Medical graphics to improve patient understanding and anxiety in elderly and cognitively impaired patients scheduled for transcatheter aortic valve implantation (TAVI)

BACKGROUND

Anxiety and limited patient comprehension may pose significant barriers when informing elderly patients about complex procedures such as transcatheter aortic valve implantation (TAVI).

OBJECTIVES

We aimed to evaluate the utility of medical graphics to improve the patient informed consent (IC) before TAVI.

METHODS

In this prospective, randomized dual center study, 301 patients were assigned to a patient brochure containing medical graphics (Comic group, n = 153) or sham information (Control group, n = 148) on top of usual IC. Primary outcomes were patient understanding of central IC-related aspects and periprocedural anxiety assessed by the validated Spielberger State Trait Anxiety Inventory (STAI), both analyzed by cognitive status according to the Montreal Cognitive Assessment (MoCA).

RESULTS

Patient understanding was significantly higher in the Comic group [mean number of correct answers 12.8 (SD 1.2) vs. 11.3 (1.8); mean difference 1.5 (95% CI 1.2-1.8); p < 0.001]. This effect was more pronounced in the presence of cognitive dysfunction (MoCA < 26) [12.6 (1.2) in the Comic vs. 10.9 (1.6) in the Control group; mean difference 1.8 (1.4-2.2), p < 0.001]. Mean STAI score declined by 5.7 (95% CI 5.1-6.3; p < 0.001) in the Comic and 0.8 points (0.2-1.4; p = 0.015) in the Control group. Finally, mean STAI score decreased in the Comic group by 4.7 (3.8-5.6) in cognitively impaired patients and by 6.6 (95% CI 5.8 to 7.5) in patients with normal cognitive function (p < 0.001 each).

CONCLUSIONS

Our results prove beneficial effects for using medical graphics to inform elderly patients about TAVI by improving patient understanding and reducing periprocedural anxiety (DRKS00021661; 23/Oct/2020). Medical graphics entailed significant beneficial effects on the primary endpoints, patient understanding and periprocedural anxiety, compared to the usual patient informed consent (IC) procedure. Patient understanding of IC-related aspects was significantly higher in the Comic group, with a more pronounced benefit in patients with cognitive impairment (p for IC method and cognitive status < 0.001, respectively; p for IC method x MoCA category interaction = 0.017). There further was a significant decline of periprocedural anxiety in patients with and without cognitive impairment (p for IC method x measuring time point < 0.001; p for IC method x MoCA category x measuring time point interaction = 0.018).

Echocardiographic assessment of left ventricular radial strain to differentiate cardiac amyloidosis from Fabry disease

Background

Left ventricular (LV) wall thickening is a typical echocardiographic finding in infiltrative cardiomyopathies like cardiac amyloidosis (CA) and Fabry disease (FD). The discrimination of both infiltrative diseases remains challenging by standard as well as 2D speckle tracking echocardiography (2DSTE)-based analysis of longitudinal LV strain patterns. Over the recent years, a constant development in image quality and data processing provided better possibilities to analyse layer specific myocardial deformation indices. With regards to FD, specific layer LV strain patterns may be useful to rule-in FD in patients with suspected infiltrative cardiomyopathy.

Purpose

The aim of the present study was to investigate differences and the diagnostic value of layer specific 2D STE-based radial LV strain indices in CA and FD.

Methods

Next to standard parameters of a comprehensive echocardiographic assessment (Vivid E9 or E95, GE Vingmed, Horton, Norway, with an M5S 1.5–4.5MHz transducer), we retrospectively analysed the transmural radial LV strain (GSradial), the subendocardial radial LV strain (GSendo), the subepicardial radial LV strain (GSepi), and the strain gradient (GSendo − GSepi) (EchoPAC software, GE) in FD patients and CA patient from the amyloidosis registry at our study site. A Receiver operating curve (ROC) analysis was used to assess the diagnostic value of the respective LV strain values and the layer-specific strain gradient to discriminate FD and CA.

Results

A total of 38 FD and 40 CA patients were included in our analyses. In patients with FD, GSepi showed a marked impairment. LV radial and layer strain were significantly reduced in CA compared to FD patients [GSradial −12.0 (−16.2 to −9.9) in CA vs. −17.7 (−20.5 to −14.6) in FD; p&lt;0.001); GSendo (−20.6 (−27.0 to −15.7) in CA vs. −30.0 (−32.0 to −25.6) in FD; p&lt;0.001); and GSepi (−7.4 (−8.9 to −4.8) in CA vs. −9.1 (−11.86 to −7.6) in FD; p&lt;0.001)]. The gradient of GSendo and GSepi was significantly lower in patients with CA compared to FD (−14.0±5.6 in CA vs. −19.4±4.3 in FD respectively; p&lt;0.001). GSendo held the highest diagnostic accuracy to discriminate CA and FD (area under the curve [AUC] 0.83, 95% confidence interval [CI] 0.73–0.92). The layer-specific strain gradient GSendo − Gsepi showed an AUC of 0.79 (CI 0.69 to 0.89).

Conclusion

Layer-specific strain analysis demonstrated significantly reduced strain values in CA patients compared to FD. The analysis of GSendo held a high diagnostic accuracy to discriminate FD and CA in patients. The integration of layer-specific LV strain indices into the diagnostic work-up may improve the management of patients with an unclear thick heart pathology in future.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Alnylam Pharmaceuticals (Cambridge, MA, USA)

Electrocardiographic changes after TAVR and their clinical impact according to new ESC Pacing Guidelines

 

Conduction disturbances after transcatheter aortic valve replacement (TAVR) remain one of the most frequent complications.

The aim of this study was to analyze ECG changes after TAVR using contemporary valves and to detect risk factors for the need of further clinical evaluation according to new ESC pacing guidelines to evaluate pacemaker implantation.

In this retrospective analysis we included 850 patients (mean age 80±9 years, 51% female), who underwent TAVR in our institution from January 2019 until December 2020. A mean follow-up of 8.9±8.4 months and 217 (25.5%) patients was performed.

55% of the implanted valves were self-expandable, 45% balloon-expandable. After TAVR, 77 (9.1%) patients developed new LBBB and QRS &gt;150ms, 26 (3.1%) new PR-time &gt;240ms. Prolongation of PR-time and prolongation of QRS duration &gt;20ms were seen in 20 (2.4%) and 90 (10.6%) patients with preexisting conduction disturbances. 152 (17.9%) patients needed pacemaker implantation post TAVR.

Developing a PR-prolongation of &gt;20ms was associated with calcification of the annulus (OR 1.2 CI 95% 1.004–1.4; p=0.04). New LBBB (OR 0.45; CI 95% 0.25–0.79; p=0.006) and pacemaker implantation (OR 0.4; CI 95% 0.2–0.8; p=0.009) were correlated with the implantation of a self-expandable valve. Coronary heart disease (OR 3, CI 95% 1.07–8.2; p=0.04) and peripheral arterial disease (OR 2.6 CI 95% 1.18–5.6; p=0.02) were associated with prolongation of QRS &gt;20ms. New LBBB with QRS &gt;150ms was seen more often after post-dilatation (OR 1.03, CI 95% 1.01–1.05; p=0.05). Pre-existing AV block I° (OR 2.8, CI 95% 1.4–5.6; p&lt;0.001), pre-existing RBBB (OR 20.5, CI 95% 7.5–56; p&lt;0.001), nicotine abuse (OR 2, CI 95% 1.05–3.8; p=0.04), prosthesis oversizing (OR 1.06, CI 95% 1.006–1.11; p=0.03) and implantation depth (OR 1.13, CI 95% 1.006–1.26; p=0.04) were independent risk factors for pacemaker implantation.

During the follow-up 161 patients (18.9%) were hospitalized in 270 inpatient stays [cardiac decompensation (n=36, 13%), pacemaker implantation (n=9, 3.3%), acute coronary syndrome (n=12, 4.4%)]. 8 patients (80%) received a pacemaker implantation because of AV Block III° and 1 (10%) patient because of sick-sinus-syndrome (SSS). Analyzing the post TAVR ECG 5 (50%) had a new LBBB (3 (30%) with QRS &gt;150ms) and 4 (40%) patients showed LBBB together with AV Block I°.

According to new guidelines 213 (25.1%) patients would have needed further clinical evaluation (EP study or ECG monitoring) after TAVR. AV-conduction abnormalities were associated with annulus calcification. Self-expandable valves were associated with new LBBB and pacemaker implantation. There seems to be a correlation between arteriosclerotic diseases and QRS width post TAVR. Pre-existing RBBB, AV block I°, implantation depth and prosthesis oversizing are important risk factors for pacemaker implantation post TAVR. New LBBB after TAVR is associated with a higher risk for pacemaker implantation in the long-term analysis.

Funding Acknowledgement

Type of funding sources: None.

New echocardiographic approaches to differentiate cardiac amyloidosis and Fabry disease: the right heart and mitral valve thickness

Background

Infiltrative cardiomyopathies such as cardiac amyloidosis (CA) and Fabry disease (FD) are associated with high cardiovascular morbidity and mortality. Diagnosis is often challenging as CA and FD may present similar cardiac phenotypes on standard echocardiographic imaging, especially in early stages of disease.

Purpose

Our study focuses on right ventricular (RV) two-dimensional speckle tracking imaging and mitral valve thickness as diagnostic strategies to discriminate CA from FD. Here, we report preliminary data of our study registry of CA and FD patients.

Methods

We retrospectively screened patients with diagnosed CA or with genetically confirmed FD from our study registry. Global and free wall RV strain and mitral leaflet thickening in both groups were analysed using 2D speckle tracking echocardiography and linear measurements from a parastenal long axis view, respectively (Vivid E9 or E95, GE Vingmed, Horton, Norway, M5S 1.5–4.5MHz transducer). The diagnostic accuracy for discriminating CA and FD in both groups was evaluated using receiver operating characteristic (ROC) curve analysis.

Results

A total of 33 FD and 27 CA patients, including 17 patients with wild-type transthyretin-related (ATTR) CA, 8 patients with hereditary ATTR CA, one patient with light chain CA, and one patient with AA CA, were included. RV function was significantly reduced in CA compared to FD patients as measured by global longitudinal RV strain (−13.6±5.1 in CA vs. −18.4±3.9 in FD, p&lt;0.001) and free wall longitudinal RV strain (−17.5±5.7 in CA vs. −21.3±4.4 in FD, p=0.005). Significantly lower longitudinal RV strain was observed in the basal to mid ventricular region in CA compared to FD patients, while RV apical strain was not significantly different between the two groups. RV global longitudinal strain had the highest diagnostic accuracy of strain analyses (area under the curve [AUC] 0.79, 95% confidence interval [CI] 0.66–0.93) to discriminate CA from FD. Additional measurement of the mitral valve in mid diastole in the parasternal long axis view revealed a significantly thickened leaflet in CA patients (4.6±1.2 mm in CA vs. 2.9±1.0 mm in FD, p&lt;0.001) corresponding to an AUC of 0.84 (95% CI 0.72–0.96) in ROC analysis.

Conclusion

Global longitudinal RV strain was significantly reduced in CA patients while the mitral valve leaflets were significantly thickened compared to FD patients. Therefore, both parameters may be useful to discriminate CA from FD in the echocardiographic workup of patients with unclear left ventricular wall thickening.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Alnylam Pharmaceuticals (Cambridge, MA, USA)

Causes of death and predictors of long-term mortality after pulmonary embolism

Background

While a large number of studies has investigated short-term outcome after pulmonary embolism (PE), the effects of PE on long-term mortality are insufficiently studied.

Purpose

To investigate long-term outcomes in an unselected real-world cohort of patients with acute PE.

Methods

Consecutive patients with acute PE enrolled in a prospective single-centre registry between 05/2005 and 12/2017 were followed for up to 14 years. The primary study outcome was all-cause mortality during follow-up. Kaplan-Meier analyses were used to evaluate the probability of long-term survival. The prognostic relevance of baseline characteristics was assessed using Cox proportional hazards models. Standardised mortality rates (SMR) were calculated to estimate relative rates of mortality in the study cohort compared to the expected mortality in the general population adjusted for sex, age and year of birth.

Results

We analysed data from 882 patients (age 69 [interquartile range (IQR) 56–77] years), followed for a total of 3,904 patient years (median follow-up 3.2 [IQR 1.3–7.2] years). Overall, 40.9% of patients died during follow-up. One- and five-year mortality rates were 19.8% and 33.7%, respectively. While most early deaths could be attributed to PE or associated complications, cancer was the predominant cause of death between 30 days and 3 years after PE, whereas cardiovascular events and infections were the most frequent causes of death after more than 3 years (Figure 1).

In patients who survived the first 30 days after PE, the observed number of deaths was higher than the expected mortality in the general population throughout the follow-up period (Figure 2; 5-year SMR 2.77 [95% CI 2.42–3.15]). The strongest predictor of late mortality was active cancer at the time of PE, that was associated with a Hazard Ratio [HR] of 4.03 [95% CI 3.07–5.28]) for death after &gt;30 days. Of note, active cancer was only associated with an increased mortality risk during the first three years of follow-up, but did not predict death after more than three years. In non-cancer patients, mortality was also elevated compared to the general population (5-year SMR 1.80 [95% CI 1.51–2.14]) and late mortality was predicted by chronic pulmonary disease (HR 2.22 [95% CI 1.51–3.27]), chronic heart failure (HR 1.90 [95% CI 1.36–2.66]), age per decade (HR 1.79 [95% CI 1.54–2.09]) and anaemia (HR 1.59 [95% CI 1.16–2.17]).

Conclusion

Even after survival of the acute phase, the mortality risk of PE patients remained elevated compared to the general population throughout the 14 year follow-up period. The main driver of late mortality is cancer. However, elevated mortality was also observed in in PE patients without cancer, in whom late mortality was predicted by chronic cardiopulmonary comorbidities, age and anaemia.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

Association of myocardial work indices with controlled arterial hypertension, age, weight and conventional echocardiographic parameters in women

Funding Acknowledgements

Type of funding sources: None.

Objective

By incorporating myocardial deformation and afterload, novel echocardiographic myocardial work indices appear to be advantageous over the load-dependent left ventricular (LV) strain. As such, these indices might provide a better and load-independent estimation of LV function in patients with chronically increased afterload. To date, however, little is known about the relation of these indices to clinical and conventional echocardiographic parameters.

Purpose

Our aim was to evaluate the relationship between myocardial work indices and age, weight, conventional echocardiographic parameters, and the presence of previously defined well-controlled arterial hypertension (AH) in women without cardiovascular diseases.

Methods

We retrospectively analyzed echocardiographic data of women, included to the BEFRI (BErlin Female RIsk evaluation) trial. Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE) were calculated using commercially available software based on noninvasive pressure-strain loops. Mulitvariate analysis of covariance was applied to investigate the relation of myocardial work indices with the above mentioned variables.

Results

A total of 224 women were included in the final analysis. 155 of them were normotensive and 69 had controlled AH. Women with AH were significantly older (67 ± 12 y. vs. 54 ± 13 y, p &lt; 0.05), had  higher blood pressure (136 ± 10/77 ± 6 mmHg vs. 121 ± 7/70 ± 6 mmHg, p &lt; 0.05), higher body mass index (28 ± 5 kg/m² vs. 24 ± 4 kg/m², p &lt; 0.05), thicker LV walls (septum: 12 ± 2 mm vs. 9 ± 1 mm; posterior wall: 11 ± 1 mm vs. 9 ± 1 mm, p &lt; 0.05 for both), higher left atrial volume index (35 ± 8 ml/m² vs. 29 ± 5 ml/m², p &lt; 0.05) and longer IVRT (103 ± 27 ms vs. 85 ± 24 ms, p &lt; 0.05). LV ejection fraction, LV internal dimensions and TAPSE were within a normal range and did not differ between groups. Patients with AH showed lower global longitudinal strain (GLS) (19 ± 3% vs. 20 ± 2%, p &lt; 0.05), higher GWI and GCW (2214 ± 285 mmHg% vs. 2045 ± 244 mmHg%, 2445 ± 316 mmHg% vs. 2256 ± 272 mmHg%; p &lt; 0.05 for both) (Fig. 1), whereas GWW and GWE did not differ significantly (112 ± 59 mmHg% vs 101 ± 51 mmHg% and 95 ± 3% vs. 95 ± 2%). In the multivariate analysis GWI and GCW, but not GWW or GWE, were significantly positively associated with the presence of AH (s. Table). Besides that, GWI and GCW were positively related to LVEF and LVEDD. GWW showed negative relation to LVEF and a positive relation with IVRT. GWE was positively related to LVEF, and negatively to IVRT. None of the indices was significantly related to age.

Conclusion

We have defined the relationship of various myocardial work indices with weight, conventional echocardiographic parameters, and the presence of AH.  The higher GWI and GCW in patients with AH might suggest higher energetic expenditure of myocardium due to increased afterload. The prognostic impact of these findings remains to be defined. Abstract Table.

Phasic left atrial strain to predict diastolic dysfunction development in women: results from the prospective Berlin Female Risk Evaluation (BEFRI) follow up trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by the DZHK (German Centre for Cardiovascular Research) and by the BMBF (German Ministry of Education and Research)

OnBehalf

BEFRI

Background/Introduction: During the past few years, left atrial strain (LAS) has been identified to be significantly associated with left ventricular diastolic dysfunction (DD). However, the predictive value of LAS reductions on the course of DD in patients without or mild DD has so far not been investigated.

Purpose

To assess the predictive impact of phasic left atrial strain (LAS) reductions on the development of left ventricular (LV) diastolic function in women with normal (DD0) or mildly impaired diastolic function in a longitudinal study design.

Methods

We reinvited 449 participants of the Berlin Female Risk Evaluation (BEFRI) study for follow-up examinations. A comprehensive clinical and echocardiographic assessment comprising the analysis of phasic LAS was performed in 256 participants. The diagnostic and predictive value of LAS analysis was assessed and compared with standard echocardiographic DD parameters using receiver operating characteristic (ROC) curve analyses and a multivariate logistic regression model. 

Results

After a mean time interval of 6.8 years, subjects with DD0 at baseline investigation and a worsening of diastolic function of at least one stage according to recent ASE / EACVI recommendations (DD_progress) showed a significantly reduced baseline LA reservoir strain (LASr) and conduit strain (LAScd) [LASr 28.1% (6.9) in DD_progress vs. 41.9% (8.5) in DD0 at follow up; and LAScd -13.2% (5.0) in DD_progress vs. -25.4% (9.1) in DD0 at follow up; p &lt; 0.001 respectively]. With an area under the curve (AUC) of 0.89 [95% confidence interval (CI) 0.83-0.94], and 0.85 (95% CI 0.80-0.90), LASr and LAScd showed the highest discriminative value to predict DD_progress while the echocardiographic standard DD parameter left atrial volume index (LAVI) featured a limited predictive diagnostic accuracy [AUC of 0.65 (95%CI 0.52-0.72)]. In a multivariate logistic regression model controlling for age, BMI, and other standard echocardiographic DD parameters including LAVI, only LASr and LAScd remained significantly associated with DD_progress over time. 

Conclusions

In addition to improving the diagnostic accuracy of the current DD algorithm, the analysis of phasic LAS reductions may be useful to predict the development of DD in previously healthy women.

Comparative analysis of phasic left atrial strain and left ventricular posterolateral strain to discriminate Fabry cardiomyopathy from other forms of left ventricular hypertrophy

Background

“Classic” echocardiographic signs of Fabry cardiomyopathy (FC), such as left ventricular hypertrophy (LVH) and posterolateral strain deficiency (PLSD) have a low diagnostic accuracy in clinical practice.

Purpose

Our aim was to evaluate the diagnostic accuracy of phasic left atrial strain impairment compared to PLSD to discriminate FC from other forms of LVH.

Methods

40 patients with LVH due to bioptically and genetically confirmed FC or with LVH due to other causes, defined by exclusion of storage diseases, such as Amyloidosis or FC, by myocardial biopsy, were retrospectively analysed. Standard echocardiographic views (Vivid E9, GE, Vingmed, Horton) were used to analyse left atrial (LA) reservoir, conduit, and contraction strain using 2D speckle tracking echocardiography (2DSTE; EchoPAC software, GE) as well as the PLSD, obtained by the mean of deformation values in basal posterior and lateral segments in a 17-segment model. Receiver operating characteristic (ROC) curve analysis and a logistic regression model were performed to assess the diagnostic accuracy of LA and LV strain impairment.

Results

FC was confirmed in 20 patients by genetic testing and myocardial biopsy. In the LVH group, 12 patients were classified to have hypertrophic cardiomyopathy, two had hypertensive heart disease, and six expressed the pattern of LV hypertrophy combined with borderline myocarditis. LV septum thickness (15.8mm±3.4 in FC; 17.9mm±4.3 in LVH) and left atrial volume index (LAVI) (36.7ml/m2±11.3 in FC; 45.7ml/m2±16.3 in LVH) as well as LVEF (54.2%± 9.8 in FC; 52.5%±7.7 in LVH,) were not statistically different between groups. LV filling parameters such as E/A (1.2±0.5 in FC; 1.2±0.7 in LVH) and E/e' (11.0±4.9 in FC; 13.2±5.3 in LVH) showed a slightly more advanced impairment in the LVH group.

Global and regional LV function was not different between groups (LVGLS −13.8±3.7% in FC and −12.8±3.7% in LVH; PLSD −10.7±5.2% in FC and −8.85±3.9% in LVH; p-value?). LA reservoir strain (LASr) and LA conduit strain (LAScd) were significantly impaired in FC compared to the LVH group (LASr 14,6±2.5% in FC and 26.3±8.5% in LVH, p&lt;0.01; LAScd −5.9±2.6% in FC and −15.8±4.7% in LVH, p&lt;0.01). In ROC analysis, LASr, with an area under the curve (AUC) of 0.81 (95% CI 0.64–0.97) and LAScd with an AUC of 0.85 (95% CI 0.71–0.99), respectively, showed the highest diagnostic accuracy to discriminate FC. PLSD, in contrast, held a low diagnostic accuracy with an AUC of only 0.47 (95% CI 0.27–0.68).

Conclusion

A substantially higher diagnostic accuracy could be shown for LASr and LAScd impairment in discriminating FD and other forms of LVH compared to PLSD. The echocardiographic assessment of phasic LA strain may help to identify FC in patients with unclear LVH.

Funding Acknowledgement

Type of funding sources: None. ROC analysisRepresentative examples

Effects of medical graphic narratives (patient comic) on Patient Reported Outcome Measures (PROMs) in patients undergoing coronary angiography and PCI

Background/Introduction

Increasing evidence suggests that patients scheduled for invasive cardiac procedures such as coronary angiography / PCI feel insufficiently informed about the planned procedure.

Purpose

To improve the Patient Informed Consent (IC) before coronary angiography by using “medical graphic narratives” (patient comic) that illustrate central IC-related aspects in a simple and understandable manner.

Methods

A patient comic illustrating central steps of the procedure, risks, treatment alternatives and behavioural measures was created in collaboration with professional scientific visual communicators. In a randomised, controlled, prospective trial, we included 121 patients undergoing coronary angiography/PCI. Patients were randomised to a group that was informed about the procedure using the usual Patient IC approach (official consent form and conversation with physician; Control group) or a group that additionally obtained a patient comic for reading (graphic illustrations of central IC aspects based on the official consent form; Comic group). Patient Reported Outcome Measures (PROMs), i.e. satisfaction with and perceived quality of the patient IC, were tested in both groups comparing single items of the Client Satisfaction Questionnaire-8 (CSQ-8) and self-designed single items in both IC groups. Differences were compared using the Fisher's exact test. A p-value &lt;0.05 was considered statistically significant.

Results

PROMs showed significant benefits in favour of the Comic group: Quality of the patient IC was perceived to be “very good” in 45.0% of the Comic group compared to 24.9% of patients in the Control group (p=0.023). Only 23.0% of the patients in the Control group, compared to 40.0% in the Comic group, stated that the IC procedure completely met their expectations (p=0.012). 57.4% in the Control group and 76.7% in the Comic group stated that all of their questions were satisfactorily adressed before the procedure (p=0.015). 43.3% in the Comic group, in contrast to 18.0% in the Control group, declared to feel “very satisfied” with the obtained IC procedure (p=0.002). The acceptance of the patient comic was very high: no patient (0%) expressed feelings of not being taken seriously by reading the patient comic.

Conclusions

Our data confirm pronounced limitations of the usual Patient IC practice before coronary angiography. The use of a patient comic that narratively illustrates central steps of the procedure positively impacts on patient-centered endpoints and significantly improves the patient IC procedure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Friede Springer Herz Stiftung

Long-term morphological appearance of transcatheter valves left in the ascending aorta after valve dislocation during transcatheter aortic valve implantation

Background

Transcatheter valve embolization and migration (TVEM) is a potential complication of transcatheter aortic valve implantation (TAVI) (1). Registries suggest low incidence but clinical relevance due to increased acute and mid-term mortality with the majority embolizing in the aorta. However, there is little data on potential late complications such as leaflet and stent thrombosis or aortic wall alterations by migrated valves.

Purpose

The aim of our study was to analyze the incidence and clinical characteristics of TVEM in a large single center cohort of TAVI patients and to examine dislocated valves by ECG-gated computed tomography (CT).

Methods and results

Between July 2009 and May 2020, 40 TVEM occurred in 3387 TAVI procedures performed in our center (1.18%). TVEM was defined according to Valve Academic Research Consortium-2 (VARC-2) criteria (3). Majority of TVEM were left in the ascending aorta (31 ascending, 3 arch, 1 descending aorta). 90% of TVEM occurred with a self-expanding valve (SEV), with no difference between older and newer valve generations, 10% with a ballon-expandable valve. Analyzing a TAVI sample cohort (n=200), horizontal aorta (p&lt;0.001, OR 11.7, 95% CI: [3.9:34.8]), defined as aortic angulation &gt;48°(4), as well as the use of SEV (p&lt;0.001, OR 12.8, 95% CI: [3.1:53.9]) were identified as a predisposing risk factor for TVEM. OR in SEV was severely increased when isolating the analysis for patients with horizontal aorta only (p=0.003, OR 23.75, 95% CI: [2.8:129]). No other predisposing risk factors were identified in this cohort. Out of 35 patients still alive, 6 patients were willing to participate in our imaging sub-study. CT exams were performed on average 47 months after TAVI (IQR 50 months [25%Q: 16.8, 75%Q: 72.8]). We detected no leaflet or stent thrombosis, yet CT identified pin protrusions in the aorta in 3 out of 6 patients.

Conclusions

TVEM is a rare complication of TAVI. TVEM was significantly associated to the use of self-expanding valves and the presence of horizontal aorta. CT did detect pin protrusions in several cases which could bear the possible risk of perforation but showed no signs of long-term damage.

Funding Acknowledgement

Type of funding sources: None. Representative CT images after TVEM

Increased expression of inactive rhomboid protein 2 in circulating monocytes after acute myocardial infarction

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft (DFG; Sachbeihilfe HE6092/2) DGK (Deutsche Gesellschaft für Kardiologie) Otto-Hess-Promotionsstipendium

Purpose

Tumor necrosis factor-alpha (TNF-α) levels in the blood increase in the course of an acute myocardial infarction (AMI) and TNF-α is involved in the impaired recovery of myocardial function following AMI. The interaction of inactive rhomboid protein 2 (iRhom2) with the TNF-α converting enzyme (TACE) is required for the proper shedding of TNF-α from the cell surface of immune cells. We hypothesized, that iRhom2 expression increases in circulating monocytes of patients following AMI. 

Methods

Circulating monocytes were MACS-sorted from peripheral blood of 50 patients with AMI (NSTEMI, n = 16; STEMI n = 34) at the day of admission (day 1) and 3 days after admission. 50 patients with chronic coronary syndrome (CCS) were recruited as control. mRNA was isolated from sorted monocytes and expression levels of iRhom2, TACE and TNF-α were evaluated by real-time RT-PCR. TNF-α protein levels were assessed in the serum. Levels of circulating classical, intermediate and non-classical monocyte subsets were determined by flow cytometry. 

Results

There was a significant increase of iRhom2 mRNA expression levels in monocytes (by 14%, p = 0.012), levels of circulating intermediate monocytes (p &lt; 0.001), and TNF-α serum levels (p &lt; 0.001) at day 3 following AMI compared to day 1 reaching levels similar to those observed in CCS patients. In contrast, TNF-α and TACE mRNA expression in circulating monocytes did not differ between day 1 and 3 following AMI. iRhom2 mRNA expression in monocytes on day 3 following AMI correlated with TACE mRNA expression in monocytes (r = 0.72, p &lt; 0.001), TNF-α serum levels (r = 0.33, p = 0.019), and levels of circulating intermediate monocytes (r = 0.37, p = 0.009).

Conclusions

Following AMI, iRhom2 expression in circulating monocytes increases in parallel to serum levels of TNF-α and levels of circulating intermediate monocytes. These findings suggest that iRhom2 contributes to inflammation following AMI and thus may serve as a potential therapeutic target.

Venous lactate predicts adverse outcomes in normotensive pulmonary embolism

Background/Introduction

Arterial lactate is an established risk marker in patients with acute pulmonary embolism (PE). However, its clinical application is limited by the need for an arterial puncture, a procedure not routinely performed in haemodynamically stable PE patients. In contrast, information on venous lactate can be easily obtained via peripheral venepuncture and might thus be more suitable for risk assessment in normotensive PE.

Purpose

To investigate the prognostic value of peripheral venous lactate for outcome prediction in normotensive patients with acute PE.

Methods

Consecutive normotensive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were studied. Study outcomes included in-hospital adverse outcome (PE-related death, cardiopulmonary resuscitation or vasopressor treatment) and all-cause mortality. An optimised venous lactate cut-off concentration was identified using receiver operating curve analysis and its prognostic value compared to the established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l). Furthermore, we tested if addition of venous lactate to the 2019 European Society of Cardiology (ESC) risk stratification algorithm improves risk prediction.

Results

We analysed data from 419 (age 70 [interquartile range (IQR) 57–79] years; 53% female) patients. Patients with an in-hospital adverse outcome had higher venous lactate concentrations than those with a favourable clinical course (3.1 [IQR 1.3–4.9] vs. 1.6 [IQR 1.2–2.3] mmol/l, p=0.001). An optimized cut-off value of 3.3 mmol/l predicted both, adverse outcome (OR 11.0 [95% CI 4.6–26.3]) and all-cause mortality (OR 3.8 [95% CI 1.3–11.3]). Venous lactate ≥2.0 mmol/l and ≥2.3 mmol/l had lower predictive value for an adverse outcome (OR 3.6 [95% CI 1.5–8.7] and OR 5.7 [95% CI 2.4–13.6], respectively) and did not predict all-cause mortality. If venous lactate was added to the 2019 ESC algorithm (Figure), a cut-off concentration of 2.3 mmol/l had high negative predictive value (0.99 [95% CI 0.97–1.00]) for an adverse outcome in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediate-high-risk group (OR 5.2 (95% CI 1.8–15.0).

Conclusions

Even modest venous lactate elevations above the upper limit of normal (2.3 mmol/l) were associated with increased risk for an in-hospital adverse outcome and a cut-off value of 3.3 mmol/l provided optimal prognostic performance predicting both, an adverse outcome and all-cause mortality. Adding venous lactate to the 2019 ESC algorithm seems to further improve risk stratification. Importantly, the established cut-off value for arterial lactate (2.0 mmol/l) has limited specificity in venous samples and should not be used.

Venous lactate for risk stratification

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503). The authors are responsible for the contents of this publication. BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany provided financial support for biomarker measurements. The sponsor was neither involved in biomarker measurements, statistical analyses, writing of the abstract nor had any influence on the scientific contents.

Impact of caval vein implantation on severity of tricuspid regurgitation, renal and hepatic function in patients with severe secondary tricuspid regurgitation

Background

Severe tricuspid regurgitation (TR) is an important determinant for functional capacity and survival. It frequently occurs in patients with advanced heart failure resulting in progressive venous congestion with cardiorenal and cardiohepatic syndrome. The prospective, randomized TRICAVAL study reported the effect of inferior caval vein implantation of an Edwards Sapien XT valve (CAVI) in comparison to optimal medical therapy (OMT) in patients with severe TR. The study did not detect a superior functional outcome after CAVI, but a significant improvement in quality of life. Due to safety concerns, the study was stopped prematurely after 4 periprocedural complications.

Purpose

We hypothesised that CAVI reduces reflux into the inferior vena cava and leads to an increase in systolic right atrial pressure, which may result in an improvement of TR severity. The present subanalysis of the TRICAVAL study evaluates the impact of inferior caval vein implantation on TR severity, right heart parameters and renal and hepatic function.

Methods

Twenty-eight patients with severe TR were randomized in either CAVI group (n=14) with caval vein implantation of an Edwards Sapien XT valve or OMT group (n=14). Medical history, clinical examination, laboratory testing and echocardiographic measurements were analysed in patients with completed FUP (OMT [n = 10], CAVI [n = 8]). Follow-up examinations were performed at baseline and three months after enrolment.

Results

After three months, the CAVI group exhibited a significant reduction of systolic hepatic vein reflux volume (5.0 [1.3–11.0] ml vs. 14.0 [10.3–18.0] ml, p&lt;0.05) and hepatic vein diameter (10.8 [10.0–12.0] mm vs. 14.0 [11.5–15.0] mm, p&lt;0.05) in comparison to OMT. Compared to baseline, CAVI improved body weight (80.7 [69.0–87.7] kg versus 75.5 [63.8–84.6] kg, p&lt;0.05) and abdominal circumference (101.5±13.8 cm versus 96.3±15.4 cm, p≤0.01) paralleled by a trend to lower doses of diuretics. However, over the FUP period, there were no significant changes regarding TR severity, right heart function and morphology as well as renal and hepatic function within both groups, nor in the comparison between CAVI and OMT.

Conclusion

As a proof of our concept, CAVI resulted in a decrease in systolic hepatic vein reflux, hepatic vein diameter and clinical signs of venous congestion. However, TR severity, right heart function and morphology as well as renal and hepatic function remained stable.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Edwards Lifesciences, Incorporated (Irvine, CA)

P1537 Myocardial work in patients with aortic stenosis before and short term after transcatheter aortic valve replacement

Objective

The newly introduced noninvasive myocardial work analysis could potentially be beneficial in predicting the best timing for aortic valve replacement as well as clinical outcomes in patients with high grade aortic valve stenosis (AS), which is the leading valvular disease in the modern aging society. However, to date there is little data on the applicability of the method in the setting of extremely increased left ventricular (LV) afterload.

Purpose

In this pilot study, we aimed to apply myocardial work analysis in patients with increased LV afterload due to severe AS and to investigate the differences of myocardial work parameters in patients with different AS entities. In addition, we analyzed the early changes of myocardial work after the afterload reduction by transcatheter aortic valve replacement (TAVR).

Methods

We retrospectively studied echocardiographic data of 28 consecutive patients with severe AS before and 7 days after TAVR. Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE) were calculated using commercially available software based on noninvasive pressure-strain loops. In order to correct for underestimation of intraventricular pressure, we added the mean aortic valve pressure gradient to the peripheral systolic blood pressure used by the software.

Results

From the included patients (mean age 76 ± 10 years) 13 were classified as having normal flow (NF) severe AS, 8 had low flow low gradient (LFLG) and 7 paradoxical low flow low gradient (PLFLG) AS. GWI and GCW were significantly lower in patients with LFLG AS compared to patients with NF or PLFLG AS (936 ± 528 mmHg% vs. 2493 ± 485 mmHg% vs. 1959 ± 469 mmHg% [p &lt; 0.005] and 1132 ± 477 mmHg% vs. 2770 ± 507 mmHg% vs. 2189 ± 603 mmHg%, [p &lt; 0.005], respectively). 7 days after TAVR, GCW and GWI decreased significantly in patients with NF AS. In other AS entities, a trend towards increased GWI and GCW was observed, but the difference did not reach statistical significance. GWI and GCW remained significantly lower in LFLG AS group when compared to NF and PLFLG groups (1069 ± 378 mmHg% vs. 1919 ± 310 mmHg% vs. 2064 ± 842 mmHg% [p &lt; 0.005] and 1286 ± 346 mmHg% vs. 2107 ± 258 mmHg% vs. 2227 ± 949 mmHg% [p &lt; 0.005]) early after TAVR. GWE and GWW did not differ between the groups and were not influenced by TAVR.

Conclusion

In this pilot study we applied the adapted myocardial work analysis in patients with increased afterload due to severe AS. We have shown that GCW and GWI are significantly higher in patients with NF AS when compared to LFLG and PLFLG AS. The differences between the groups persisted early after TAVR in spite of significant reduction of GWI and GWC in patients with NF AS. The clinical and prognostic importance of these findings are still to be investigated in a bigger cohort study.

1038 Comparative assessment of phasic left atrial and regional left ventricular strain in patients with cardiac amyloidosis and LV hypertrophy

Background

Echocardiographic hallmarks of cardiac amyloidosis (CA), such as increased wall thickness of the LV and sparkling appearance of the myocardium, are limited by a reduced diagnostic accuracy.

Purpose

We sought to evaluate the diagnostic value of phasic left atrial strain alterations and of regional global longitudinal systolic LV strain (LVGLS) reductions in patients with CA and with other forms of LV hypertrophy.

Methods

Standard apical 4-chamber views were stored for offline analysis (Vivid E9, GE, Vingmed, Horton) in 54 patients who underwent endomyocardial biopsy for unclear LV hypertrophy. We then analyzed LVGLS as well as LA reservoir, conduit, and contraction strain using 2D speckle tracking echocardiography (2DSTE; EchoPAC software, GE). To assess regional LVGLS, the average of apical strain values / (average of mid + basal LV strain values) was calculated (relative apical sparing; RELAPS). Receiver operating characteristic (ROC) curve analyses and a multivariate logistic regression analysis were performed to investigate the diagnostic value of the respective LA and LV deformation analysis.

Results

CA was bioptically confirmed in 34 patients (13 TTR, 1 AA, 20 AL amyloidosis). In 18 patients, myocardial biopsy revealed other forms of LV hypertrophy, such as hypertensive heart disease (n = 2), hypertrophic cardiomyopathy (n = 12), and inflammatory myocardial diseases (n = 4). Mean septal wall thickness (17.7 ± 2.9 mm and 17.9 ± 4.3 mm) and left atrial volume index (43.8 ± 12.2 and 44.1 ± 17.2) were not different between groups. RELAPS was significantly higher in patients with CA (1.37 ± 0.94 vs. 0.86 ± 0.29, p&lt;.007). Phasic atrial mechanics were significantly worse in CA (LA reservoir, conduit, and contraction strain 10.0 ± 5.2%, -6.5 ± 3.5%, and -5.0 ± 4.1%, respectively, in CA; and 22.7 ± 7.8%, -13.9 ± 5.2%, and -13.0 ± 5.5%, in LVH, respectively; p&lt;.001). With an area under the curve (AUC) of 0.91, and a sensitivity and specificity of 91.2 and 84.2% for a cut-off value of &lt;15.8%, LA reservoir strain showed a higher diagnostic accuracy in discriminating CA from LVH than the parameter RELPAS (AUC 0.74, sensitivity and specificity 60% and 71% for a cut-off of &gt;1.0; p&lt;.05). LA conduit and contraction strain performed significantly better than RELAPS as well (AUC 0.87 for conduit, and AUC 0.86 for contraction function; p&lt;.001 each). Of all echocardiographic parameters, LA reservoir strain remained significantly associated with CA in a multivariate regression model.

Conclusions

LA strain during all three phases of the atrial cycle was significantly reduced in patients with CA compared to other forms of LVH, and showed a markedly higher diagnostic accuracy than regional LV strain analysis, with LA reservoir strain showing highest discriminative value. The assessment of LA strain, as part of a comprehensive echocardiographic assessment, may be useful to rule-in the possible diagnosis of CA in patients with unclear LV hypertrophy.

P4379Pathophysiology of left atrial filling in mitral regurgitation. A new volumetric flow rate index describing disturbed left atrial filling behavior in mitral regurgitation by 3D TTE

Background

In chronic mitral regurgitation (MR) the left atrium (LA) is one of the first cardiac structures involved in remodeling by progressive volume overload. Real-time three-dimensional echocardiography is able to monitor volumetric changes of the left atrium during the heart cycle.

Purpose

We hypothesized that chronic volume overload due to MR leads to detectable changes in the LA filling behavior described by mean and maximum filling flow rates and their relation called volumetric flow rate index.

Methods

We prospectively analyzed data of 36 patients in different stages of chronic MR and 13 patients without MR. Transthoracic echocardiography was conducted using the Epiq 7G Ultrasound System. Standard 2D- and 3D apical 4-chamber views were recorded and stored for offline analysis. We generated volume-time-curves by 3D volume analysis to derive mean and maximum volumetric flow rates during LA reservoir, conduit and pump phase. Volumetric flow rate index was calculated as the quotient of mean flow rate/maximum flow rate.

Results

Average MR severity, calculated with the MR Scoring system introduced from Buck et al. and implicated in the ESC Guidelines, was 6.2 points (±2.5) according to Grade I-II. We included 13 patients without MR, 18 with mild MR, 12 patients with moderate MR, 6 patients with severe MR. Left ventricular ejection fraction was similar in the different groups (51,2±12,3%). Maximum and mean flow rate showed no significant correlation with MR severity. Correlation of MR severity with LA dilation (ml/m2 BSA) was r=0.41; p<0.001. Flow rate index showed strong significant correlation with MR severity in left atrial reservoir phase (r=−0.75; p<0.001). There was no statistically relevant difference of volumetric flow rate parameters in left atrial pump and conduit phase.

Line chart

Conclusions

We observed a significant correlation of the volumetric flow rate index to MR severity in the left atrial reservoir phase with stronger correlation than MR severity to left atrial dilation. The results of this work encourage further investigations to establish the presented volumetric flow rate index as a progression marker of MR and to evaluate its prognostic value.

P727Metabolic and functional differences between male and female endothelial cells from umbilical cords (HUVEC) of twin pairs

Background

Personalised Medicine is one of the hallmarks of future medicine. Sex and gender differences exist in the incidence, clinical manifestation and outcome of cardiovascular diseases. Gonadal hormones are thought to account for most of these sex differences. However, besides hormones, sexual dimorphisms at the cellular level may also contribute to physiological and pathophysiological cardiovascular differences between women and men.

Purpose

To analyse intrinsic sex differences at the cellular level, we aimed to elucidate sex-specific differences in endothelial cell migration and energy metabolism under pro-migratory conditions in male and female HUVECs. To reduce biological variability, we used HUVECS obtained from umbilical cords from twin pairs of the opposite sex. These cells are exposed in utero to the same maternal environment, and therefore represent a valuable tool to study intrinsic sex-specific differences at the cellular level.

Methods

Vascular endothelial growth factor (VEGF)-stimulated migration was determined with IBIDI migration chambers. Sex-specific levels of proteins were studied using proteome profiling. Cellular metabolism was measured by Seahorse and levels of intracellular metabolites were analysed using GC-MS based technology.

Results

Female cells showed significantly higher VEGF-induced cell migration than male HUVECs. Proteomic profiling revealed a sex-specific response to VEGF treatment. Mitochondrial respiration rate was higher in VEGF-stimulated male HUVECs compared to female cells. Whereas mean glycolytic rates did not significantly differ between sexes, the ratio of glycolysis/mitochondrial respiration after VEGF stimulation was higher in female than in male HUVECs. Female cells had higher intracellular ATP levels after serum starvation and treatment with VEGF. Under both conditions, female cells showed altered levels of metabolite pools compared to male HUVECs.

Conclusions

Higher intracellular ATP and metabolite levels in female cells after serum starvation and VEGF may contribute to the observed functional sexual dimorphisms, and may also point to an increased stress tolerance of female cells. The results of our study provide a strong argument to discriminate between male and female cells in in vitro experiments.

Acknowledgement/Funding

The work was supported by the DZHK (German Centre for Cardiovascular Research) and by the BMBF (German Ministry of Education and Research).

1439PRAS40 attenuates mTOR-dependent endothelial inflammation and atherosclerosis

Introduction

Endothelial inflammation plays a pivotal role in atherosclerosis. Many inflammatory and metabolic signals converge upon mechanistic target of rapamycin (mTOR), and inhibition of mTOR has been shown to reduce atherosclerosis. However, clinical use of mTOR-inhibitors is limited by serious adverse effects, of which insulin resistance and dyslipidemia are particularly troubling in the context of atherosclerosis. In that respect, targeting PRAS40, an endogenous modulator of mTOR complex 1 (mTORC1) with highly cell type-specific effects on mTOR signaling, may be a more promising approach. In fact, we have previously demonstrated that, in contrast to conventional mTOR inhibitors, PRAS40 gene therapy substantially improves metabolic profile in obese mice. However, the function of PRAS40 in endothelial cells and its role in atherosclerosis have never been investigated.

Methods and results

To define the impact of PRAS40 on endothelial mTORC1-signaling in this context, cultured human umbilical vein endothelial cells (HUVECs) were exposed to the atherogenic cytokine TNFα. TNFα induced mTOR signaling as evidenced by increased phosphorylation of S6 kinase and ribosomal S6 protein. Interestingly, this effect was strongly augmented upon siRNA-mediated knock-down of PRAS40, indicating a negative regulation of mTORC1 by PRAS40 in endothelial cells. Moreover, PRAS40-knockdown promoted TNFα-induced inflammatory signaling as reflected by increased proliferative activity, upregulation of atherogenic markers like CCL2 and VCAM-1, as well as enhanced monocyte recruitment in the THP-1 adhesion assay. In contrast, PRAS40-overexpression blocked TNFα-induced activation of mTORC1 and consistently suppressed all of these measures of inflammatory activation. All effects of PRAS40-overexpression could be reproduced by the mTORC1 inhibitors rapamycin and torin1. Thus, our in vitro studies suggest that in endothelial cells PRAS40 exerts anti-atherogenic effects by negative regulation of mTORC1. To validate these findings in vivo in the context of atherosclerosis we created transgenic mice with tamoxifen-inducible endothelium-specific PRAS40-deficiency (EC-PRAS40-KO). These mice were exposed to a model of accelerated atherosclerosis based on western diet and partial carotid ligation: Four weeks after partial carotid ligation, neointimal and atherosclerotic lesion formation was strongly enhanced in EC-PRAS40-KO mice. Moreover, mTORC1 activity as well as CCL2 and VCAM-1 expression were markedly increased compared to control mice.

Conclusion

Our data indicate that PRAS40 suppresses atherosclerosis via inhibition of mTORC1-mediated inflammatory signaling in endothelial cells. In conjunction with its favourable effects on metabolic homeostasis, the overall therapeutic profile of PRAS40-treatment appears to be beneficial compared to conventional mTOR-inhibitors. Taken together PRAS40 may qualify as a promising therapeutic target for the treatment of atherosclerosis.

Acknowledgement/Funding

German Federal Ministry of Education and Research, DZHK (German Centre for Cardiovascular Research)

5894The biased angiotensin receptor 1-ligand TRV023 attenuates atherosclerosis through selective inhibition of Gq-mediated signaling

Introduction

Antagonists of the angiotensin II receptor type 1 (AT1) belong to the most successful treatments of cardiovascular disease. Besides G-protein-independent β-arrestin-mediated signaling, AT1 preferencially signals via G-proteins of the families Gq and G13. Conventional AT1-antagonists equally inhibit all of these pathways, even though the beneficial effects are generally attributed to the inhibition of Gq only. While data on β-arrestin signaling in the vascular disease context are conflicting, we found an excessive pathological remodeling and dramatic exacerbation of atherosclerosis upon interference with G13-mediated signaling. Against this background, selective inhibition of the Gq-pathway seems desirable. Thus, based on the novel concept of ligand-biased signaling, we aimed to identify biased AT1-antagonists that selectively inhibit the Gq-pathway, while allowing for continued signaling through G13.

Methods and results

We systematically profiled known AT1-ligands and identified the angiotensin analogue Sar-Arg-Val-Tyr-Lys-His-Pro-Ala-OH (TRV023) as a Gq-selective AT1-antagonist: TRV023 has recently been described as a β-arrestin-biased ligand; however its signaling properties regarding distinct G-protein isoforms have never been defined. Indeed, using bioluminescence reporter assays, we found that TRV023 inhibits Gq-signaling at least as potently as losartan and telmisartan, but unlike the conventional antagonists, it does not impair β-arrestin-signaling (Fig. 1A). Intriguingly, while the conventional antagonists effectively inhibited induction of a G13 luciferase reporter, TRV023 did not significantly interfere with G13-mediated signaling, indicating Gq-selective antagonistic effects. According to our hypothesis, these G-protein-biased signaling properties could render TRV023 superior to conventional antagonists in the treatment of vascular disease. In order to test this hypothesis, we exposed ApoE-deficient mice to one of two different atherosclerosis models: A novel model for accelerated atherosclosis based on partial carotid ligation and western diet, or a conventional atherosclerosis model based on 12 weeks of western diet. Using osmotic pumps, mice were continuously treated with vehicle control, TRV023 or losartan in doses that proved equipotent with respect to blood pressure lowering effects. In line with our hypothesis, TRV023 but not losartan significantly attenuated plaque development in both atherosclerosis models (Fig. 1B).

Figure 1

Conclusion

Our studies have identified TRV023 as a Gq-biased AT1-antagonist and indicate that selective inhibition of AT1-dependent Gq-mediated signaling by biased ligands may be a promising approach for the treatment of atherosclerosis. Hence, TRV023 qualifies as a drug candidate, particularly since it has already proven to be safe and well-tolerable in clinical phase I and II trials in the context of acute heart failure.

Acknowledgement/Funding

Else Kröner-Fresenius-Foundation

RAGE-dependent regulation of calcium-binding proteins S100A8 and S100A9 in human THP-1

Proinflammatory cell activation via the receptor for advanced glycation end products (RAGE) pathway may play a central pathogenetic role in atherosclerosis. Since S100A8/A9 was recently identified as ligand of RAGE, we determined the effects of proinflammatory cytokines on RAGE-mediated induction of gene expression of S100A8 and S100A9. mRNA levels of S100A8 and S100A9 were upregulated following cytokine stimulation with IL-6 (1, 10, 100 ng/ml) or TNFα (10 ng/ml) in human THP-1 cells. Preincubation of cells with 2000 ng/ml AGE (advanced glycation end products) before cytokine stimulation resulted in upregulation of RAGE. Pretreatment of THP-1 with AGE followed by stimulation with IL-6 (10 ng/ml) or TNFα (10 ng/ml) further increased S100A8 and S100A9 mRNA expression and S100A8/A9 release into cell culture supernatant, as compared to pretreatment with non-glycated albumin as control. Binding of AGE to RAGE was blocked with a neutralizing anti-RAGE antibody. Normal mouse IgG served as control. Cytokine-stimulated induction of S100A8 and S100A9 mRNA levels as well as of S100A8/A9 release after preincubation of cells with AGE were significantly suppressed by RAGE blockade, indicating a RAGE-dependent pathway of AGE-mediated S100A8/A9 expression.The cytokine-induced potentiated S100A8 and S100A9 expression under conditions with a high AGE burden is able to aggravate proinflammatory conditions via activation of the RAGE pathway.