical and Molecular Pathology, and Critical Care MedicineUniversity of PisaPisaItaly
| | - Danilo Neglia
- Cardiovascular DepartmentFondazione Toscana Gabriele Monasterio per la Ricerca Medica e di Sanità PubblicaPisaItaly
| | - Pellegrino Masiello
- Department of Translational Research and New Technologies in Medicine and SurgeryUniversity of PisaPisaItaly
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