Improvement of aortic valve stenosis by ApoA-I mimetic therapy is associated with decreased aortic root and valve remodelling in mice

BACKGROUND AND PURPOSE

We have shown that infusions of apolipoprotein A-I (ApoA-I) mimetic peptide induced regression of aortic valve stenosis (AVS) in rabbits. This study aimed at determining the effects of ApoA-I mimetic therapy in mice with calcific or fibrotic AVS.

EXPERIMENTAL APPROACH

Apolipoprotein E-deficient (ApoE(-/-) ) mice and mice with Werner progeria gene deletion (Wrn(Δhel/Δhel) ) received high-fat diets for 20 weeks. After developing AVS, mice were randomized to receive saline (placebo group) or ApoA-I mimetic peptide infusions (ApoA-I treated groups, 100 mg·kg(-1) for ApoE(-/-) mice; 50 mg·kg(-1) for Wrn mice), three times per week for 4 weeks. We evaluated effects on AVS using serial echocardiograms and valve histology.

KEY RESULTS

Aortic valve area (AVA) increased in both ApoE(-/-) and Wrn mice treated with the ApoA-I mimetic compared with placebo. Maximal sinus wall thickness was lower in ApoA-I treated ApoE(-/-) mice. The type I/III collagen ratio was lower in the sinus wall of ApoA-I treated ApoE(-/-) mice compared with placebo. Total collagen content was reduced in aortic valves of ApoA-I treated Wrn mice. Our 3D computer model and numerical simulations confirmed that the reduction in aortic root wall thickness resulted in improved AVA.

CONCLUSIONS AND IMPLICATIONS

ApoA-I mimetic treatment reduced AVS by decreasing remodelling and fibrosis of the aortic root and valve in mice.

The effect of aortic wall and aortic leaflet stiffening on coronary hemodynamic: a fluid-structure interaction study

Pathologies of the aortic valve such as aortic sclerosis are thought to impact coronary blood flow. Recent clinical investigations have observed simultaneous structural and hemodynamic variations in the aortic valve and coronary arteries due to regional pathologies of the aortic valve. The goal of the present study is to elucidate this observed and yet unexplained phenomenon, in which a local pathology in the aortic valve region could potentially lead to the initiation or progression of coronary artery disease. Results revealed a considerable impact on the coronary flow, velocity profile, and consequently shear stress due to an increase in the aortic wall or aortic leaflet stiffness and thickness which concur with clinical observations. The cutoff value of 0.75 for fractional flow reserve was reached when the values of leaflet thickness and aortic wall stiffness were approximately twice and three times their normal value, respectively. Variations observed in coronary velocity profiles as well as wall shear stress suggest a possible link for the initiation of coronary artery disease.

A three-layer model for buckling of a human aortic segment under specific flow-pressure conditions

Human aortas are subjected to large mechanical stresses because of blood flow pressurization and through contact with the surrounding tissue. It is essential that the aorta does not lose stability by buckling with deformation of the cross-section (shell-like buckling) (i) for its proper functioning to ensure blood flow and (ii) to avoid high stresses in the aortic wall. A numerical bifurcation analysis employs a refined reduced-order model to investigate the stability of a straight aorta segment conveying blood flow. The structural model assumes a nonlinear cylindrical orthotropic laminated composite shell composed of three layers representing the tunica intima, media and adventitia. Residual stresses because of pressurization are evaluated and included in the model. The fluid is formulated using a hybrid model that contains the unsteady effects obtained from linear potential flow theory and the steady viscous effects obtained from the time-averaged Navier-Stokes equations. The aortic segment loses stability by divergence with deformation of the cross-section at a critical flow velocity for a given static pressure, exhibiting a strong subcritical behaviour with partial or total collapse of the inner wall. Preliminary results suggest directions for further study in relation to the appearance and growth of dissection in the aorta.

Deformable Mock Stenotic Artery With a Lipid Pool

The comparison, evaluation, and optimization of new techniques, models, or algorithms often require the use of realistic deformable test phantoms. The purpose of this paper is to present a multilayer deformable test specimen mimicking an atherosclerotic coronary artery, suitable for mechanical testing and intravascular imaging. Mock arteries were constructed in three phases using two molds: building a first layer of polyvinyl alcohol (PVA) cryogel, adding a lipid pool and building a second layer of PVA cryogel. To illustrate the deformation of the mock arteries, one has been placed in a custom-made bath, axially stretched then inflated while acquiring intravascular ultrasound (IVUS) images. The resulting specimen presents a progressing lumen narrowing of 25% in cross-sectional area at the peak and a lipid pool. The average inner gel layer is about 0.4 mm thick and the outer about 0.6 mm. The dimensions are of the same order as clinical observations, the first gel layer mimicking the intima-media and the second layer the adventitia. In the sequence of IVUS images, the different components of the mock artery are visible and differentiable. The variation in diameter of the segmented contours is presented for a specific specimen subjected to intraluminal pressure. This double-layer stenotic mock artery is approximately the size of a human coronary artery, has a lipid inclusion, can withstand relative large deformation, suitable for (intravascular) ultrasound imaging, and has customizable geometry and wall material parameters.

Large-displacement 3D structural analysis of an aortic valve model with nonlinear material properties

Grafts used in aortic valve-sparing procedures should ideally not only reproduce the geometry of the natural aortic root but also its material properties. Indeed, a number of studies using the finite element method have shown the importance of the natural sinus shape of the root in the functioning of the normal aortic valve, and the relative increase in stresses due to the replacement of the valve by a stiffer synthetic graft. Because of the wide range in experimentally measured values of aortic wall and leaflet material properties, studies by different research groups have incorporated very different material properties in their models. The aim of the present study was to investigate the influence of material properties on aortic wall displacements, and to determine which material properties would most closely match reported experimental data. Two geometrically accurate 3D models corresponding to the closed and open valve configurations were created in Pro/Engineer CAD software. Loads corresponding to systolic and diastolic pressures were specified and large-displacement structural analyses were carried out using the ANSYS package. Results have indicated that the closest match to experiments using isotropic material properties occurred for a Young's modulus of about 2000 KPa. Nonlinear models based on experimental stress-strain curves have shown similar displacements, but altered strain distribution patterns and significantly lower stresses. These results suggest that an accurate comparison of potential new graft models would have to be made with natural aortic valve models incorporating nonlinear material behavior.

A Method for Matching the Refractive Index and Kinematic Viscosity of a Blood Analog for Flow Visualization in Hydraulic Cardiovascular Models

In this work, we propose a simple method to simultaneously match the refractive index and kinematic viscosity of a circulating blood analog in hydraulic models for optical flow measurement techniques (PIV, PMFV, LDA, and LIF). The method is based on the determination of the volumetric proportions and temperature at which two transparent miscible liquids should be mixed to reproduce the targeted fluid characteristics. The temperature dependence models are a linear relation for the refractive index and an Arrhenius relation for the dynamic viscosity of each liquid. Then the dynamic viscosity of the mixture is represented with a Grunberg-Nissan model of type 1. Experimental tests for acrylic and blood viscosity were found to be in very good agreement with the targeted values (measured refractive index of 1.486 and kinematic viscosity of 3.454 milli-m2/s with targeted values of 1.47 and 3.300 milli-m2/s).

A novel realistic three-layer phantom for intravascular ultrasound imaging

Intravascular ultrasound (IVUS) is an imaging modality that experienced a tremendous development over the last 20 years. Phantoms for IVUS are rare and poorly documented. The aim of this paper is to propose an original IVUS phantom that has geometries and specular textures closer to those of coronary arteries than conventional tube-like phantoms. The proposed phantom has a three-layer aspect, reproducing the intima, media and adventitia that compose the arterial wall. It is made of an agar-based compound, with water, glycerol and cellulose particles. Fourteen phantoms were quantified using IVUS. Six phantoms were evaluated by both photomacroscopy and IVUS. There was an excellent correlation between phantom dimensions evaluated by photomacroscopy and the nominal values (mold dimensions). The IVUS quantification of the phantom was closely correlated to the measurements obtained by photomacroscopy. These results demonstrate that a multilayer phantom, with known and reproducible dimensions and with realistic geometric and echographic properties has been developed.

Reliability of mechanical and phased-array designs for serial intravascular ultrasound examinations--animal and clinical studies in stented and non-stented coronary arteries

BACKGROUND

Both mechanical and multi-element intravascular ultrasound designs have potential advantages and limitations that may impact on their value for clinical and research purposes. Determination of the reproducibility of measurements is critical before a given system can be used in studies such as regression of atherosclerosis trials.

METHODS

We performed serial intravascular ultrasound imaging with catheters using mechanical and phased-array designs in stented and non-stented coronary arteries in dogs and in patients.

RESULTS

Both systems correlated well for areas (r > or = 0.90, p < 0.0001) and diameters (r > or = 0.84. p < 0.0001) in dogs and in patients. There was a slight difference between multi-element and mechanical designs for measurements of area (mean difference in dogs and in patients: -0.24 and 0.96 mm2, p < 0.055) and diameter (-0.08 and 0.16 mm, p < 0.0001). The reproducibility of the multi-element system for reanalysis of the same frames and for analysis of serial pullbacks was similar to the same measurements with the mechanical system (r > or = 0.96 for all measurements). The differences in absolute and relative variability between the mechanical and phased-array designs, both for reanalysis of same frames and serial pullbacks, were very small.

CONCLUSIONS

Although multi-element and mechanical intravascular ultrasound designs are not strictly interchangeable, their similar reproducibility and the small differences in measurements demonstrate that both designs are acceptable alternatives for trials of regression of atherosclerosis. Determination of the variability for serial pullbacks of both designs was also important to assess the statistical power of such trials.

In vitro response of human and porcine vascular cells exposed to high dose-rate gamma-irradiation

AIM

The objective of this study was to compare the in vitro response of human and pig endothelial cells, smooth muscle cells and fibroblasts exposed to conventional high dose-rate gamma-irradiation.

MATERIALS AND METHODS

Clonogenic cell survival and growth responses were obtained after irradiation of plateau-phase cells with a 60Co source at a dose-rate of 1.5 Gy/min. DNA single-strand breaks were also evaluated using an alkaline filter elution technique.

RESULTS

Overall, both the pig and human cell lines showed a similar response to conventional high dose-rate irradiation. Using clonogenic assays, the human aortic smooth muscle cell line was more sensitive than the fibroblast and endothelial cell lines, whereas the pig endothelial cell line was more sensitive than smooth muscle cells and fibroblasts. Shortly after irradiation (10 days) there was a temporary growth arrest, which was similar for endothelial, smooth muscle cells and fibroblasts with doses above 6 Gy. There was also a non-linear, dose-dependent growth delay up to 4 weeks after irradiation. This effect was also consistent between the different cell lines. Using alkaline filter elution, there was no significant difference in relative elution between endothelial cells, smooth muscle cells and fibroblasts, indicating similar DNA damage among the different cell lines.

CONCLUSION

The in vitro response of human and pig endothelial cells, smooth muscle cells and fibroblasts exposed to high dose-rate irradiation appeared similar. The pig model seems well suited to evaluate the short- and long-term effects of ionizing radiation in the prevention of restenosis after vessel injury.

Effects of low-dose-rate beta-irradiation on vascular smooth muscle cells: comparison with high-dose-rate exposure

PURPOSE

Radiation therapy is undergoing extensive preclinical and clinical testing as a new tool to reduce restenosis after vessel injury. To date, however, no definite dose threshold has been identified after radioactive stent implantation. In this study, we compared the in vitro response of pig vascular smooth muscle cells (SMC) to conventional high-dose-rate (HDR) irradiation with the response to continuous low-dose rate (LDR) that could result from exposure to a radioactive stent.

MATERIALS AND METHODS

Catheter-based radiotherapy delivers single doses at HDR whereas radioactive stents use a continuous LDR approach. Single doses in excess of 10 Gy have clearly shown a reduction in neointima formation and negative vessel remodeling in several animal models. Because dose rate is an important parameter modulating the overall biological response to ionizing radiation, we have compared the in vitro response of pig aortic SMC at conventional HDR (1.5 Gy/min) and at LDR (0.675 Gy/h).

RESULTS

SMC showed significant repair of sublethal DNA damage and about twice the dose was necessary at the LDR to produce the same effect as that seen at the HDR.

CONCLUSION

In vitro SMC exhibit a significant dose-rate effect that indicates that radioactive stents could deliver the dose at a sufficiently high dose rate to compensate for cell proliferation while at the same time the total dose should be increased to account for sublethal damage repair. This finding has important implications for the design of a radioactive stent.

Study of catheter designs and drug mixing processes using 2D steady numerical simulations

The effectiveness of substance delivery through catheters is an important issue in interventional radiology, especially for infusion therapies where the pharmacokinetic advantage of local intra-arterial drug administration has been firmly established. In principle, the procedure is used to provide appropriate local concentrations while maintaining low systemic values so as to minimise the global effect and toxicity of the intervention. However, poor drug mixing may produce excessive local concentrations potentially damaging for the surrounding tissues and may lead to unsuccessful therapies. These phenomena have been observed in the infusion therapies of liver cancers through the hepatic artery and with brain tumour therapies through the carotid artery. Many aspects of the drug delivery methodology have been explored in order to determine the infusion conditions that would provide optimal mixing: the catheter tip design is considered one of the most important characteristics to be investigated for this purpose. Interestingly, it turns out that angiographic procedures could also benefit from this, because better mixing properties are associated with designs that provide potentially less harmful flow conditions such as jets, whipping and recoil of the catheter on the vascular wall. A 2D steady numerical model is proposed, to simulate the main physical processes occurring during catheter substance infusion: blood dynamics is taken into account with the Navier-Stokes equations and substance dispersion by the flowing blood with the advection-diffusion equation. The model is used to evaluate mixing properties of certain catheter designs in different flow conditions. In particular, two types of side hole catheter are compared in the context of water bath injection and in the context of vessel injection. The simulations suggest that the improved mixing reported with water bath experiments would not be maintained in the clinical context of arterial circulation.

Biocompatibility aspects of new stent technology

Stent implantation represents a major step forward since the introduction of coronary angioplasty. As indications continue to expand, better understanding of the early and late biocompatibility issues appears critical. Persisting challenges to the use of intracoronary stents include the prevention of early thrombus formation and late neointima development. Different metals and designs have been evaluated in animal models and subsequently in patients. Polymer coatings have been proposed to improve the biocompatibility of metallic stents or to serve as matrix for drug delivery and they are currently undergoing clinical studies. The promises of a biodegradable stent have not yet been fulfilled although encouraging results have recently been reported. Continuous low dose-rate brachytherapy combining the scaffolding effect of the stent with localized radiation therapy has witnessed the development and early clinical testing of radioactive stents. The combined efforts of basic scientists and clinicians will undoubtedly contribute to the improvement of stent biocompatibility in the future.

Development of coronary aneurysm after cutting balloon angioplasty: assessment by intracoronary ultrasound

We report the case of a coronary aneurysm observed 6 mo after cutting balloon angioplasty complicated by a mild perforation. Intravascular ultrasound allowed characterization of the malformation as a true aneurysm. The clinical course was uneventful.

[Use of ionizing radiation to prevent restenosis in interventional cardiology]

Recently, the use of ionizing radiations has received much interest as a new treatment tool to reduce restenosis after angioplasty or stent implantation. There are two main approaches for delivering endovascular radiation: one is based on gamma or beta sources with very high activities to deliver locally through a catheter the dose in a limited period of time. The other approach is based on a stent rendered radioactive for long exposure and continuous low-dose rate treatment. External radiation is also contemplated but indications seem more oriented towards the peripheral vascular system. After a brief introduction to fundamentals of radiobiology, radiation physics and radioprotection, we review the experimental data which have led to large ongoing multicenter trials. The results of these trials involving more than 2000 patients will be available in the next few years and will allow to better define the risk/benefit ratio of this potentially new indication for radiotherapy.

Simultaneous determination of aortic valve area by the Gorlin formula and by transesophageal echocardiography under different transvalvular flow conditions. Evidence that anatomic aortic valve area does not change with variations in flow in aortic stenosis

OBJECTIVES

The purpose of this study was to determine the impact of changes in flow on aortic valve area (AVA) as measured by the Gorlin formula and transesophageal echocardiographic (TEE) planimetry.

BACKGROUND

The meaning of flow-related changes in AVA calculations using the Gorlin formula in patients with aortic stenosis remains controversial. It has been suggested that flow dependence of the calculated area could be due to a true widening of the orifice as flow increases or to a disproportionate flow dependence of the formula itself. Alternatively, anatomic AVA can be measured by direct planimetry of the valve orifice with TEE.

METHODS

Simultaneous measurement of the planimetered and Gorlin valve area was performed intraoperatively under different hemodynamic conditions in 11 patients. Left ventricular and ascending aortic pressures were measured simultaneously after transventricular and aortic punctures. Changes in flow were induced by dobutamine infusion. Using multiplane TEE, AVA was planimetered at the level of the leaflet tips in the short-axis view.

RESULTS

Overall, cardiac output, stroke volume and transvalvular volume flow rate ranged from 2.5 to 7.3 liters/min, from 43 to 86 ml and from 102 to 306 ml/min, respectively. During dobutamine infusion, cardiac-output increased by 42% and mean aortic valve gradient by 54%. When minimal flow was compared with maximal flow, the Gorlin area varied from (mean +/- SD) 0.44 +/- 0.12 to 0.60 +/- 0.14 cm2 (p < 0.005). The mean change in Gorlin area under different flow rates was 36 +/- 32%. Despite these changes, there was no significant change in the planimetered area when minimal flow was compared with maximal flow. The mean difference in planimetered area under different flow rates was 0.002 +/- 0.01 cm2 (p = 0.86).

CONCLUSIONS

By simultaneous determination of Gorlin formula and TEE planimetry valve areas, we showed that acute changes in transvalvular volume flow substantially altered valve area calculated by the Gorlin formula but did not result in significant alterations of the anatomic valve area in aortic stenosis. These results suggest that the flow-related variation in the Gorlin AVA is due to a disproportionate flow dependence of the formula itself and not a true change in valve area.