Diabetes concomitant to aortic stenosis is associated with increased expression of NF-κB and more pronounced valve calcification

Diabetes mellitus aggravates myocardial inflammation and oxidative stress in aortic stenosis: a mechanistic link to HFpEF features

BACKGROUND

Patients diagnosed with both aortic stenosis (AS) and diabetes mellitus (DM) encounter a distinctive set of challenges due to the interplay between these two conditions. This study aimed to investigate the effects of DM on the left ventricle in AS patients, specifically focusing on the inflammatory response, oxidative stress, and their implications for cardiomyocyte function, titin phosphorylation, and the nitric oxide (NO)-soluble guanylyl cyclase (sGC)-cyclic guanosine monophosphate (cGMP)-protein kinase G (PKG) signaling pathway.

METHODS AND RESULTS

Left ventricular myocardial biopsies (in total: n = 28) were obtained from patients with diabetic AS (n = 11) and compared with those from non-diabetic AS patients (n = 17). Enzyme-linked immunosorbent assay (ELISA) demonstrated significantly elevated levels of pro-inflammatory mediators, including high mobility group box protein 1 (HMGB1) and calprotectin, as well as receptors associated with the inflammatory response, such as Toll-like receptor 2 (TLR2), 4 (TLR4), and receptor for advanced glycation endproducts (RAGE). These were correlated with an enhanced NOD-like receptor protein 3 (NLRP3) inflammasome and the release of interleukins (IL) 1, 6, and 18 in diabetic AS patients compared to their non-diabetic counterparts. Additionally, in the diabetic AS cohort, there was an increase in oxidative stress markers (hydrogen peroxide (H2O2), 3-nitrotyrosine, lipid peroxidation (LPO), oxidative glutathione (GSSG)/reduced glutathione (GSH) ratio) within the myocardium and mitochondria, accompanied by impaired NO-sGC-cGMP-PKG signaling, decreased titin phosphorylation, and increased passive stiffness (Fpassive) of cardiomyocytes relative to non-diabetic AS patients. In vitro anti-inflammatory treatment with an IL-6 inhibitor and antioxidant treatment with GSH effectively normalized the elevated Fpassive observed in AS patients with DM to levels comparable to the non-diabetic group. Furthermore, treatment with PKG and the sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin also resulted in a reduction of Fpassive in cardiomyocytes from diabetic AS patients, although not to the levels observed in non-diabetic AS patients.

CONCLUSION

DM exacerbates inflammation and oxidative stress in AS patients, leading to impaired NO-sGC-cGMP-PKG signaling and increased cardiomyocyte Fpassive. These conditions are reminiscent of the pathophysiology of heart failure with preserved ejection fraction (HFpEF). These alterations can be ameliorated through anti-inflammatory and antioxidant therapies, indicating potential therapeutic strategies for diabetic patients suffering from AS.

Diabetes and calcific aortic valve disease: implications of glucose-lowering medication as potential therapy

Calcific aortic valve disease (CAVD) is a progressive disease, of which the 2-year mortality is >50% for symptomatic disease. However, there are currently no pharmacotherapies to prevent the progression of CAVD unless transcatheter or surgical aortic valve replacement is performed. The prevalence of diabetes among CAVD has increased rapidly in recent decades, especially among those undergoing aortic valve replacement. Diabetes and its comorbidities, such as hypertension, hyperlipidemia, chronic kidney disease and ageing, participated jointly in the initiation and progression of CAVD, which increased the management complexity in patients with CAVD. Except from hyperglycemia, the molecular links between diabetes and CAVD included inflammation, oxidative stress and endothelial dysfunction. Traditional cardiovascular drugs like lipid-lowering agents and renin-angiotensin system blocking drugs have proven to be unsuccessful in retarding the progression of CAVD in clinical trials. In recent years, almost all kinds of glucose-lowering medications have been specifically assessed for decelerating the development of CAVD. Based on the efficacy for atherosclerotic cardiovascular disease and CAVD, this review summarized current knowledge about glucose-lowering medications as promising treatment options with the potential to retard CAVD.

Impact of glycemic control metrics on short- and long-term mortality in transcatheter aortic valve replacement patients: a retrospective cohort study from the MIMIC-IV database

BACKGROUND

Glycemic control is critical for managing transcatheter aortic valve replacement (TAVR) patients, especially those in intensive care units (ICUs). Emerging metrics such as the hemoglobin glycation index (HGI), stress hyperglycemia ratio (SHR), and glycemic variability (GV) offer advanced insights into glucose metabolism. However, their prognostic implications for short- and long-term outcomes post-TAVR remain underexplored.

METHODS

This retrospective cohort study analyzed 3342 ICU-admitted TAVR patients via the MIMIC-IV database. Patients were stratified into tertiles for HGI, SHR, and GV levels. Survival analyses, including Kaplan‒Meier curves, Cox proportional hazards models and restricted cubic splines (RCSs), were used to assess associations between glycemic control metrics and 30-day and 365-day all-cause mortality in these patients. Sensitivity analyses, subgroup assessments, and external validation were also performed to verify the study findings.

RESULTS

During follow-up, 1.6% and 6.9% of patients experienced 30-day and 365-day mortality after TAVR, respectively. In the fully adjusted cox regression model, lower HGI (HR 1.48, 95% CI 1.05-2.09, P = 0.025) and higher SHR (HR 1.63, 95% CI 1.15-2.32, P = 0.006) were most significantly associated with an increased risk of 365-day mortality. Higher SHR was also significantly associated with an increased risk of 30-day mortality in patients (HR 2.92, 95% CI 1.32-6.45, P = 0.008). Both lower (HR 0.59, 95% CI 0.38-0.92, P = 0.019) and higher GV levels (HR 1.43, 95% CI 1.06-1.93, P = 0.020) were associated with the risk of 365-day mortality.

CONCLUSIONS

In critically ill TAVR patients, glycemic control metrics are closely associated with long-term all-cause mortality. The HGI, SHR, and GV provide prognostic insights into clinical outcomes that surpass conventional glucose measurements. These findings highlight the importance of personalized glycemic management strategies in improving TAVR patient outcomes.

Dysglycaemia is associated with the pattern of valvular calcification in micro-computed tomography analysis: an observational study in patients with severe aortic stenosis

BACKGROUND

Diabetes mellitus (DM) has been shown to increase the rate of aortic stenosis (AS) progression. However, the impact of impaired plasma glucose on valvular calcification remains poorly understood. Using ex vivo micro-computed tomography (micro-CT), we aimed to determine whether plasma glucose, glycated haemoglobin (HbA1c), or concentrations of advanced glycation end products (AGEs) and their soluble receptor (sRAGE) are associated with a specific pattern of valvular calcification in severe AS.

METHODS

In this case-control study, 14 (48%) normoglycaemic patients with AS were compared to 15 individuals (52%) with elevated glucose levels (≥ 5.6 mmol/L), all with HbA1c ≤ 6.5%. Stenotic aortic valves obtained surgically were analysed using micro-CT to assess structure of tissue mineralization. Calcium volume (CV), surface volume (SV), CV/SV ratio, and trabecular thickness (TbTh) were evaluated. Plasma AGEs and sRAGE were assessed by ELISAs. DM patients or those using antidiabetic agents were excluded from the study.

RESULTS

Patients with impaired and high glucose, including 10 (67%) with glucose between 5.6 and 6.9 mmol/L and 5 (33%) ranging from 7 to 7.6 mmol/L, exhibited higher HbA1c (+ 17%) and AGEs levels (+ 44.6%), but not sRAGE compared to those with normal glucose. Patients with impaired and high glucose had also 19.2% higher maximal transvalvular pressure gradient (PGmax) and 9.3% higher peak transvalvular velocity (Vmax) compared to normoglycaemic individuals. Micro-CT indices correlated with fasting glucose, HbA1c, and AGEs levels (all p < 0.05), but not with sRAGE (p > 0.05). Valves extracted from patients with impaired and high glucose exhibited higher mineralization volume, folding, and structural integrity, as reflected by increased CV (+ 127.6%), CV/SV ratio (+ 59%) and calcium deposits microarchitecture as indicated by about 50% higher TbTh, compared to normoglycaemic patients. When patients with AS were divided into three groups based on their glucose levels (< 5.5 mmol/L, 5.6-6.9 mmol/L, and 7.0-7.6 mmol/L), micro-CT analysis showed more distinct structural differences among the groups. The valves in the highest glucose group were the most severely affected. Micro-CT parameters were also associated with both transvalvular pressure gradients (PGmean and PGmax), Vmax and aortic valve area (all p < 0.05).

CONCLUSIONS

Strict glycaemic control could potentially reduce the rate of valve mineralization and calcium deposit accumulation in patients with AS.

RESEARCH INSIGHTS

WHAT IS CURRENTLY KNOWN ABOUT THIS TOPIC?: Diabetes mellitus (DM) is a risk factor for the progression of aortic stenosis (AS). Accumulation of advanced glycation end products (AGEs) enhances glycation of valvular proteins. WHAT IS THE KEY RESEARCH QUESTION?: Is dysglycaemia associated with more severe aortic valve calcification in patients with severe AS? Is ex vivo micro-CT suitable for assessing differences in calcification pattern within stenoticvalves? WHAT IS NEW?: Pre-diabetic patients with AS show increased valvular calcium volume, surface corrugation, and calcium deposit integrity. Micro-CT parameters associate with glycaemic status and echocardiographic measures of AS severity. Micro-CT provides precise assessment of calcification, offering insights beyond traditional methods. HOW MIGHT THIS STUDY INFLUENCE CLINICAL PRACTICE?: Strict glycaemic control together with CT calcium scoring should be performed in patients with AS to monitor disease progression.

The Relationship Between Aortic Stenosis and the Possibility of Subsequent Macular Diseases: A Nationwide Database Study

Objectives: This study aimed to investigate the possible relationship between aortic stenosis (AS) occupancy and the incidence of subsequent macular diseases. Methods: A retrospective cohort study was conducted using the TriNetX database, and participants with AS were enrolled and matched to non-AS participants. A total of 421,860 and 421,860 participants were evenly divided into the AS and non-AS groups, respectively. The major outcomes of the present study include the development of age-related macular degeneration (AMD), retinal vascular occlusion (RVO), epiretinal membrane (ERM), and central serous chorioretinopathy (CSC). Cox proportional hazard regression was utilized for statistical analysis. Results: There were 4426 and 3013 AMD events; 7315 and 4753 RVO events; 2780 and 1910 ERM events; and 113 and 64 CSC events in the AS and non-AS groups, respectively. According to the results of Cox proportional hazard regression analysis, the AS group demonstrated significantly higher incidences of all macular diseases, including AMD, RVO, ERM, and CSC, compared to the non-AS group (all p < 0.05). The cumulative probabilities of all macular diseases were significantly higher in the AS group than in the non-AS group (all p < 0.05). In the sensitivity analysis, the developmental risks of AMD were significantly higher in the AS group than in the non-AS group with all traits. Conclusions: This study determined that AS occupancy is related to a higher risk of developing macular diseases, which positively correlated to the disease time of AS.

Regulation of the immune microenvironment by SUMO in diabetes mellitus

Post-translational modifications such as SUMOylation are crucial for the functionality and signal transduction of a diverse array of proteins. Analogous to ubiquitination, SUMOylation has garnered significant attention from researchers and has been implicated in the pathogenesis of various human diseases in recent years, such as cancer, neurological lesions, cardiovascular diseases, diabetes mellitus, and so on. The pathogenesis of diabetes, particularly type 1 and type 2 diabetes, has been closely associated with immune dysfunction, which constitutes the primary focus of this review. This review will elucidate the process of SUMOylation and its impact on diabetes mellitus development and associated complications, focusing on its regulatory effects on the immune microenvironment. This article summarizes various signaling pathways at both cellular and molecular levels that are implicated in these processes. Furthermore, it proposes potential new targets for drug development aimed at the prevention and treatment of diabetes mellitus based on insights gained from the SUMOylation process.

The association between aortic stenosis and the risk of consecutive eyelid inflammatory diseases

Aortic stenosis (AS) is a fatal cardiovascular disease characterized by an inflammatory response. Blepharitis and hordeolum are two eyelid conditions that also involve ocular inflammation. The aim of this study is to assess the association between AS and the subsequent development of eyelid inflammatory diseases. This retrospective cohort study included individuals diagnosed with AS, who were matched to a control group of non-AS individuals from the TriNetX database. A total of 431,027 individuals were assigned to both the AS and non-AS groups. The primary outcomes of this study were the incidence rates of eyelid inflammatory diseases, including blepharitis and hordeolum. Cox proportional hazards regression was used for statistical analysis. After the follow-up period, 4,464 cases of blepharitis were recorded in the AS group, compared to 3,139 in the non-AS group. Additionally, there were 2,184 cases of hordeolum in the AS group, compared to 1,724 in the non-AS group. Cox proportional hazards regression analysis revealed that the AS group had a significantly higher risk of developing blepharitis (P < 0.001) and hordeolum (P < 0.001) compared to the non-AS group. The AS group also showed significantly higher cumulative probabilities of both blepharitis and hordeolum than the non-AS group (both P < 0.001). In subgroup analyses, AS patients exhibited a higher risk of developing blepharitis than the non-AS population, except for the Asian population and individuals aged 20-45 years. Similarly, the AS group showed a higher risk of developing hordeolum than the non-AS group, with exceptions in the African and Asian populations and individuals aged 20-45 years. In conclusion, the presence of AS is associated with a higher risk of developing subsequent eyelid inflammatory diseases.

Management of Surgical Aortic Valve Replacement Degeneration With Transcatheter Aortic Valve Implantation (TAVI in SAVR): Experience in Nicaragua

Severe aortic valve stenosis poses a significant risk for the aging population, often escalating from mild symptoms to life-threatening heart failure and sudden death. Without timely intervention, this condition can lead to disastrous outcomes. The advent of transcatheter aortic valve implantation (TAVI) has gained popularity, emerging as an effective alternative for managing severe aortic stenosis (AS) in high-risk patients experiencing deterioration of previously implanted bioprosthetic surgical aortic valves (SAV), which introduces complex challenges such as device compatibility and anatomical considerations. We report the case of a 76-year-old male with a history of stage III hypertension, compensated type 2 diabetes, and aortic valve disease who underwent bioprosthetic valve replacement in 2013. His medications included metoprolol, metformin/glibenclamide, and levothyroxine. He presented with moderate exertional dyspnea (NYHA II) over four months, relieved by rest. Physical examination revealed a crescendo-decrescendo systolic murmur at the aortic focus. The aortic prosthesis stenosis was confirmed by a transthoracic echocardiogram. A CT angiogram showed bioprosthetic degeneration and significant calcification, allowing for transcatheter aortic valve implantation in the surgical aortic valve. The procedure was successfully performed via the transfemoral route using a 21.5 mm MyVal balloon-expandable valve. The intervention improved the patient's quality of life, resolving NYHA class III dyspnea and enabling greater independence in daily activities. Echocardiographic findings demonstrated a significant reduction in the transvalvular gradient, enhancing cardiac function and eliminating the immediate risk of valvular dysfunction progression, contributing to increased life expectancy and emotional well-being. This case highlights the feasibility and clinical benefits of transcatheter aortic valve implantation in surgical aortic valves for managing valve degeneration in a resource-limited setting, thereby representing a significant advancement in the treatment of aortic valve disease. The successful outcome demonstrates the importance of adopting innovative, minimally invasive techniques, particularly in regions with limited advanced interventions, by alleviating dyspnea, enhancing cardiac function, and significantly improving the patient's quality of life, emotional well-being, and prognosis.

Effect of Glucagon-like Peptide-1 Receptor Agonism on Aortic Valve Stenosis Risk: A Mendelian Randomization Analysis

Background: Aortic valve repair is currently the only effective treatment for calcific aortic valve stenosis (CAVS), as no pharmacological therapies exist to prevent or slow its progression. Recent promising results showed that glucagon-like peptide-1 (GLP-1) attenuates the calcification of aortic valve interstitial cells. Therefore, we conducted a two-sample Mendelian randomization analysis to investigate the effect of GLP-1 receptor agonism (GLP-1Ra) on the risk of CAVS. Methods: The inverse variance weighted (IVW) method was used to obtain the primary causal inference, and several sensitivity analyses, including MR-Egger, were performed to assess the robustness of the results. Results: Based on the IVW estimates, the GLP-1Ra showed a neutral effect on the risk of CAVS (odds ratio [OR] per 1 mmol/mol decrease in glycated hemoglobin = 0.87, 95% CI = [0.69, 1.11], p = 0.259; I2 = 4.5%, Cohran's Q = 2.09, heterogeneity p = 0.35; F statistic = 16.8). A non-significant effect was also derived by the sensitivity analyses. No evidence of horizontal pleiotropy was identified. Conclusions: GLP-1Ra was not significantly associated with the risk of CAVS. Furthermore, pragmatically designed studies are required to evaluate the effect of GLP-1Ra on the clinical course of CAVS in different patient subgroups.

Mesenchymal stem cells improve cardiac function in diabetic rats by reducing cardiac injury biomarkers and downregulating JAK/STAT/iNOS and iNOS/Apoptosis signaling pathways

Cardiovascular complications are prevalent manifestations of type 2 diabetes mellitus (T2DM) and are usually the main cause of death. This study aims to show the underlying mechanisms of the potential therapeutic effect of mesenchymal stem cells (MSCs) on diabetic cardiac dysfunction. Twenty-four male Wistar rats were randomly assigned to one of three groups The control group received standard laboratory chow, and the groups with T2DM received a single dose of 45 mg/kg body weight of streptozotocin (STZ) after 3 weeks of pretreatment with a high-fat diet (HFD). Eight weeks after the diagnosis of T2DM, rats were divided into two groups: the T2DM model group and the T2DM + MSCs group. BM-MSCs were administered systemically at 2 × 106 cells/rat doses. A Significant amelioration in Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) and dyslipidemia was noted 2 weeks post-administration of MSCs. Administration of MSCs improved dyslipidemia, the altered cardiac injury biomarkers (p ≤ 0.0001), downregulated Janus kinase 2/signal transducer and activator of transcription 3(JAK2/STAT3)/inducible Nitric oxide synthase (iNOS) and iNOS/Apoptosis signaling pathways. This was associated with improved cardiac dysfunction (impaired left ventricular performance and decreased contractility index). Our results show that MSCs ameliorate cardiac dysfunction associated with diabetic cardiomyopathy by lowering dyslipidemia and insulin resistance, inhibiting oxidative stress, and inflammation, downregulating JAK2/STAT3/iNOS and iNOS/Apoptosis signaling pathways.

Hyperglycemia-simulating environment attenuated experimentally induced calcification in cultured human aortic valve interstitial cells

Objectives: The role of diabetes mellitus as a risk factor for the development of calcific aortic valve disease has not been fully clarified. Aortic valve interstitial cells (VICs) have been suggested to be crucial for calcification of the valve. Induced calcification in cultured VICs is a good in vitro model for aortic valve calcification. The purpose of this study was to investigate whether increased glucose levels increase experimentally induced calcification in cultured human VICs. Design: VICs were isolated from explanted calcified aortic valves after valve replacement. Osteogenic medium induced calcification of cultured VICs at different glucose levels (5, 15, and 25 mM). Calcium deposits were visualized using Alizarin Red staining and measured spectrophotometrically. Results: The higher the glucose concentration, the lower the level of calcification. High glucose (25 mM) reduced calcification by 52% compared with calcification at a physiological (5 mM) glucose concentration (correlation and regression analysis: r = -0.55, p = .025 with increased concentration of glucose). Conclusions: In vitro hyperglycemia-like conditions attenuated calcification in VICs. High glucose levels may trigger a series of events that secondarily stimulate calcification of VICs in vivo.

Prevalence and impact of diabetes in patients with valvular heart disease

This study aimed to investigate the prevalence of diabetes in valvular heart disease (VHD), as well as the relationship of diabetes with severity of valvular lesions and clinical outcome. A total of 11,862 patients with significant (≥moderate) VHD from the China Valvular Heart Disease study were included in the analysis. The primary outcome was the composite of all-cause death, hospitalization for heart failure, and myocardial infarction during two-year follow-up. The prevalence of diabetes was 14.5% (1,721/11,862) in VHD. After adjusting for patients' demographics, diabetes was associated with a significantly lower risk of severe valvular lesion in aortic regurgitation and mitral regurgitation (MR). In multivariable analysis, diabetes was identified as an independent predictor of two-year outcome in patients with MR (hazard ratio: 1.345, 95% confidence interval: 1.069-1.692, p = 0.011). More efforts should be made to enhance our understanding and improve outcomes of concomitant VHD and diabetes.

CysLTR1 antagonism by montelukast can ameliorate diabetes-induced aortic and testicular inflammation

AIMS

Montelukast, a cysteinyl leukotriene receptor (CysLTR)1 antagonist, is emerging as an attractive strategy to curtail diabetic complications; however, its role in aortic and testicular tissues is unknown. This study investigated the effect of CysLTR1 antagonism by montelukast on toll-like receptor (TLR)4 and nuclear factor kappa B (NF-κB) pathways in diabetes-induced aortic and testicular injury.

METHODS

Adult male Sprague-Dawley rats were made diabetic with Streptozotocin (STZ, 55 mg/kg). Following this, Streptozotocin-induced diabetic (SD) rats were administered montelukast (10 and 20 mg/kg, orally) for 8 weeks. Blood glucose, serum malondialdehyde (MDA), inflammatory markers, and histopathology were evaluated.

RESULTS

Montelukast showed protection against diabetic complications, as evidenced by the ameliorative effect against STZ-induced alterations in oxidative stress as indicated by serum MDA levels. Moreover, montelukast conferred a significant decrease in the aortic and testicular levels of CysLTR1, TLR4, and NF-κB with a subsequent decrease in the levels of NOD-like receptor family pyrin domain containing (NLRP)3, caspase 1, interleukin (IL)-1β, IL-6, monocyte chemoattractant protein (MCP)-1, and tumor necrosis factor (TNF)-α. Additionally, administration of montelukast resulted in autophagy stimulation, as shown by decreased p62/Sequestosome (SQSTM)1 levels. Finally, montelukast protection resulted in normal thickness of whole aortic wall, regular tunica (t.) intima, mild vacuolation of smooth muscle fibers in aorta, increased size of seminiferous tubules, and increased spermatogenesis in testis as demonstrated by histopathology.

CONCLUSIONS

The protective effect of montelukast against diabetes-induced aortic and testicular injury is due to its antioxidant, anti-inflammatory, and autophagy stimulation characteristics.

The role of miR-433-3p in vascular calcification in type 2 diabetic patients: targeting WNT/β-Catenin and RANKL/RANK/OPG signaling pathways

BACKGROUND

Vascular calcification (VC) is a major predictor of cardiovascular diseases that represent the principal cause of mortality among type-2 diabetic patients. Accumulating data suggest the vital role of some microRNAs on vascular calcification as an epigenetic regulator. Thus, we assessed herein, the role of serum miR-433-3p in vascular calcification in type-2 diabetic patients.

METHODS

Twenty healthy subjects (control group) and forty diabetic patients (20 without VC and 20 with VC) were involved in the study. miR-433-3p gene expression was measured. Runx2, Dickkopf-1 (DKK1), β-catenin, Receptor activator of nuclear factor kappa-B ligand (RANKL), and osteoprotegerin (OPG) levels in serum were assessed by ELISA technique.

RESULTS

Diabetes patients had significantly lower levels of miR-433-3p expression in comparison to the control group, with the lowest levels being found in diabetic patients with VC. Furthermore, Runx2, β-catenin, and RANKL levels were significantly increased with concomitant lower DKK1 and OPG levels detected in the two diabetic groups especially those with VC.

CONCLUSION

Collectively, the study documented that down-regulation of miR-433-3p may contribute to the development of VC through activating WNT/β-Catenin and RANKL/RANK/OPG signaling pathways.

Influence of diabetes mellitus on the pathological profile of aortic stenosis: a sex-based approach

BACKGROUND

Diabetes mellitus (DM) accelerates the progression of aortic stenosis (AS), but how their underlying molecular mechanisms interact is not clear. Moreover, whether DM contributes to clinically relevant sex-differences in AS is unknown. In this work we aim to characterize the sex-specific profile of major pathological mechanisms fundamental to aortic valve (AV) degeneration in AS patients with or without concomitant DM.

METHODS

283 patients with severe AS undergoing surgical valve replacement (27.6% DM, 59.4% men) were recruited. Expression of pathological markers related to AS were thoroughly assessed in AVs and valve interstitial cells (VICs) according to sex and presence of DM. Complementary in vitro experiments in VICs in the presence of high-glucose levels (25 mM) for 24, 48 and 72 h were performed.

RESULTS

Oxidative stress and metabolic dysfunction markers were increased in AVs from diabetic AS patients compared to non-diabetic patients in both sexes. However, disbalanced oxidative stress and enhanced inflammation were more predominant in AVs from male AS diabetic patients. Osteogenic markers were exclusively increased in the AVs of diabetic women. Basal characterization of VICs confirmed that oxidative stress, inflammation, calcification, and metabolic alteration profiles were increased in diabetic VICs with sex-specific differences. VICs cultured in hyperglycemic-like conditions triggered inflammatory responses in men, whereas in women rapid and higher production of pro-osteogenic molecules.

CONCLUSIONS

DM produces sex-specific pathological phenotypes in AV of AS patients. Importantly, women with diabetes are more prone to develop AV calcification. DM should be considered as a risk factor in AS especially in women.

Inactive Matrix Gla Protein in Relation to Renal and Cardiac Functions and Cardiac Valvular Calcification Among Type 2 Diabetes Patients

Background

Matrix Gla protein (MGP) is a robust innate suppressor of the detrimental process of vascular calcification in the human body.

Objectives

The interrelationship between circulating MGP levels and renal and cardiac dysfunction, besides echocardiographic calcification score (ECS) was investigated in a sample of type 2 diabetes (T2D) patients.

Methods

The study included 130 subjects. They were 95 patients with T2D and 35 age- and sex-matched healthy controls. Patients were further subdivided into 52 T2D patients without DKD (eGFR ⩾ 60 ml/minute/1.73 m²) and 43 T2D persons with DKD (eGFR > 60 ml/minute/1.73 m²). Serum MGP levels, determined by ELISA, renal function tests, lipid profile, and echocardiography were studied in all participants.

Results

Significantly elevated circulating inactive MGP level was noted in individuals having T2D compared to controls. It correlated negatively with eGFR and left ventricular (LV) diastolic and systolic functions and positively with indices of LV hypertrophy. ECS was significantly increased in both T2D groups compared to controls and in DKD group compared to the diabetic group without DKD. A significant positive correlation was observed between inactive MGP and ECS.

Conclusion

Serum inactive MGP may contribute to the development of DKD and to the associated process of cardiac valvular calcification. It may be a beneficial diagnostic marker for early prediction of cardiac calcification and preclinical LV systolic and diastolic dysfunction in T2D patients, especially in those complicated with DKD.

Focusing on the Native Matrix Proteins in Calcific Aortic Valve Stenosis

Calcific aortic valve stenosis (CAVS) is a widespread valvular heart disease affecting people in aging societies, primarily characterized by fibrosis, inflammation, and progressive calcification, leading to valve orifice stenosis. Understanding the factors associated with CAVS onset and progression is crucial to develop effective future pharmaceutical therapies. In CAVS, native extracellular matrix proteins modifications, play a significant role in calcification in vitro and in vivo. This work aimed to review the evidence on the alterations of structural native extracellular matrix proteins involved in calcification development during CAVS and highlight its link to deregulated biomechanical function.

PAI-1 Overexpression in Valvular Interstitial Cells Contributes to Hypofibrinolysis in Aortic Stenosis

Aortic stenosis (AS) is associated with hypofibrinolysis, but its mechanism is poorly understood. We investigated whether LDL cholesterol affects plasminogen activator inhibitor 1 (PAI-1) expression, which may contribute to hypofibrinolysis in AS. Stenotic valves were obtained from 75 severe AS patients during valve replacement to assess lipids accumulation, together with PAI-1 and nuclear factor-κB (NF-κB) expression. Five control valves from autopsy healthy individuals served as controls. The expression of PAI-1 in valve interstitial cells (VICs) after LDL stimulation was assessed at protein and mRNA levels. PAI-1 activity inhibitor (TM5275) and NF-κB inhibitor (BAY 11-7082) were used to suppress PAI-1 activity or NF-κB pathway. Clot lysis time (CLT) was performed to assess fibrinolytic capacity in VICs cultures. Solely AS valves showed PAI-1 expression, the amount of which was correlated with lipid accumulation and AS severity and co-expressed with NF-κB. In vitro VICs showed abundant PAI-1 expression. LDL stimulation increased PAI-1 levels in VICs supernatants and prolonged CLT. PAI-1 activity inhibition shortened CLT, while NF-κB inhibition decreased PAI-1 and SERPINE1 expression in VICs, its level in supernatants and shortened CLT. In severe AS, valvular PAI-1 overexpression driven by lipids accumulation contributes to hypofibrinolysis and AS severity.

Aortic stenosis: a review on acquired pathogenesis and ominous combination with diabetes mellitus

BACKGROUND

Aortic stenosis (AS) is a progressive disease, with no pharmacological treatment. The prevalence of diabetes mellitus (DM) among AS patients is higher than in the general population. DM significantly increases the risk of AS development and progression from mild to severe. The interplay between AS and DM's mechanism is not entirely known yet.

MAIN BODY

The increased accumulation of advanced glycation end products (AGEs) was linked to increased valvular oxidative stress, inflammation, expression of coagulation factors, and signs of calcification, according to an analysis of aortic stenotic valves. It is interesting to note that in diabetic AS patients, valvular inflammation did not correlate with serum glucose levels but rather only with long-term glycemic management markers like glycated haemoglobin and fructosamine. Transcatheter aortic valve replacement, which has been shown to be safer than surgical aortic valve replacement, is advantageous for AS patients who also have concurrent diabetes. Additionally, novel anti-diabetic medications have been proposed to lower the risk of AS development in DM patients, including sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonist that target reduction of AGEs-mediated oxidative stress.

CONCLUSIONS

There are little data on the effects of hyperglycemia on valvular calcification, but understanding the interactions between them is essential to develop a successful treatment strategy to stop or at least slow the progression of AS in DM patients. There is a link among AS and DM and that DM negatively impacts the quality of life and longevity of AS patients. The sole successful treatment, despite ongoing efforts to find new therapeutic modalities, involves aortic valve replacement. More research is required to find methods that can slow the advancement of these conditions, enhancing the prognosis and course of people with AS and DM.

Systemic proinflammatory-profibrotic response in aortic stenosis patients with diabetes and its relationship with myocardial remodeling and clinical outcome

BACKGROUND

Previous studies have mainly focused more on how diabetes affects the valve than the myocardium in aortic stenosis (AS). In the pressure-overloaded heart, myocardial fibrosis is an important driver of the progression from compensated hypertrophy to heart failure. Using comprehensive noninvasive imaging and plasma proteomics, we investigated whether and how diabetes aggravates the remodeling of the myocardium and its relation with prognosis in AS patients.

METHODS

Severe AS patients were enrolled in two prospective cohorts for imaging and biomarker analysis. The imaging cohort (n = 253) underwent echocardiography and cardiac magnetic resonance, and the biomarker cohort (n = 100) blood sampling with multiplex proximity extension assay for 92 proteomic biomarkers. The composite outcome of hospitalization for heart failure admissions and death was assessed in the imaging cohort.

RESULTS

Diabetic patients were older (70.4 ± 6.8 versus 66.7 ± 10.1 years) with more advanced ventricular diastolic dysfunction and increased replacement and diffuse interstitial fibrosis (late gadolinium enhancement % 0.3 [0.0-1.6] versus 0.0 [0.0-0.5], p = 0.009; extracellular volume fraction % 27.9 [25.7-30.1] versus 26.7 [24.9-28.5], p = 0.025) in the imaging cohort. Plasma proteomics analysis of the biomarker cohort revealed that 9 proteins (E-selectin, interleukin-1 receptor type 1, interleukin-1 receptor type 2, galectin-4, intercellular adhesion molecule 2, integrin beta-2, galectin-3, growth differentiation factor 15, and cathepsin D) were significantly elevated and that pathways related to inflammatory response and extracellular matrix components were enriched in diabetic AS patients. During follow-up (median 6.3 years), there were 53 unexpected heart failure admissions or death in the imaging cohort. Diabetes was a significant predictor of heart failure and death, independent of clinical covariates and aortic valve replacement (HR 1.88, 95% CI 1.06-3.31, p = 0.030).

CONCLUSIONS

Plasma proteomic analyses indicate that diabetes potentiates the systemic proinflammatory-profibrotic milieu in AS patients. These systemic biological changes underlie the increase of myocardial fibrosis, diastolic dysfunction, and worse clinical outcomes in severe AS patients with concomitant diabetes.

Diabetes mellitus in transfemoral transcatheter aortic valve implantation: a propensity matched analysis

BACKGROUND

Diabetes Mellitus (DM) affects a third of patients with symptomatic severe aortic valve stenosis undergoing transcatheter aortic valve implantation (TAVI). DM is a well-known risk factor for cardiac surgery, but its prognostic impact in TAVI patients remains controversial. This study aimed to evaluate outcomes in diabetic patients undergoing TAVI.

METHODS

This multicentre registry includes data of > 12,000 patients undergoing transfemoral TAVI. We assessed baseline patient characteristics and clinical outcomes in patients with DM and without DM. Clinical outcomes were defined by the second valve academic research consortium. Propensity score matching was applied to minimize potential confounding.

RESULTS

Of the 11,440 patients included, 31% (n = 3550) had DM and 69% (n = 7890) did not have DM. Diabetic patients were younger but had an overall worse cardiovascular risk profile than non-diabetic patients. All-cause mortality rates were comparable at 30 days (4.5% vs. 4.9%, RR 0.9, 95%CI 0.8-1.1, p = 0.43) and at one year (17.5% vs. 17.4%, RR 1.0, 95%CI 0.9-1.1, p = 0.86) in the unmatched population. Propensity score matching obtained 3281 patient-pairs. Also in the matched population, mortality rates were comparable at 30 days (4.7% vs. 4.3%, RR 1.1, 95%CI 0.9-1.4, p = 0.38) and one year (17.3% vs. 16.2%, RR 1.1, 95%CI 0.9-1.2, p = 0.37). Other clinical outcomes including stroke, major bleeding, myocardial infarction and permanent pacemaker implantation, were comparable between patients with DM and without DM. Insulin treated diabetics (n = 314) showed a trend to higher mortality compared with non-insulin treated diabetics (n = 701, Hazard Ratio 1.5, 95%CI 0.9-2.3, p = 0.08). EuroSCORE II was the most accurate risk score and underestimated 30-day mortality with an observed-expected ratio of 1.15 in DM patients, STS-PROM overestimated actual mortality with a ratio of 0.77 and Logistic EuroSCORE with 0.35.

CONCLUSION

DM was not associated with mortality during the first year after TAVI. DM patients undergoing TAVI had low rates of mortality and other adverse clinical outcomes, comparable to non-DM TAVI patients. Our results underscore the safety of TAVI treatment in DM patients.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov (NCT03588247).

Contribution of Oxidative Stress (OS) in Calcific Aortic Valve Disease (CAVD): From Pathophysiology to Therapeutic Targets

Calcific aortic valve disease (CAVD) is a major cause of cardiovascular mortality and morbidity, with increased prevalence and incidence. The underlying mechanisms behind CAVD are complex, and are mainly illustrated by inflammation, mechanical stress (which induces prolonged aortic valve endothelial dysfunction), increased oxidative stress (OS) (which trigger fibrosis), and calcification of valve leaflets. To date, besides aortic valve replacement, there are no specific pharmacological treatments for CAVD. In this review, we describe the mechanisms behind aortic valvular disease, the involvement of OS as a fundamental element in disease progression with predilection in AS, and its two most frequent etiologies (calcific aortic valve disease and bicuspid aortic valve); moreover, we highlight the potential of OS as a future therapeutic target.

Left-Sided Degenerative Valvular Heart Disease in Type 1 and Type 2 Diabetes

BACKGROUND

The role of diabetes in the development of valvular heart disease, and, in particular, the relation with risk factor control, has not been extensively studied.

METHODS

We included 715 143 patients with diabetes registered in the Swedish National Diabetes Register and compared them with 2 732 333 matched controls randomly selected from the general population. First, trends were analyzed with incidence rates and Cox regression, which was also used to assess diabetes as a risk factor compared with controls, and, second, separately in patients with diabetes according to the presence of 5 risk factors.

RESULTS

The incidence of valvular outcomes is increasing among patients with diabetes and the general population. In type 2 diabetes, systolic blood pressure, body mass index, and renal function were associated with valvular lesions. Hazard ratios for patients with type 2 diabetes who had nearly all risk factors within target ranges, compared with controls, were as follows: aortic stenosis 1.34 (95% CI, 1.31-1.38), aortic regurgitation 0.67 (95% CI, 0.64-0.70), mitral stenosis 1.95 (95% CI, 1.76-2.20), and mitral regurgitation 0.82 (95% CI, 0.79-0.85). Hazard ratios for patients with type 1 diabetes and nearly optimal risk factor control were as follows: aortic stenosis 2.01 (95% CI, 1.58-2.56), aortic regurgitation 0.63 (95% CI, 0.43-0.94), and mitral stenosis 3.47 (95% CI, 1.37-8.84). Excess risk in patients with type 2 diabetes for stenotic lesions showed hazard ratios for aortic stenosis 1.62 (95% CI, 1.59-1.65), mitral stenosis 2.28 (95% CI, 2.08-2.50), and excess risk in patients with type 1 diabetes showed hazard ratios of 2.59 (95% CI, 2.21-3.05) and 11.43 (95% CI, 6.18-21.15), respectively. Risk for aortic and mitral regurgitation was lower in type 2 diabetes: 0.81 (95% CI, 0.78-0.84) and 0.95 (95% CI, 0.92-0.98), respectively.

CONCLUSIONS

Individuals with type 1 and 2 diabetes have greater risk for stenotic lesions, whereas risk for valvular regurgitation was lower in patients with type 2 diabetes. Patients with well-controlled cardiovascular risk factors continued to display higher risk for valvular stenosis, without a clear stepwise decrease in risk between various degrees of risk factor control.

Towards Personalized Therapy of Aortic Stenosis

Calcific aortic stenosis (CAS) is the most common cause of acquired valvular heart disease in adults with no available pharmacological treatment to inhibit the disease progression to date. This review provides an up-to-date overview of current knowledge of molecular mechanisms underlying CAS pathobiology and the related treatment pathways. Particular attention is paid to current randomized trials investigating medical treatment of CAS, including strategies based on lipid-lowering and antihypertensive therapies, phosphate and calcium metabolism, and novel therapeutic targets such as valvular oxidative stress, coagulation proteins, matrix metalloproteinases, and accumulation of advanced glycation end products.