Statins and Progression of Calcified Aortic Stenosis

High-throughput investigation of endothelial-to-mesenchymal transformation (EndMT) with combinatorial cellular microarrays

In the developing heart, a specific subset of endocardium undergoes an endothelial-to-mesenchymal transformation (EndMT) thus forming nascent valve leaflets. Extracellular matrix (ECM) proteins and growth factors (GFs) play important roles in regulating EndMT but the combinatorial effect of GFs with ECM proteins is less well understood. Here we use microscale engineering techniques to create single, binary, and tertiary component microenvironments to investigate the combinatorial effects of ECM proteins and GFs on the attachment and transformation of adult ovine mitral valve endothelial cells to a mesenchymal phenotype. With the combinatorial microenvironment microarrays, we utilized 60 different combinations of ECM proteins (Fibronectin, Collagen I, II, IV, Laminin) and GFs (TGF-β1, bFGF, VEGF) and were able to identify new microenvironmental conditions capable of modulating EndMT in MVECs. Experimental results indicated that TGF-β1 significantly upregulated the EndMT while either bFGF or VEGF downregulated EndMT process markedly. Also, ECM proteins could influence both the attachment of MVECs and the response of MVECs to GFs. In terms of attachment, fibronectin is significantly better for the adhesion of MVECs among the five tested proteins. Overall collagen IV and fibronectin appeared to play important roles in promoting EndMT process. Great consistency between macroscale and microarrayed experiments and present studies demonstrates that high-throughput cellular microarrays are a promising approach to study the regulation of EndMT in valvular endothelium. Biotechnol. Bioeng. 2016;113: 1403-1412. © 2015 Wiley Periodicals, Inc.

Medical therapy for calcific aortic stenosis

Severe aortic stenosis due to calcification of the aortic valve is the most common indication for aortic valve replacement in the United States and Europe. The standard therapy for symptomatic patients with severe aortic stenosis is replacement of the valve. Some of the risk factors and pathophysiologic mechanisms in atherosclerosis play an important role in the development of calcific aortic stenosis. In the last few years, there have been an increased number of publications regarding the use of medications in order to delay the progression of aortic stenosis. These medications include statins, angiotensin-converting enzyme inhibitors, and biphosphanates. This article describes and summarizes some of the medical approaches that have emerged to alter the progression of aortic stenosis. Currently, only statins have been evaluated in randomized, placebo-control trials. Furthermore, statins have not proven to alter the progression of aortic stenosis. Ongoing randomized controlled trials with the use of angiotensin-converting enzyme inhibitors, statins, and biphosphonates will determine the use of these medications to delay the progression of aortic stenosis.

Early identification of aortic valve sclerosis using iron oxide enhanced MRI

PURPOSE

To test the ability of MION-47 enhanced MRI to identify tissue macrophage infiltration in a rabbit model of aortic valve sclerosis (AVS).

MATERIALS AND METHODS

The aortic valves of control and cholesterol-fed New Zealand White rabbits were imaged in vivo pre- and 48 h post-intravenous administration of MION-47 using a 1.5 Tesla (T) MR clinical scanner and a CINE fSPGR sequence. MION-47 aortic valve cusps were imaged ex vivo on a 3.0T whole-body MR system with a custom gradient insert coil and a three-dimensional (3D) FIESTA sequence and compared with aortic valve cusps from control and cholesterol-fed contrast-free rabbits. Histopathological analysis was performed to determine the site of iron oxide uptake.

RESULTS

MION-47 enhanced the visibility of both control and cholesterol-fed rabbit valves in in vivo images. Ex vivo image analysis confirmed the presence of significant signal voids in contrast-administered aortic valves. Signal voids were not observed in contrast-free valve cusps. In MION-47 administered rabbits, histopathological analysis revealed iron staining not only in fibrosal macrophages of cholesterol-fed valves but also in myofibroblasts from control and cholesterol-fed valves.

CONCLUSION

Although iron oxide labeling of macrophage infiltration in AVS has the potential to detect the disease process early, a macrophage-specific iron compound rather than passive targeting may be required.

The in vivo diagnosis of early-stage aortic valve sclerosis using magnetic resonance imaging in a rabbit model

PURPOSE

To use magnetic resonance imaging (MRI) to identify and monitor early aortic valve sclerosis (AVS) induced by cholesterol feeding in rabbits. AVS is a highly prevalent disease process, affecting more than 25% of the population over age 65. A major obstacle to early stage medical management of AVS has been the lack of an objective noninvasive technique to identify its presence and monitor its progress.

MATERIALS AND METHODS

Retrospectively gated CINE fast spoiled gradient echo (fSPGR) images of aortic valve cusps were collected at 3-month intervals starting at 6 months using a 1.5 T MR scanner interfaced with a customized surface radiofrequency coil. At 16 months a subset of animals was sacrificed and excised cusps were examined with both high frequency ultrasound (US) and histopathological techniques to validate the MRI method.

RESULTS

MR and US analysis identified significant thickening of diseased AV cusps when compared to control (P < 0.05). Histopathological analysis confirmed the presence of human-like AVS in diseased rabbit valves.

CONCLUSION

Early AVS, exemplified by increased valve thickness, can be identified in vivo using high-resolution MRI.

Optimum management of elderly patients with calcified aortic stenosis

Increased life-expectancy has led to a growing elderly population frequently presenting with aortic stenosis. This review focuses on the pathogenesis of calcific aortic stenosis, diagnosis and possible ways to halt the progression to severe symptomatic aortic stenosis, methods of assessing symptoms and severity, and modalities and timing of aortic valve replacement. At present the treatment of aortic stenosis for the majority of patients is surgical, and any patient with symptomatic severe aortic stenosis should be considered for aortic valve replacement. This article also discusses the role of emerging techniques of closed heart valve implantation either transfemoral or transapical, and which patients might be candidates for these new approaches to the treatment of aortic stenosis in the elderly population.

Anesthetic Considerations in the Patient With Valvular Heart Disease Undergoing Noncardiac Surgery

Valvular heart disease can be an important finding in patients presenting for noncardiac surgery. Valvular heart disease and resulting comorbidity, such as heart failure or atrial fibrillation, significantly increase the risk for perioperative adverse events. Appropriate preoperative assessment, adequate perioperative monitoring, and early intervention, should hemodynamic disturbances occur, may help prevent adverse events and improve patient outcome. This review article aims to guide the practitioner in the various aspects of anesthetic management in the perioperative care of patients with valvular heart disease. The pharmacological approach to optimization of patient outcome with drugs, such as βblockers and lipid-lowering medications (statins), is an evolving field, and recent developments are discussed in this article.