Loss of ceramide synthase 5 inhibits the development of experimentally induced aortic valve stenosis

AIM

Inflammation and calcification are hallmarks in the development of aortic valve stenosis (AVS). Ceramides mediate inflammation and calcification in the vascular tissue. The highly abundant d18:1,16:0 ceramide (C16) has been linked to increased cardiovascular mortality and obesity. In this study, we investigate the role of ceramide synthase 5 (CerS5), a critical enzyme for C16 ceramide synthesis, in the development of AVS, particularly in conjunction with a high-fat/high-cholesterol diet (Western diet, WD).

METHODS

We used wild-type (WT) and CerS5-/- mice on WD or normal chow in a wire injury model. We measured the peak velocity to determine AVS development and performed histological analysis of the aortic valve area, immune cell infiltration (CD68 staining), and calcification (von Kossa). In vitro experiments involved measuring the calcification of human aortic valvular interstitial cells (VICs) and evaluating cytokine release from THP-1 cells, a human leukemia monocytic-like cell line, following CerS5 knockdown.

RESULTS

CerS5-/- mice showed a reduced peak velocity compared to WT only in the experiment with WD. Likewise, we observed reduced immune cell infiltration and calcification in the aortic valve of CerS5-/- mice, but only on WD. In vitro, calcification was reduced after knockdown of CerS5 in VICs, while THP-1 cells exhibited a decreased inflammatory response following CerS5 knockdown.

CONCLUSION

We conclude that CerS5 is an important mediator for the development of AVS in mice on WD and regulates critical pathophysiological hallmarks of AVS formation. CerS5 is therefore an interesting target for pharmacological therapy and merits further investigation.

[Midwives as influencers in skin care for newborns at risk of atopic diseases : Survey of midwives' current recommendations]

INTRODUCTION

The prevalence of atopic diseases remains high. Initial studies suggest that primary prevention with regular basic care may influence the incidence of atopic dermatitis in infants; however, data are unclear. Midwives play an important role in the care of women in the peripartum period and therefore also in providing advice on topics such as skin care, breastfeeding and nutrition of the newborn and young infant. The aim of this study was to determine the care recommendations for newborns by midwives.

METHODS

We conducted a cross-sectional survey among German midwives using questionnaires on the topic of newborn skin care.

RESULTS

A total of 128 questionnaires were analyzed. The most common recommendations were oil-based herbal topicals (34.9%) and plain water (34.0%). Approximately 70% of midwives reported recommending various options when there was a known family history of atopic diathesis. It was remarkable that most of the midwives' recommendations were identical regardless of the presence of an atopic diathesis. Essential care products are only used "when necessary".

CONCLUSION

Training programs for midwives on the topic of "care and strengthening of the skin barrier", taking into account the current guidelines for allergy prevention, should be implemented.

Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock

BACKGROUND

The effects of temporary mechanical circulatory support with a microaxial flow pump on mortality among patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock remains unclear.

METHODS

In an international, multicenter, randomized trial, we assigned patients with STEMI and cardiogenic shock to receive a microaxial flow pump (Impella CP) plus standard care or standard care alone. The primary end point was death from any cause at 180 days. A composite safety end point was severe bleeding, limb ischemia, hemolysis, device failure, or worsening aortic regurgitation.

RESULTS

A total of 360 patients underwent randomization, of whom 355 were included in the final analysis (179 in the microaxial-flow-pump group and 176 in the standard-care group). The median age of the patients was 67 years, and 79.2% were men. Death from any cause occurred in 82 of 179 patients (45.8%) in the microaxial-flow-pump group and in 103 of 176 patients (58.5%) in the standard-care group (hazard ratio, 0.74; 95% confidence interval [CI], 0.55 to 0.99; P = 0.04). A composite safety end-point event occurred in 43 patients (24.0%) in the microaxial-flow-pump group and in 11 (6.2%) in the standard-care group (relative risk, 4.74; 95% CI, 2.36 to 9.55). Renal-replacement therapy was administered to 75 patients (41.9%) in the microaxial-flow-pump group and to 47 patients (26.7%) in the standard-care group (relative risk, 1.98; 95% CI, 1.27 to 3.09).

CONCLUSIONS

The routine use of a microaxial flow pump with standard care in the treatment of patients with STEMI-related cardiogenic shock led to a lower risk of death from any cause at 180 days than standard care alone. The incidence of a composite of adverse events was higher with the use of the microaxial flow pump. (Funded by the Danish Heart Foundation and Abiomed; DanGer Shock ClinicalTrials.gov number, NCT01633502.).

The role of coronary artery disease in lung transplantation: a propensity-matched analysis

BACKGROUND AND AIMS

Candidate selection for lung transplantation (LuTx) is pivotal to ensure individual patient benefit as well as optimal donor organ allocation. The impact of coronary artery disease (CAD) on post-transplant outcomes remains controversial. We provide comprehensive data on the relevance of CAD for short- and long-term outcomes following LuTx and identify risk factors for mortality.

METHODS

We retrospectively analyzed all adult patients (≥ 18 years) undergoing primary and isolated LuTx between January 2000 and August 2021 at the LMU University Hospital transplant center. Using 1:1 propensity score matching, 98 corresponding pairs of LuTx patients with and without relevant CAD were identified.

RESULTS

Among 1,003 patients having undergone LuTx, 104 (10.4%) had relevant CAD at baseline. There were no significant differences in in-hospital mortality (8.2% vs. 8.2%, p > 0.999) as well as overall survival (HR 0.90, 95%CI [0.61, 1.32], p = 0.800) between matched CAD and non-CAD patients. Similarly, cardiovascular events such as myocardial infarction (7.1% CAD vs. 2.0% non-CAD, p = 0.170), revascularization by percutaneous coronary intervention (5.1% vs. 1.0%, p = 0.212), and stroke (2.0% vs. 6.1%, p = 0.279), did not differ statistically between both matched groups. 7.1% in the CAD group and 2.0% in the non-CAD group (p = 0.078) died from cardiovascular causes. Cox regression analysis identified age at transplantation (HR 1.02, 95%CI [1.01, 1.04], p < 0.001), elevated bilirubin (HR 1.33, 95%CI [1.15, 1.54], p < 0.001), obstructive lung disease (HR 1.43, 95%CI [1.01, 2.02], p = 0.041), decreased forced vital capacity (HR 0.99, 95%CI [0.99, 1.00], p = 0.042), necessity of reoperation (HR 3.51, 95%CI [2.97, 4.14], p < 0.001) and early transplantation time (HR 0.97, 95%CI [0.95, 0.99], p = 0.001) as risk factors for all-cause mortality, but not relevant CAD (HR 0.96, 95%CI [0.71, 1.29], p = 0.788). Double lung transplant was associated with lower all-cause mortality (HR 0.65, 95%CI [0.52, 0.80], p < 0.001), but higher in-hospital mortality (OR 2.04, 95%CI [1.04, 4.01], p = 0.039).

CONCLUSION

In this cohort, relevant CAD was not associated with worse outcomes and should therefore not be considered a contraindication for LuTx. Nonetheless, cardiovascular events in CAD patients highlight the necessity of control of cardiovascular risk factors and a structured cardiac follow-up.

Outcome of right ventricular microaxial pump support in patients undergoing cardiac surgery

Right ventricular failure (RVF) after cardiac surgery is associated with an in-hospital mortality rate of up to 75%. Microaxial flow pumps are one of the mechanical circulatory supports (MCS) options available for the treatment of RVF, however the specifics of timing and indication for MCS, as well as predictors for survival, remain unclear due to a dearth of published data. We evaluated the clinical outcome of patients treated with Impella-RP for predictors of mortality and the hemodynamic effects of the pump. This is a single-center retrospective observational study involving adult patients who underwent cardiac surgery with cardiopulmonary bypass between January 2019 and December 2020 in cardiac surgery and required therapeutic management of RVF with an Impella-RP. Overall, 18 patients were included and analyzed for factors that could be associated with mortality, or that could be predictors of patient outcomes for this population. Treatment of RVF with Impella-RP improved the patient hemodynamics significantly and had a survival rate of 61% within 30 days. Patients with isolated CABG or better liver function before implantation had a better survival rate, which may indicate that underlying disease and timing of implantation are significant for successful treatment of RVF.

Scrutinizing the Role of Venoarterial Extracorporeal Membrane Oxygenation: Has Clinical Practice Outpaced the Evidence?

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.

Changes in right ventricular function and clinical outcomes following tricuspid transcatheter edge-to-edge repair

AIMS

Prognostic impact of post-procedural changes in right ventricular (RV) function after tricuspid transcatheter edge-to-edge repair (T-TEER) is still unclear. We investigated association of RV function and its post-procedural changes with clinical outcomes in patients undergoing T-TEER.

METHODS AND RESULTS

We retrospectively analysed 204 patients who underwent T-TEER and echocardiographic follow-up at 3 months after T-TEER. RV function was assessed by RV fractional area change (RVFAC), and RV dysfunction was defined as RVFAC <35%. Patients with an increase in RVFAC from baseline to the follow-up were considered as RV responders. Patients were divided into four groups according to baseline RVFAC and the RV responder. The primary outcome was a composite of mortality and hospitalization due to heart failure within 1 year. Forty-five of 204 patients (22.1%) had RVFAC <35% at baseline, and 71 (34.8%) were RV responders. The association between the RV responder and the composite outcome had a significant interaction with RVFAC at baseline. Among patients with baseline RVFAC <35%, RV responders had a lower risk of the composite outcome than RV non-responders, while this association was not significant in those with baseline RVFAC ≥35%. Among patients with baseline RVFAC <35%, a smaller RV diameter and a greater reduction of tricuspid regurgitation were predictors for the RV responder.

CONCLUSION

Post-procedural increase in RVFAC after T-TEER is associated with improved outcomes in patients with RV dysfunction. The factors related to the increase in RVFAC may support patient selection for T-TEER in patients with RV dysfunction.

Transcatheter Edge-to-Edge Mitral Valve Repair versus Minimally Invasive Mitral Valve Surgery: An Observational Study

Background: Minimally invasive mitral valve surgery (MIC-MVS) has been established as preferred treatment of mitral regurgitation (MR), but mitral transcatheter edge-to-edge valve repair (M-TEER) is routinely performed in patients at high surgical risk and is increasingly performed in intermediate risk patients. Methods: From 2010 to 2021, we performed 723 M-TEER and 123 isolated MIC-MVS procedures. We applied a sensitivity analysis by matching age, left ventricular ejection fraction (LVEF), EuroSCORE II and etiology of MR. Results: Baseline characteristics showed significant differences in the overall cohort (p < 0.01): age 78.3 years vs. 61.5 years, EuroSCORE II 5.5% vs. 1.3% and LVEF 48.4% vs. 60.4% in M-TEER vs. MIC-MVS patients. Grade of MR at discharge was moderate/severe in 24.5% (171/697) in M-TEER vs. 6.5% (8/123) in MIC-MVS (p < 0.01). One-year survival was 91.5% (552/723) in M-TEER vs. 97.6% (95/123) in MIC-MVS (p = 0.04). A matching with 49 pairs (n = 98) showed comparable survival during follow-up, but a numerically higher mean mitral valve gradient of 4.1 mmHg (95% CI: 3.6-4.6) vs. 3.4 mmHg (95% CI: 3.0-3.8) in M-TEER (p = 0.04). Conclusions: Patients undergoing M-TEER had lower one-year survival than MIC-MVS, but differences disappeared after matching. Reduction in MR was less effective in M-TEER patients and postprocedural mitral valve gradients were higher.

CT-derived Epicardial Adipose Tissue Inflammation Predicts Outcome in Patients Undergoing Transcatheter Aortic Valve Replacement

PURPOSE

Inflammatory changes in epicardial (EAT) and pericardial adipose tissue (PAT) are associated with increased overall cardiovascular risk. Using routine, preinterventional cardiac CT data, we examined the predictive value of quantity and quality of EAT and PAT for outcome after transcatheter aortic valve replacement (TAVR).

MATERIALS AND METHODS

Cardiac CT data of 1197 patients who underwent TAVR at the in-house heart center between 2011 and 2020 were retrospectively analyzed. The amount and density of EAT and PAT were quantified from single-slice CT images at the level of the aortic valve. Using established risk scores and known independent risk factors, a clinical benchmark model (BMI, Chronic kidney disease stage, EuroSCORE 2, STS Prom, year of intervention) for outcome prediction (2-year mortality) after TAVR was established. Subsequently, we tested whether the additional inclusion of area and density values of EAT and PAT in the clinical benchmark model improved prediction. For this purpose, the cohort was divided into a training (n=798) and a test cohort (n=399).

RESULTS

Within the 2-year follow-up, 264 patients died. In the training cohort, particularly the addition of EAT density to the clinical benchmark model showed a significant association with outcome (hazard ratio 1.04, 95% CI: 1.01-1.07; P =0.013). In the test cohort, the outcome prediction of the clinical benchmark model was also significantly improved with the inclusion of EAT density (c-statistic: 0.589 vs. 0.628; P =0.026).

CONCLUSIONS

EAT density as a surrogate marker of EAT inflammation was associated with 2-year mortality after TAVR and may improve outcome prediction independent of established risk parameters.

Outcomes of transcatheter edge-to-edge repair for atrial functional mitral regurgitation

BACKGROUND

The prognostic benefits of transcatheter edge-to-edge repair (TEER) remain unclear in patients with atrial functional mitral regurgitation (AFMR).

AIMS

We aimed to investigate the clinical outcomes of TEER for patients with AFMR.

METHODS

We retrospectively classified functional mitral regurgitation (FMR) patients undergoing TEER into those with AFMR or ventricular FMR (VFMR). A residual MR ≤1+ at discharge was considered optimal mitral regurgitation (MR) reduction, and an elevated mean mitral valve pressure gradient (MPG) was defined as an MPG ≥5 mmHg at discharge. The primary outcome was a composite of all-cause mortality and hospitalisation due to heart failure within one year.

RESULTS

Of 441 FMR patients, 125 patients were considered as having AFMR. Residual MR ≤1+ was associated with a lower risk of the composite outcome in both AFMR and VFMR patients, while an MPG ≥5 mmHg was associated with a higher risk of the composite outcome in patients with AFMR but not with VFMR. AFMR patients with residual MR ≤1+ and an MPG ≥5 mmHg, as well as those with residual MR >1+, had a higher incidence of the composite outcome than those with residual MR ≤1+ and an MPG <5 mmHg (50.7%, 41.8%, and 14.3%, respectively; p<0.001). This association was consistent after adjustment for clinical and echocardiographic characteristics.

CONCLUSIONS

An MR reduction to ≤1+ following TEER was associated with a lower risk of clinical outcomes in patients with AFMR, while an MPG ≥5 mmHg was related to a higher risk of clinical outcomes. Optimal MR reduction by TEER may have potential benefits on the prognosis of patients with AFMR, although the prognostic benefit may be attenuated by an elevated MPG.

Cholesterol Crystal Dissolution Rate of Serum Predicts Outcomes in Patients With Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Aortic stenosis has pathophysiological similarities with atherosclerosis, including the deposition of cholesterol-containing lipoproteins. The resulting cholesterol crystals activate the NLRP3 (NOD-like receptor protein 3) inflammasome, leading to inflammation and cardiovascular diseases. We aimed to investigate the cholesterol crystal dissolution rate (CCDR) of serum in patients with aortic stenosis and to assess the prognostic value of this biomarker.

METHODS AND RESULTS

The study included 348 patients with aortic stenosis undergoing transcatheter aortic valve replacement. The CCDR was measured using flow cytometry to enumerate cholesterol crystals that were added to a serum solution, at baseline and after 2 hours of incubation. Based on the median CCDR, the cohort was stratified into high and low cholesterol crystal dissolvers. The incidence of the primary end point, a composite of 1-year all-cause mortality and major vascular complication, was significantly lower in the high CCDR group (7.3 per 100 person-years) compared with the low CCDR group (17.0 per 100 person-years, P=0.01). This was mainly driven by a lower 1-year mortality rate in patients with a high CCDR (7.3 versus 15.1 per 100 person-years, P=0.04). Unplanned endovascular interventions were significantly less frequent in high cholesterol crystal dissolvers (12.8 versus 22.6 per 100 person-years, P=0.04). Although low-density lipoprotein cholesterol levels were comparable in both groups (101.8±37.3 mg/dL versus 97.9±37.6 mg/dL, P=0.35), only patients with a low CCDR showed a benefit from statin treatment. In multivariate analysis, low CCDR (hazard ratio, 2.21 [95% CI, 0.99-4.92], P=0.04) was significantly associated with 1-year mortality.

CONCLUSIONS

The CCDR is a novel biomarker associated with outcome in patients with aortic stenosis undergoing transcatheter aortic valve replacement. It may provide new insights into patients' anti-inflammatory capacity and additional prognostic information beyond classic risk assessment.

Impact of body mass index in patients with tricuspid regurgitation after transcatheter edge-to-edge repair

BACKGROUND

Obesity and underweight represent classical risk factors for outcome in patients treated for cardiovascular disease. This study describes the impact of different body mass index (BMI) categories on 1-year clinical outcome in patients with tricuspid regurgitation (TR) undergoing transcatheter-edge-to-edge repair (TEER).

METHODS

We analyzed 211 consecutive patients (age 78.3 ± 7.2 years, 55.5% female, median EuroSCORE II 9.6 ± 6.7) with tricuspid regurgitation undergoing TEER from June 2015 until May 2021. Patients were prospectively enrolled in our single center registry and were retrospectively analyzed. Patients were stratified according to body mass index (BMI) into 4 groups: BMI < 20 kg/m2 (underweight), BMI 20.0 to < 25.0 kg/m2 (normal weight), BMI 25.0 to > 30.0 kg/m2 (overweight) and BMI ≥ 30 kg/m2 (obese).

RESULTS

Kaplan-Meier survival curves demonstrated inferior survival for underweight and obese patients, but comparable outcomes for normal and overweight patients (global log rank test, p < 0.01). Cardiovascular death was significantly higher in underweight patients compared to the other groups (24.1% vs. 7.0% vs. 6.3% vs. 6.4%; p < 0.01). Over all, there were comparable rates of bleeding, stroke and myocardial infarction. Multivariable Cox regression analysis (adjusted for age, gender, coronary artery disease, chronic obstructive pulmonary disease, tricuspid annular plane systolic excursion, left-ventricular ejection fraction) confirmed underweight (HR 3.88; 95% CI 1.64-7.66; p < 0.01) and obesity (HR 3.24; 95% CI 1.37-9.16; p < 0.01) as independent risk factors for 1-year all-cause mortality.

CONCLUSIONS

Compared to normal weight and overweight patients, obesity and underweight patients undergoing TEER display significant higher 1-year all-cause mortality.

Refining accuracy of RV-PA coupling in patients undergoing transcatheter tricuspid valve treatment

BACKGROUND

Assessing right ventricular (RV) function is paramount for risk stratification, which remains challenging in patients with tricuspid regurgitation (TR). We assessed RV-pulmonary artery (PA) coupling and its predictability of outcomes after transcatheter tricuspid valve repair (TTVR).

METHODS

Study participants comprised patients undergoing transcatheter tricuspid valve repair to treat symptomatic TR from June 2015 to July 2021. We calculated an RV-PA coupling ratio using a formula, which is dividing tricuspid annular plane systolic excursion (TAPSE) by echocardiographically estimated (ePASP) or invasively measured PASP (iPASP) at baseline. The primary outcome was all-cause mortality or heart failure rehospitalization within one year.

RESULTS

The study participants (n = 206) were at high surgical risk (EuroSCORE II: 7.4 ± 4.8%). The primary outcome occurred in 57 patients within one year. The c-statistics for the outcome were 0.565 (95% CI 0.488-0.643) for TAPSE/ePASP and 0.695 (95% CI 0.631-0.759) for TAPSE/iPASP. The correlation between the ePASP and iPASP was attenuated in patients with massive/torrential TR compared to those with severe TR (interaction p = 0.01). In the multivariable Cox proportional model, TAPSE/iPASP was inversely associated with the risk of the primary outcome (per 0.1-point increase: adjusted-HR 0.67, 95% CI 0.56-0.82, p < 0.001), independent of baseline demographics. According to the TAPSE/iPASP quartiles (i.e., ≤ 0.316; 0.317-0.407; 0.408-0.526; ≥ 0.527), the event-free survival was 43.4%, 48.3%, 77.9%, and 85.4% at one year after TTVR.

CONCLUSION

RV-PA coupling predicts one-year mortality and heart failure rehospitalization after TTVR in patients with TR. The predictability is improved if invasively-measured PA pressure is included.

Cardiac computed tomography-based assessment of mitral annular calcification in patients undergoing mitral transcatheter edge-to-edge repair

BACKGROUND

The role of assessment of mitral annular calcification (MAC) using cardiac computed tomography (CCT) in mitral transcatheter edge-to-edge repair (TEER) remains unclear. The aim of this study was to investigate the association of MAC assessed by CCT with procedural and clinical outcomes in patients undergoing TEER.

METHODS

We retrospectively analyzed 275 patients who underwent pre-procedural CCT prior TEER. Mitral calcium volume (MCV) and MAC score were measured by CCT. Functional procedural success was defined as residual mitral regurgitation of ≤2+ with mean transmitral gradient of <5 ​mmHg at discharge. All-cause mortality within two years after TEER was collected.

RESULTS

MAC was present in 115 of 275 patients (41.8 %). The median MCV was 198 ​mm3 (interquartile range [IQR]: 84 to 863 ​mm3), and the median MAC score was 3 (IQR: 2 to 4). Higher MCV and MAC score were inversely related to the rate of functional procedural success, independently of anatomical features of mitral valve. Patients with moderate/severe MAC, defined as MAC score of ≥4, had a lower rate of functional procedural success than those without MAC (56.1 ​% vs. 81.3 ​%; p ​= ​0.002). Moreover, higher MCV and MAC score were associated with a higher risk of all-cause mortality within two years, irrespective of baseline characteristics and functional procedural success.

CONCLUSIONS

The presence and burden of MAC assessed by CCT were associated with procedural and clinical outcomes in patients undergoing TEER. The CCT-based assessment of MAC may improve patient selection for TEER.

A simply calculated nutritional index provides clinical implications in patients undergoing transcatheter aortic valve replacement

BACKGROUND

Malnutrition is associated with adverse outcomes in patients with aortic stenosis. The Triglycerides × Total Cholesterol × Body Weight Index (TCBI) is a simple scoring model to evaluate the status of nutrition. However, the prognostic relevance of this index in patients undergoing transcatheter aortic valve replacement (TAVR) is unknown. This study aimed to evaluate the association of the TCBI with clinical outcomes in patients undergoing TAVR.

METHODS

A total of 1377 patients undergoing TAVR were evaluated in this study. The TCBI was calculated by the formula; triglyceride (mg/dL) × total cholesterol (mg/dL) × body weight (kg)/1000. The primary outcome was all-cause mortality within 3 years.

RESULTS

Patients with a low TCBI, based on a cut-off value of 985.3, were more likely to have elevated right atrial pressure (p = 0.04), elevated right ventricular pressure (p < 0.01), right ventricular systolic dysfunction (p < 0.01), tricuspid regurgitation ≥ moderate (p < 0.01). Patients with a low TCBI had a higher cumulative 3-year all-cause (42.3% vs. 31.6%, p < 0.01; adjusted HR 1.36, 95% CI 1.05-1.77, p = 0.02) and non-cardiovascular mortality (15.5% vs. 9.1%, p < 0.01; adjusted HR 1.95, 95% CI 1.22-3.13, p < 0.01) compared to those with a high TCBI. Adding a low TCBI to EuroSCORE II improved the predictive value for 3-year all-cause mortality (net reclassification improvement, 0.179, p < 0.01; integrated discrimination improvement, 0.005, p = 0.01).

CONCLUSION

Patients with a low TCBI were more likely to have right-sided heart overload and exhibited an increased risk of 3-year mortality. The TCBI may provide additional information for risk stratification in patients undergoing TAVR.

Characteristics and outcomes of patients undergoing transcatheter mitral valve replacement with the Tendyne system

BACKGROUND

Transcatheter mitral valve replacement (TMVR) has emerged as alternative to transcatheter edge-to-edge repair (TEER) for treatment of mitral regurgitation (MR); however, the role of TMVR with the Tendyne system among established treatments of MR is not well defined. We assessed characteristics and outcomes of patients treated with the Tendyne system in the current clinical practice.

METHODS

We reviewed patients who underwent cardiac computed tomography and were judged eligible for the Tendyne system.

RESULTS

A total of 63 patients were eligible for TMVR with the Tendyne system. Of these, 17 patients underwent TMVR, and 46 were treated by TEER. Patients treated with the Tendyne system were more likely to have a high transmitral pressure gradient and unsuitable mitral valve morphology for TEER than those treated with TEER. TMVR with the Tendyne system reduced the severity of MR to less than 1 + in 94.1% of the patients at discharge and achieved a greater reduction in left ventricular (LV) end-diastolic volume at the 30-day follow-up compared with TEER. In contrast, patients treated with the Tendyne system had a higher 30-day mortality than those treated with TEER, while the mortality between 30 days and one year was comparable between Tendyne and TEER.

CONCLUSIONS

Among patients eligible for the Tendyne system, approximately a quarter of the patients underwent TMVR with the Tendyne system, which led substantial reduction of MR and LV reverse remodeling than TEER. In contrast, the 30-day mortality rate was higher after TMVR with the Tendyne compared to TEER.

Opportunistic CT-derived analysis of fat and muscle tissue composition predicts mortality in patients with cardiogenic shock

Prognosis estimation in patients with cardiogenic shock (CS) is important to guide clinical decision making. Aim of this study was to investigate the predictive value of opportunistic CT-derived body composition analysis in CS patients. Amount and density of fat and muscle tissue of 152 CS patients were quantified from single-slice CT images at the level of the intervertebral disc space L3/L4. Multivariable Cox regression and Kaplan-Meier survival analyses were performed to evaluate the predictive value of opportunistically CT-derived body composition parameters on the primary endpoint of 30-day mortality. Within the 30-day follow-up, 90/152 (59.2%) patients died. On multivariable analyses, lactate (Hazard Ratio 1.10 [95% Confidence Interval 1.04-1.17]; p = 0.002) and patient age (HR 1.04 [95% CI 1.01-1.07], p = 0.017) as clinical prognosticators, as well as visceral adipose tissue (VAT) area (HR 1.004 [95% CI 1.002-1.007]; p = 0.001) and skeletal muscle (SM) area (HR 0.987 [95% CI 0.975-0.999]; p = 0.043) as imaging biomarkers remained as independent predictors of 30-day mortality. Kaplan-Meier survival analyses showed significantly increased 30-day mortality in patients with higher VAT area (p = 0.015) and lower SM area (p = 0.035). CT-derived VAT and SM area are independent predictors of dismal outcomes in CS patients and have the potential to emerge as new imaging biomarkers available from routine diagnostic CT.

Left ventricular reverse remodeling after transcatheter aortic valve implantation in patients with low-flow low-gradient aortic stenosis

OBJECTIVES

Left ventricular reverse remodeling (LVRR) is associated with improved outcome in patients with heart failure. Factors associated with and predictive of LVRR in patients with low-flow low-gradient aortic stenosis (LFLG AS) after transcatheter aortic valve implantation (TAVI) and its impact on outcome were assessed.

METHODS

Pre- and postprocedural left ventricular (LV) function and volume were investigated in 219 patients with LFLG. LVRR was defined as an absolute increase of ≥10% in LV ejection fraction (LVEF) and reduction of ≥15% in LV end-systolic volume (LVESV). The primary endpoint was the combination of all-cause mortality and rehospitalization for heart failure.

RESULTS

The mean LVEF was 35.0 ± 10.0%, with a stroke volume index (SVI) of 25.9 ± 6.0 mL/m2 and LVESV of 94.04 ± 46.0 mL. At a median of 5.2 months (interquartile range, 2.7-8.1 months), 77.2% (n = 169) of the patients showed echocardiographic evidence of LVRR. A multivariate model revealed three independent factors for LVRR after TAVI: SVI of <25 mL/m2 (hazard ratio [HR], 2.31; 95% confidence interval [CI], 1.08-3.58; p < 0.01), LVEF of <30% (HR, 2.76; 95% CI, 1.53-2.91; p < 0.01), and valvulo-arterial impedance (Zva) of <5 mmHg/mL/m2 (HR, 5.36; 95% CI, 1.80-15.98; p < 0.01). Patients without evidence of LVRR showed a significantly higher incidence of the 1-year combined endpoint (32 [64.0%] vs. 75 [44.4%], p < 0.01).

CONCLUSIONS

The majority of patients with LFLG AS show LVRR after TAVI, which is associated with favorable outcomes. An SVI of <25 mL/m2, LVEF of <30%, and Zva < 5mmHg/mL/m2 represent predictors of LVRR.

Right ventricular ejection fraction assessed by computed tomography in patients undergoing transcatheter tricuspid valve repair

AIMS

The role of right ventricular function in patients undergoing transcatheter tricuspid valve repair (TTVR) is poorly understood. This study investigated the association of right ventricular ejection fraction (RVEF) assessed by cardiac computed tomography (CCT) with clinical outcomes in patients undergoing TTVR.

METHODS AND RESULTS

We retrospectively assessed three-dimensional (3D) RVEF by using pre-procedural CCT images in patients undergoing TTVR. RV dysfunction was defined as a CT-RVEF of <45%. The primary outcome was a composite outcome, consisting of all-cause mortality and hospitalization due to heart failure, within 1 year after TTVR. Of 157 patients, 58 (36.9%) presented with CT-RVEF <45%. Procedural success and in-hospital mortality were comparable between patients with CT-RVEF <45% and ≥45%. However, CT-RVEF of <45% was associated with a higher risk of the composite outcome (hazard ratio: 2.99; 95% confidence interval: 1.65-5.41; P = 0.001), which had an additional value beyond two-dimensional echocardiographic assessments of RV function to stratify the risk of the composite outcome. In addition, patients with CT-RVEF ≥45% exhibited the association of procedural success (i.e. residual tricuspid regurgitation of ≤2+ at discharge) with a decreased risk of the composite outcome, while this association was attenuated in those with CT-RVEF <45% (P for interaction = 0.035).

CONCLUSION

CT-RVEF is associated with the risk of the composite outcome after TTVR, and a reduced CT-RVEF might attenuate the prognostic benefit of TR reduction. The assessment of 3D-RVEF by using CCT may refine the patient selection for TTVR.

Femoral or Axillary Cannulation for Extracorporeal Circulation during Minimally Invasive Heart Valve Surgery (FAMI): Protocol for a Multi-Center Prospective Randomized Trial

BACKGROUND

Minimally invasive heart valve surgery via anterolateral mini-thoracotomy with full endoscopic 3D visualization (MIS) has become the standard treatment of patients with valvular heart disease and low operative risk over the past two decades. It requires extracorporeal circulation and cardioplegic arrest. The most established form of arterial cannulation for MIS is through the femoral artery and is used by most surgeons, but it is suspected to increase the risk of stroke through retrograde blood flow. An alternative route of cannulation is the axillary artery, producing antegrade blood flow during extracorporeal circulation.

METHODS

Femoral or axillary cannulation for extracorporeal circulation during minimally invasive heart valve surgery (FAMI) is a multicenter randomized controlled trial designed to determine whether axillary cannulation is superior to femoral cannulation for the outcome of a manifest stroke within 7 days postoperatively. The target sample size was 848 participants. Patients ≥ 18 years of age, with valvular regurgitation or stenosis scheduled for minimally invasive surgery via anterolateral mini-thoracotomy, were randomized to axillary cannulation (treatment group) or to femoral cannulation (standard care). Patients were followed up for seven days postoperatively. A CT scan was performed pre-operatively to screen patients for vascular calcifications and to assess the safety of femoral cannulation. The standard of care is femoral artery cannulation, but is performed only in patients without significant vascular calcifications or severe kinking of the iliac arteries and in patients with sufficient vessel diameter. The cannulation is performed via Seldinger's technique, and the vessel closed percutaneously using a plug-based vascular closure device. Only patients without significant vascular calcifications are considered for femoral cannulation, as an increased risk of stroke is assumed. In patients with vascular calcifications, axillary cannulation is the standard of care to avoid these risks. Retrospective studies have hinted that, even in patients without vascular calcifications, there may be a lower stroke risk with axillary cannulation compared to femoral cannulation. We present a protocol for a multi-center randomized trial to investigate this hypothesis.

DISCUSSION

To date, evidence on the best access for peripheral artery cannulation during minimally invasive heart valve surgery has been scarce. Patients may benefit from axillary cannulation for extracorporeal circulation in terms of stroke risk and other neurological and vascular complications, though femoral cannulation is the gold standard. The aim of this study is to determine the risks of peri-operative stroke in a prospective randomized comparison of femoral vs. axillary cannulation.

Carotid Stiffness After Transcatheter Aortic Valve Replacement

The present study aimed to analyze common carotid artery strain properties in patients (n = 59) with severe aortic valve stenosis who underwent transcatheter aortic valve replacement (TAVR). Arterial compliance of the common carotid artery was assessed by ultrasound speckle-tracking before and after TAVR. For sub-analysis the study cohort was divided according to aortic valve area <.75 cm2 (n = 30) vs ≥.75 cm2 (n = 29). Comparison of pre- and post-procedural strain variables showed an improvement in median radial velocity (P < .0001), radial displacement (P = .007), circumferential strain (P = .004), radial strain rate (P = .023), and circumferential strain rate (P < .0001), while the increase of radial strain showed a trend (P = .082). Analysis of aortic valve area revealed an inverse correlation between aortic valve area and the differences (post-procedural-pre-procedural values) for radial strain rate, and circumferential strain. Moreover, sub-analysis revealed that the increase of carotid strain variables before and after TAVR were more pronounced in the sub-group of aortic valve area .75 vs ≥.75 cm2. TAVR led to a reduction of arterial wall stiffness of the common carotid artery assessed by ultrasound speckle-tracking. The decrease of arterial wall stiffness after TAVR was more pronounced in more severe aortic valve stenosis.

Clinical effects of cognitive behavioral therapy in heart failure patients: a meta-analysis of randomized controlled trials

BACKGROUND

About 20-40% of people with Heart failure (HF) suffer from some depression, which is 4-5% greater than the overall population. This depression can lead to undesirable outcomes, including elevated mortality rate and frequent hospitalization.

PURPOSE

The current study aims to evaluate the impact of cognitive behavioural therapy (CBT) on self-care and the symptoms of depression and anxiety in HF patients.

METHODS

We searched PubMed, Web of Science (WOS), Scopus, and Cochrane Library till 15 October 2022. All relevant randomized controlled trials (RCTs) were included. The data were extracted and pooled using Review Manager software (RevMan 5.4). Continuous data were pooled as mean difference and 95% confidence interval (CI).

RESULTS

Our search retrieved 1146 records, and 7 studies (611 patients) were finally included. We assessed the Beck Depression Inventory-II (BDI-II) as the primary outcome of the study. Hamilton Rating Scale for Depression (HRSD-17), Change in Beck Anxiety Inventory, Kansas City Cardiomyopathy Questionnaire (KCCQ), and Self-Care of Heart Failure Index (SCHFI) were also assessed as secondary outcomes. With CBT, BDI-II showed a significant reduction after 4 to 6 months follow-up (MD = -4.87, 95% CI: [-8.06; -1.69], P = 0.003) as well as 8 to 9 months follow-up (MD = -5.71, 95% CI: [-8.95; -2.46], P = 0.0006). But no significant difference was shown with 3 months follow-up (M.D=-4.34; 95%CI: [-10.70; 2.03], P = 0.18).

CONCLUSIONS

CBT has long-term (4-9 months) significant favorable outcomes decreasing anxiety and depression compared to non-CBT groups. No significant short-term (less than 3 months) impact on HF patients' self-care, depression, or anxiety were shown.

A novel and simple cardiac magnetic resonance score (PE2RT) predicts outcome in takotsubo syndrome

OBJECTIVES

To find simple imaging-based features on cardiac magnetic resonance (CMR) that are associated with major adverse cardiovascular events (MACE) in takotsubo syndrome (TTS).

METHODS

Patients with TTS referred for CMR between 2007 and 2021 were retrospectively evaluated. Besides standard CMR analysis, commonly known complications of TTS based on expert knowledge were assessed and summarised via a newly developed PE2RT score (one point each for pleural effusion, pericardial effusion, right ventricular involvement, and ventricular thrombus). Clinical follow-up data was reviewed up to three years after discharge. The relationship between PE2RT features and the occurrence of MACE (cardiovascular death or new hospitalisation due to acute myocardial injury, arrhythmia, or chronic heart failure) was examined using Cox regression analysis and Kaplan-Meier estimator.

RESULTS

Seventy-nine patients (mean age, 68 ± 14 years; 72 women) with TTS were included. CMR was performed in a median of 4 days (IQR, 2-6) after symptom onset. Over a median follow-up of 13.3 months (IQR, 0.4-36.0), MACE occurred in 14/79 (18%) patients: re-hospitalisation due to acute symptoms (9/79, 11%) or chronic heart failure symptoms (4/79, 5%), and cardiac death (1/79, 1%). Patients with MACE had a higher PE2RT score (median [IQR], 2 [2-3] vs 1 [0-1]; p < 0.001). PE2RT score was associated with MACE on Cox regression analysis (hazard ratio per PE2RT feature, 2.44; 95%CI: 1.62-3.68; p < 0.001). Two or more PE2RT complications were strongly associated with the occurrence of MACE (log-rank p < 0.001).

CONCLUSIONS

The introduced PE2RT complication score might enable an easy-to-assess outcome evaluation of TTS patients by CMR.

KEY POINTS

• Complications like pericardial effusion, pleural effusion, right ventricular involvement, and ventricular thrombus (summarised as PE2RT features) are relatively common in takotsubo syndrome. • The proposed PE2RT score (one point per complication) was associated with the occurrence of major adverse cardiac events on follow-up. • Complications easily detected by cardiac magnetic resonance imaging can help clinicians derive long-term prognostic information on patients with takotsubo syndrome.

Human and porcine aortic valve endothelial and interstitial cell isolation and characterization

Background

Calcific aortic valve stenosis (AVS) is defined by pathological changes in the aortic valve (AV) and their predominant cell types: valvular interstitial (VICs) and endothelial cells (VECs). Understanding the cellular and molecular mechanisms of this disease is a prerequisite to identify potential pharmacological treatment strategies. In this study, we present a unique aortic valve cell isolation technique to acquire specific human and porcine cell populations and compared VICs and VECs of these species with each other for the first time.

Methods

AV cells were isolated from tissue obtained from human patients undergoing surgical aortic valve replacement (SAVR) or from porcine hearts. Functional analysis and in vitro experiments revealed that endothelial-to-mesenchymal transition (EndMT) can be induced in hVECs, leading to a significant increase in mesenchymal markers. In vitro calcification experiments of VICs demonstrated pronounced expression of calcification markers and visible calcific deposits in Alizarin Red staining in both species after incubation with pro-calcific media.

Results

Cells isolated from patient-derived AVs showed mesenchymal and endothelial-specific gene signatures (VIC and VEC, respectively). For instance, von Willebrand factor (vWF) and platelet endothelial adhesion molecule-1 (PECAM1) were upregulated in VECs, while the myofibroblastic markers alpha-smooth muscle actin (α-SMA) and vimentin (VIM) were downregulated in VECs compared to VICs. Analysis of cell function by migration revealed that VECs are more migratory than VICs. Induction of EndMT in vitro in VECs displayed increased expression of EndMT markers and decreased expression of endothelial markers, confirming their mesenchymal transdifferentiation ability. In vitro calcification of VICs revealed upregulation of alkaline phosphatase (ALPL), a hallmark of calcification. In addition, other calcification-related genes such as osteocalcin (BGLAP) and runt-related factor 2 (RUNX2) were upregulated. Alizarin red staining of calcified cells provided a further layer of confirmation that the isolated cells were VICs with osteoblastic differentiation capacity.

Conclusion

This study aims to take a first step towards standardizing a reproducible isolation technique for specific human and porcine VEC and VIC populations. A comparison of human and porcine aortic valve cells demonstrated that porcine cells may serve as an alternative cellular model system in settings where human tissue is difficult to obtain.

Impact of transradial versus transfemoral access for preprocedural coronary angiography on TAVR-associated complications

Background

Vascular injury and bleeding complications remain frequent after transcatheter aortic valve replacement (TAVR). Whether the access-site of preprocedural coronary angiography (CAG) affects TAVR-related complications is not known. The aim of this study was to evaluate the impact of transradial (TRA) versus transfemoral access (TFA) for preprocedural CAG on outcomes in patients undergoing subsequent TAVR.

Methods

The study cohort included 1002 patients undergoing transfemoral TAVR, of whom 39.4% (395/1002) had undergone radial and 60.6% (607/1002) femoral access for pre-TAVR CAG. The primary endpoint was a composite of 30-day mortality and major vascular complications after TAVR. Key secondary endpoints included VARC-3-defined complications.

Results

The primary endpoint occurred less frequently in patients with prior TRA (3.3%) as compared to patients with prior TFA (6.3%, p = 0.04), which was mainly driven by significantly lower rates of major vascular complications (0.8% vs 2.5%, p = 0.05). Moreover, incidences of periprocedural access-related vascular injury and unplanned endovascular interventions were lower in TRA patients (13.2% vs 18.0%, p = 0.05). The rate of major bleeding tended to be lower in the TRA (1.5%) as compared to the TFA group (3.5%) but was not significantly different (p = 0.07). Moreover, the rate of life-threatening bleeding was comparable between both groups (0.5% vs 0.8%, p = 0.71).

Conclusion

Transradial access for preprocedural CAG was associated with significantly lower rates of vascular complications following subsequent TAVR as compared to transfemoral access. However, despite the tendency to lower major bleedings with transradial access, no significant association was detectable between the access-site of coronary angiography and TAVR-related bleeding complications.

Cardiovascular Magnetic Resonance in Survivors of Critical Illness: Cardiac Abnormalities Are Associated With Acute Kidney Injury

Background The objective of this study was to investigate cardiac abnormalities in intensive care unit (ICU) survivors of critical illness and to determine whether temporary acute kidney injury (AKI) is associated with more pronounced findings on cardiovascular magnetic resonance. Methods and Results There were 2175 patients treated in the ICU (from 2015 until 2021) due to critical illness who were screened for study eligibility. Post-ICU patients without known cardiac disease were prospectively recruited from March 2021 to May 2022. Participants underwent cardiovascular magnetic resonance including assessment of cardiac function, myocardial edema, late gadolinium enhancement, and mapping including extracellular volume fraction. Student t test, Mann-Whitney U test, and χ2 tests were used. There were 48 ICU survivors (46±15 years of age, 28 men, 29 with AKI and continuous kidney replacement therapy, and 19 without AKI) and 20 healthy controls who were included. ICU survivors had elevated markers of myocardial fibrosis (T1: 995±31 ms versus 957±21 ms, P<0.001; extracellular volume fraction: 24.9±2.5% versus 22.8±1.2%, P<0.001; late gadolinium enhancement: 1% [0%-3%] versus 0% [0%-0%], P<0.001), more frequent focal late gadolinium enhancement lesions (21% versus 0%, P=0.03), and an impaired left ventricular function (eg, ejection fraction: 57±6% versus 60±5%, P=0.03; systolic longitudinal strain: 20.3±3.7% versus 23.1±3.5%, P=0.004) compared with healthy controls. ICU survivors with AKI had higher myocardial T1 (1002±33 ms versus 983±21 ms; P=0.046) and extracellular volume fraction values (25.6±2.6% versus 23.9±1.9%; P=0.02) compared with participants without AKI. Conclusions ICU survivors of critical illness without previously diagnosed cardiac disease had distinct abnormalities on cardiovascular magnetic resonance including signs of myocardial fibrosis and systolic dysfunction. Findings were more abnormal in participants who experienced AKI with necessity of continuous kidney replacement therapy during their ICU stay. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05034588.

Contemporary Treatment and Outcomes of High Surgical Risk Mitral Regurgitation

Before the development of transcatheter interventions, patients with mitral regurgitation (MR) and high surgical risk were often conservatively treated and subject to poor prognoses. We aimed to assess the therapeutic approaches and outcomes in the contemporary era. The study participants were consecutive high-risk MR patients from April 2019 to October 2021. Among the 305 patients analyzed, 274 (89.8%) underwent mitral valve interventions, whereas 31 (10.2%) received medical therapy alone. Of the interventions, transcatheter edge-to-edge mitral repair (TEER) was the most frequent (82.0% of overall), followed by transcatheter mitral valve replacement (TMVR) (4.6%). In patients treated with medical therapy alone, non-optimal morphologies for TEER and TMVR were shown in 87.1% and 65.0%, respectively. Patients undergoing mitral valve interventions experienced less frequent heart failure (HF) rehospitalization compared to those with medical therapy alone (18.2% vs. 42.0%, p < 0.01). Mitral valve intervention was associated with a lower risk of HF rehospitalization (HR 0.36 [0.18-0.74]) and an improved New York Heart Association class (p < 0.01). Most high-risk MR patients can be treated with mitral valve interventions. However, approximately 10% remained on medical therapy alone and were considered as unsuitable for current transcatheter technologies. Mitral valve intervention was associated with a lower risk of HF rehospitalization and improved functional status.

Infective endocarditis and stroke: when does it bleed? A single center retrospective study

BACKGROUND

Infective endocarditis (IE) is a serious condition with a high mortality, represents a rare cause of stroke and an increased risk of intracranial hemorrhage. In this single center study, we characterize stroke patients with IE. We were interested in risk factors for intracranial hemorrhage and outcome of patients with intracranial hemorrhage compared to patients with ischemic stroke.

METHODS

Patients with IE and symptomatic ischemic stroke or intracranial hemorrhage admitted to our hospital between January 2019 and December 2022 were included in this retrospective study.

RESULTS

48 patients with IE and ischemic stroke or intracranial hemorrhage were identified. 37 patients were diagnosed with ischemic stroke, 11 patients were diagnosed with intracranial hemorrhage. The intracranial hemorrhage occurred within the first 12 days after admission. We identified Staphylococcus aureus detection and thrombocytopenia as risk factors for hemorrhagic complications. An increased in-hospital mortality in patients with intracranial hemorrhage (63.6% vs. 22%, p = 0.022) was found, whereas patients with ischemic stroke and patients with intracranial hemorrhage do not differ regarding favorable clinical outcome (27% vs. 27.3%, p = 1.0). 27.3% patients with intracranial hemorrhage and 43.2% patients with ischemic stroke underwent cardiac surgery. Overall, 15.7% new ischemic strokes occurred after valve reconstruction, whereas no new intracranial hemorrhage was observed.

CONCLUSIONS

We found an increased in-hospital mortality in patients with intracranial hemorrhage. Beside thrombocytopenia, we identified S. aureus detection as a risk factor for intracranial hemorrhage.

Cusp overlap versus standard three-cusp technique for self-expanding Evolut transcatheter aortic valves

BACKGROUND

Reducing rates of permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) is important for achieving the best procedural outcomes. The cusp overlap technique (COT) implements procedural steps including an overlap angulation of the right and left coronary cusp to mitigate this complication.

AIMS

We investigated the incidence of PPI and complication rates following the COT compared to the standard three-cusp implantation technique (3CT) in an all-comers cohort.

METHODS

A total of 2,209 patients underwent TAVI with the self-expanding Evolut platform from January 2016 to April 2022 at five sites. Baseline, procedural and in-hospital outcome characteristics were compared for both techniques before and after one-to-one propensity score matching.

RESULTS

A total of 1,151 patients were implanted using the 3CT and 1,058 using the COT. At discharge, the rates of PPI (17.0 vs 12.3%; p=0.002) and moderate/severe paravalvular regurgitation (4.6% vs 2.4%; p=0.006) were significantly reduced with the COT compared with 3CT within the unmatched cohort. Overall procedural success and complication rates were similar; major bleeding was less common in the COT group (7.0% vs 4.6%; p=0.020). These results remained consistent after propensity score matching. In multivariable logistic regression analysis, right bundle branch block (odds ratio [OR] 7.19, 95% confidence interval [CI]: 5.18-10.0; p<0.001) and diabetes mellitus (OR 1.38, 95% CI: 1.05-1.80; p=0.021) emerged as predictors of PPI, whereas the COT (OR 0.63, 95% CI: 0.49-0.82; p<0.001) was protective.

CONCLUSIONS

The introduction of the COT was associated with a significant and relevant reduction of PPI and paravalvular regurgitation rates without an increase in complication rates.

Impact of New eGFR Equations on Risk Assessment In Patients Undergoing Transcatheter Aortic Valve Implantation

BACKGROUND

Recently, the Chronic Kidney Disease-Epidemiology Collaboration working group has published new formulas for race-independent estimation of glomerular filtration rate (GFR). We investigated the old and new eGFR equations in patients transcatheter aortic valve implantation (TAVI).

METHODS

We conducted a retrospective analysis based on the data from a prospective registry of patients who underwent TAVI from January 2008 to May 2019. The primary endpoint was 30-day mortality after TAVI, and the secondary endpoints included one- and three-year mortality.

RESULTS

In total, 1792 patients undergoing TAVI were included in the present analysis. The thirty-day mortality was 4.6 % (95 % CI 3.8-5.7 %), and the one- and three-year mortality were 17.5 % (95 % CI 15.7-19.4 %) and 34.4 % (95 % CI 32.0-37.0 %). After the application of the new eGFR formula, 12.0 % of patients were reclassified within the GFR category in CKD, while 13.2 % of patients were reclassified within the GFR categories of the EuroSCORE II. Hazard ratios for 30-day, one-year, and three-year mortality increased after introduction of the new creatine-based eq. (1.51, 1.52, 1.49 vs. 1.87, 1.79, 1.74, respectively). Compared to the old equation, the new eGFR <60 ml/min/1.73 m² had a better discrimination ability for the 30-day mortality (Harell's C: 0.563 (95 % CI 0.518-0.608) vs, 0.583 (95 % CI 0.546-0.636); delta Harell's C, 0.031 ± 0.022, p < 0.001). Similar findings were consistently observed in the cystatin creatinine-based equations.

CONCLUSIONS

The application of the new race-independent estimators of GFR results in the reassessment of renal function in a significant proportion of TAVI patients and may influence the risk stratification of this population.

Toll-like receptor-3 contributes to the development of aortic valve stenosis

Aortic valve stenosis (AS) development is driven by distinct molecular and cellular mechanisms which include inflammatory pathways. Toll-like-receptor-3 (TLR3) is a lysosomal pattern-recognition receptor that binds double-stranded RNA and promotes pro-inflammatory cellular responses. In recent years, TLR3 has emerged as a major regulator of vascular inflammation. The exact role of TLR3 in the development of AS has not been investigated. Isolated human valvular interstitial cells (VICs) were stimulated with the TLR3-agonist polyIC and the resulting pro-inflammatory and pro-osteogenic response measured. Severe AS was induced in wildtype- and TLR3^-/- mice via mechanical injury of the aortic valve with a coronary springwire. TLR3 activation was achieved by polyIC injection every 24 h after wire injury, while TLR3 inhibition was realized using Compound 4a (C4a) every 48 h after surgery. Endothelial mesenchymal transition (EndoMT) of human valvular endothelial cells (VECs) was assessed after polyIC stimulation. Stimulation of human VICs with polyIC promoted a strong inflammatory and pro-osteogenic reaction. Similarly, injection of polyIC marginally increased AS development in mice after wire injury. AS induction was significantly decreased in TLR3^-/- mice, confirming the role of endogenous TLR3 ligands in AS pathology. Pharmacological inhibition of TLR3 with C4a not only prevented the upregulation of inflammatory cytokines and osteogenic markers in VICs, and EndoMT in VECs, but also significantly abolished the development of AS in vivo. Endogenous TLR3 activation significantly contributes to AS development in mice. Pharmacological inhibition of TLR3 with C4a prevented AS formation. Therefore, targeting TLR3 may be a viable treatment option.

Circulating MicroRNA-122-5p Is Associated With a Lack of Improvement in Left Ventricular Function After Transcatheter Aortic Valve Replacement and Regulates Viability of Cardiomyocytes Through Extracellular Vesicles

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a well-established treatment option for high- and intermediate-risk patients with severe symptomatic aortic valve stenosis. A majority of patients exhibit improvements in left ventricular ejection fraction (LVEF) after TAVR in response to TAVR-associated afterload reduction. However, a specific role for circulating microRNAs (miRNAs) in the improvement of cardiac function for patients after TAVR has not yet been investigated. Here, we profiled the differential expression of miRNAs in circulating extracellular vesicles (EVs) in patients after TAVR and, in particular, the novel role of circulating miR-122-5p in cardiomyocytes.

METHODS

Circulating EV-associated miRNAs were investigated by use of an unbiased Taqman-based human miRNA array. Several EV miRNAs (miR-122-5p, miR-26a, miR-192, miR-483-5p, miR-720, miR-885-5p, and miR-1274) were significantly deregulated in patients with aortic valve stenosis at day 7 after TAVR compared with the preprocedural levels in patients without LVEF improvement. The higher levels of miR-122-5p were negatively correlated with LVEF improvement at both day 7 (r=-0.264 and P=0.015) and 6 months (r=-0.328 and P=0.0018) after TAVR.

RESULTS

Using of patient-derived samples and a murine aortic valve stenosis model, we observed that the expression of miR-122-5p correlates negatively with cardiac function, which is associated with LVEF. Mice with graded wire injury-induced aortic valve stenosis demonstrated a higher level of miR-122-5p, which was related to cardiomyocyte dysfunction. Murine ex vivo experiments revealed that miR-122-5p is highly enriched in endothelial cells compared with cardiomyocytes. Coculture experiments, copy-number analysis, and fluorescence microscopy with Cy3-labeled miR-122-5p demonstrated that miR-122-5p can be shuttled through large EVs from endothelial cells into cardiomyocytes. Gain- and loss-of-function experiments suggested that EV-mediated shuttling of miR-122-5p increases the level of miR-122-5p in recipient cardiomyocytes. Mechanistically, mass spectrometry, miRNA pulldown, electrophoretic mobility shift assay, and RNA immunoprecipitation experiments confirmed that miR-122-5p interacts with the RNA-binding protein hnRNPU (heterogeneous nuclear ribonucleoprotein U) in a sequence-specific manner to encapsulate miR-122-5p into large EVs. On shuttling, miR-122-5p reduces the expression of the antiapoptotic gene BCL2 by binding to its 3' untranslated region to inhibit its translation, thereby decreasing the viability of target cardiomyocytes.

CONCLUSIONS

Increased levels of circulating proapoptotic EV-incorporated miR-122-5p are associated with reduced LVEF after TAVR. EV shuttling of miR-122-5p regulates the viability and apoptosis of cardiomyocytes in a BCL2-dependent manner.

Coronary Artery Aneurysm Rupture in a Patient With Polyarteritis Nodosa

We present the case of a 42-year-old male patient with ST-segment elevation myocardial infarction and pericardial effusion due to rupture of the left anterior descending artery most likely secondary to polyarteritis nodosa. Successful surgery was performed under cardiopulmonary bypass using antegrade and retrograde cardioplegia combined. (Level of Difficulty: Intermediate.).

Cardiac magnetic resonance follow-up of COVID-19 vaccine associated acute myocarditis

BACKGROUND

Mass COVID-19 vaccination campaigns have helped impede the COVID-19 pandemic. In rare cases, some vaccines have led to vaccine associated myocarditis in a specific subset of the population, usually young males. Cardiac magnetic resonance (CMR) can reliably diagnose vaccine associated myocarditis, but follow-up data of CMR proven acute myocarditis is scarce.

MATERIALS AND METHODS

Nine patients with acute vaccine associated myocarditis underwent baseline and follow-up CMR examinations and were compared to baseline parameters at initial presentation and to a group of 20 healthy controls. CMR protocol included functional assessment, T1 and T2 mapping, T2 signal intensity ratio, strain feature tracking, and late gadolinium enhancement (LGE).

RESULTS

Myocarditis patients (n = 9, aged 24 ± 6 years, 8 males) underwent CMR follow-up after an average of 5.8 ± 4.3 months. All patients showed a complete resolution of visual myocardial edema while also demonstrating a reduction in overall LGE extent from baseline to follow-up (4.2 ± 2.1 vs. 0.9 ± 0.8%, p < 0.001), although visual LGE was still noted in all patients. Left ventricular ejection fraction was normal at baseline and at follow-up (58 ± 6 vs. 62 ± 4%, p = 0.10) as well as compared to a healthy control group (60 ± 4%, p = 0.24). T1 (1024 ± 77 vs. 971 ± 34 ms, p = 0.05) and T2 relaxations times (57 ± 6 vs. 51 ± 3 ms, p = 0.03) normalized at follow-up. Most patients reported a resolution of clinical symptoms, while two (22%) reported new onset of exertional dyspnea.

CONCLUSION

Patients with COVID-19 vaccine associated acute myocarditis showed a complete, uncomplicated resolution of myocardial inflammation on follow-up CMR, which was associated with a near complete resolution of symptoms. Minor, residual myocardial scarring was present on follow-up LGE imaging. The long-term implications of the remaining myocardial scar-tissue after vaccine associated myocarditis remain unknown warranting further studies.

Optimal protamine-to-heparin dosing ratio for the prevention of bleeding complications in patients undergoing TAVR-A multicenter experience

BACKGROUND

Despite major advances, transcatheter aortic valve replacement (TAVR) is still associated with procedure-specific complications. Although previous studies reported lower bleeding rates in patients receiving protamine for heparin reversal, the optimal protamine-to-heparin dosing ratio is unknown.

HYPOTHESIS

The aim of this study was a comparison of two different heparin antagonization regimens for the prevention of bleeding complications after TAVR.

METHODS

The study included 1446 patients undergoing TAVR, of whom 623 received partial and 823 full heparin antagonization. The primary endpoint was a composite of 30-day mortality, life-threatening, and major bleeding. Safety endpoints included stroke and myocardial infarction at 30 days.

RESULTS

Full antagonization of heparin resulted in lower rates of the primary endpoint as compared to partial heparin reversal (5.6% vs. 10.4%, p < .01), which was mainly driven by lower rates of life-threatening (0.5% vs. 1.6%, p = .05) and major bleeding (3.2% vs. 7.5%, p < .01). Moreover, the incidence of major vascular complications was significantly lower in patients with full heparin reversal (3.5% vs. 7.5%, p < .01). The need for red-blood-cell transfusion was lower in patients receiving full as compared to partial heparin antagonization (10.4% vs. 15.9%, p < .01). No differences were observed in the incidence of stroke and myocardial infarction between patients with full and partial heparin reversal (2.2% vs. 2.6%, p = .73 and 0.2% vs. 0.4%, p = .64, respectively).

CONCLUSIONS

Full heparin antagonization resulted in significantly lower rates of life-threatening and major bleeding after TAVR as compared to partial heparin reversal. The occurrence of stroke and myocardial infarction was low and comparable between both groups.

Prognostic impact of acute kidney injury following tricuspid transcatheter edge-to-edge repair

Background

A considerable risk of acute kidney injury (AKI) following transcatheter interventions without iodinated contrast agents has also been recognized; however, little is known about the incidence and clinical relevance of post-procedural AKI in patients undergoing transcatheter edge-to-edge repair (TEER) for tricuspid regurgitation (TR).

Purpose

This study aimed to investigate the prognostic impact and predictors of post-procedural AKI following TEER for TR.

Methods

We retrospectively analyzed 218 consecutive patients who underwent TEER for TR. Post-procedural AKI was defined as an increase in serum creatinine of ≥0.3 mg/dl within 48 hours or of ≥50% within seven days after the procedure, compared to baseline. Procedural success was defined as at least one grade reduction in TR severity upon discharge. We determined the association between post-procedural AKI and the composite outcome consisting of all-cause mortality and re-hospitalization due to heart failure within one year after the procedure.

Results

Overall, the mean age of the patients was 79±7 years, and 46.3% of the patients were male. Post-procedural AKI occurred in 32 patients (14.7%) (Figure 1). Among baseline characteristics, male sex and an estimated glomerular filtration rate of &lt;60 ml/min/m2 were associated with the occurrence of AKI. In addition, patients without procedural success had a higher incidence of post-procedural AKI (30.4% vs. 1.8%; p=0.024).

Patients with AKI had a higher incidence of in-hospital mortality compared to those without AKI (12.5% vs. 1.1%; p=0.005). Moreover, AKI was associated with the incidence of the composite outcome within one year after TEER for TR (adjusted hazard ratio: 2.06; 95% confidence interval: 1.11–3.84; p=0.023). In addition, our restricted cubic spline curve showed that a post-procedural increase in the creatinine level within seven days after the procedure was associated with a linear trend of the risk of the composite outcome after TEER (Figure 2).

Conclusions

Post-procedural AKI occurred in 14.7% of patients undergoing TEER for TR, despite the absence of iodinated contrast agents, which was associated with worse clinical outcomes. Male sex and CKD at baseline were related to the occurrence of AKI, and the procedural success of TEER was associated with a lower incidence of AKI. Our findings highlight the clinical impact of AKI following TEER for TR and should help with identifying patients at high risk of AKI.

Funding Acknowledgement

Type of funding sources: None.

Effectiveness of transcatheter edge-to-edge repair for atrial secondary mitral regurgitation

Background

Atrial secondary mitral regurgitation (ASMR) is a subtype of SMR that is characterized by normal left ventricular (LV) function, an enlarged left atrium and mitral annulus, and flattened leaflets. This anatomical feature is different from ventricular SMR (VSMR) and might therefore impact the procedural results of transcatheter edge-to-edge repair (TEER). The effectiveness and durability of TEER in patients with ASMR has not yet been well-studied.

Purpose

This study aimed to investigate the effectiveness of TEER and anatomical characteristics related to optimal MR reduction in patients with ASMR.

Methods

We retrospectively analyzed consecutive patients who underwent MitraClip at our institution. ASMR was defined as cases that met all of the following criteria: 1) normal mitral leaflets without organic disorder, 2) LV ejection fraction &gt;50%, and 3) absence of LV enlargement and segmental abnormality. The primary outcome measure was MR reduction to ≤1+, and its predictors were explored in a logistic regression analysis. Leaflet-to-annulus index (LAI) was measured using the mid-esophageal long-axis view in the A2-P2 segment as follows: (anterior leaflet length + posterior leaflet length) / anteroposterior length of the mitral annulus.

Results

Among 415 patients with SMR, 118 patients met the criteria for ASMR (mean age: 80±8 years; male: 39.8%) (Figure 1). Patients with ASMR had a larger mitral annulus diameter, shorter mobile posterior leaflet length, and smaller coaptation depth compared to those with VSMR.

The technical success rate was 90.7%, and the MR reduction to ≤1+ after TEER was achieved in 94 (79.7%) patients with ASMR, which was comparable with VSMR. The in-hospital mortality rate was 2.5%. In multivariable logistic analysis, a large left-atrial (LA) volume index and a low LAI were associated with a lower rate of MR reduction to ≤1+ after TEER for ASMR (odds ratio [OR]: 0.98; 95% confidence interval [CI]: 0.97–0.99, and OR per 0.1 increase: 1.98; 95% CI: 1.13–3.45, respectively). The combined assessment of the LA volume index and LAI stratified the risk of residual MR ≥2+ after TEER (Figure 2).

In addition, the use of a newer generation of the MitraClip systems (NTR/XTR or G4 systems) was associated with a higher rate of MR reduction to ≤1+ compared to older generations (OR: 4.65; 95% CI: 1.67–13.00).

Conclusions

TEER with the MitraClip system achieved a high rate of MR reduction to ≤1+ in patients with ASMR. Furthermore, the new generations of the MitraClip system may provide a more effective reduction in ASMR. Although our findings suggest that TEER with the MitraClip system is a safe and feasible approach in patients with ASMR, the combined assessment of the LA volume index and LAI might be useful to refine the device selection for transcatheter mitral valve treatment in this subgroup of SMR patients.

Funding Acknowledgement

Type of funding sources: None.

Novel assay for quantifying the cholesterol crystal dissolution capacity of serum predicts outcomes in patients with severe aortic stenosis undergoing TAVR

Background

Aortic stenosis (AS) is the most common valvular heart disease (VHD) in developed countries. The pathophysiology of calcific AS has several clinical and pathobiological findings in common with atherosclerosis including chronic inflammation and lipoprotein deposition. Histopathological examination has revealed atherosclerosis-like lesions, that mainly contain cholesterol crystals (CC) in resected calcific aortic valve cusps. Previous studies have demonstrated that CCs can activate the NLRP3 inflammasome, resulting in an IL-1 driven systemic inflammation, that leads to the development of atherosclerotic plaques.

Purpose

In this study, we sought to validate a novel assay for measuring the serum capacity to dissolve cholesterol crystals (CCDC) in patients with AS and to examine whether this biomarker may be associated with clinical outcomes.

Methods

Our study cohort included 348 patients with AS undergoing transcatheter aortic valve replacement. The CCDC was measured using flow cytometry to enumerate CC, that were added to a 50% serum solution, at baseline and after two hours of incubation. The dissolution capacity was indicated as percentage change in CC count at baseline and after incubation. The study cohort was stratified according to the median CCDC into high and low CC dissolvers.

Results

The study population was 47.7% female and had a mean age of 80.9±6.2 years. The primary end point, a composite of one-year all-cause mortality and major vascular complication occurred less frequently in the high CCDC group (7.0%) as compared with the low CCDC group (15.3%, p=0.01). This was mainly driven by lower rates of one-year mortality in patients with a high CCDC (7.0% vs 13.6%, p=0.05), as presented in Figure 1. Furthermore, unplanned endovascular interventions were significantly less frequent in high CC dissolvers in contrast to low CC dissolvers (12.2% vs 20.5%, p=0.04). Although LDL cholesterol (101.8±37.3 mg/dL vs 97.9±37.6 mg/dL, p=0.35) and total cholesterol levels (158.1±43.8 mg/dL vs 154.1±40.2, p=0.41) were comparable in the high and low CCDC group, only patients with a low CCDC showed a benefit from statin treatment (Figure 2). In multivariate analysis, only low CCDC (OR: 2.51 [95% CI: 1.02–6.15], p=0.05) and Albumin (OR: 0.88 [95% CI: 0.79–0.98], p=0.03) were independently associated with one-year all-cause mortality

Conclusion

The CCDC is a novel biomarker associated with clinical outcome in patients with AS undergoing TAVR. It may provide new insights into patient's preventative anti-inflammatory capacity and additional prognostic information to identify vulnerable patients beyond classic risk assessment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation).

Loss of ceramide synthase 5 reduces the development of aortic valve stenosis in mice with high fat diet

Background

Ceramide synthase 5 (CerS5) is essential to maintain C:16 ceramide levels in mice. Ceramides contribute to inflammation and calcification, two hallmarks of aortic valve stenosis development. It is known, that loss of CerS5 function reduces diet-induced obesity.

Purpose

The aim of this study was to investigate the effect of ceramide synthase 5 and high-fat diet on the development of aortic valve stenosis with a mouse model.

Methods

Our experiment consists of four groups of mice: Wild type (WT) and CerS5 (−/−) mice, with normal and high fat diet. We induced the aortic valve stenosis development through a wire-injury. For this model, a coronary angiography wire is introduced into the left ventricle over the right carotid artery, followed by rotation on the aortic valve level to generate a defined injury. Development of aortic valve stenosis was determined by measuring the peak velocity 14, 28 and 42 days after the wire-injury. With histological analysis of the aortic valve, we measured macrophage infiltration with CD68 immunostaining and calcification using von Kossa staining. For statistical analysis ANOVA and Turkeys multiple comparisons were performed.

Results

Histological analysis of the aortic valve revealed, that in CerS5 (−/−) mice with high fat diet (HFD) immune cell infiltration is reduced, while there is no difference between CerS5 (−/−) mice and wild type, when fed with normal diet (A). Also calcification showed a trend towards a reduction in CerS5 mice with high fat diet, but was not statistically significant (B). Echocardiography could detect a reduced peak velocity of CerS5 mice with high fat diet, in comparison to the other groups, four and six weeks after wire injury (C).

Conclusion

Our experiments indicate that loss of CerS5 function reduces the development of aortic valve stenosis in mice with high fat diet, by decreasing immune cell infiltration and calcification. Interestingly, in the groups with normal chow, loss of CerS5 function had no effect. In addition, high-fat diet alone had no negative effect in our mouse model. Based on our results it can be assumed that upon high fat diet CerS5 mediates for pro-inflammatory effects in the aortic valve, which are absent on normal diet.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Ernst & Berta Grimmke Foundation (13/19)

Characterization of the mitochondrial unfolded protein response in human coronary artery endothelial cells

Background

The unfolded protein response of the endoplasmic reticulum (UPRER) is highly activated in cardiovascular diseases and aims to restore homeostasis by improving protein folding. An analogue cytoprotective mitochondrial unfolded protein response (UPRMito) regulated by an orthologue of the activating transcription factor 5 (ATF5) was described in model organism c. elegans. However, in humans it is not clear if there is a distinct UPRMito, and if there is an activation of an UPRMito during stress induced by cardiovascular diseases. The endothelium is subjected to high levels of mitochondrial stress, e.g. in atherosclerosis.

Purpose

To provide a systematic characterization of the UPRMito in human coronary artery endothelial cells (HCAEC).

Methods and results

HCAEC were treated with Nicotinamide Riboside (NR), a NAD+ precursor that activates UPRMito without inducing cellular stress. NR treatment did not induce toxicity and improved cell viability at a concentration of 100μM NR. Quantitative PCR confirmed a dose-dependent upregulation of UPRMito markers. Additionally, we measured expression of ATF4, which is discussed to regulate an integrated stress response in mammals by activating both the UPRMito and UPRER. ATF4 upregulation upon NR treatment was more pronounced than ATF5 upregulation. Analysis of GTEX-Data showed that ATF5 is almost exclusively expressed in liver tissue, while ATF4 shows ubiquitous expression. Among 54 tissues, aortic tissue and coronary arterial tissue are among the five tissues with the highest ATF4 expression.

Analysis of RNA-seq-data of human carotid atherosclerosis revealed that the two transcription factors are differentially regulated. ATF4 is downregulated in unstable plaque, while ATF5 is upregulated. Moreover, ATF4 is in both conditions highly more abundant than ATF5. Accordingly, endothelial cells incubated under atherosclerotic conditions (oxLDL + high glucose) exhibited a ATF4 down- and ATF5 upregulation. Genes previously described to be involved in the UPRMito exhibited a similar expression pattern as ATF4.

To further elucidate these findings, we will perform transcriptomic analyses of HCAEC treated with atherosclerotic stimuli (IL-1β, oxLDL), UPRER inductors (Thapsigargin, Tunicamycin) and stressors of mitochondrial proteostasis (Oligomycin, MitoBloCK-6), to analyze, if ATF5- or ATF4-related pathways are dysregulated. Specific inhibitors and UPRMito activators will be used to investigate the significance of ATF4 and ATF5 on endothelial cell function (proliferation, migration, apoptosis, monocyte adhesion).

Conclusion

The UPRMito is dysregulated during the pathogenesis of atherosclerosis in HCAEC. Further findings are required to elucidate, if the UPRMito is activated separately and specifically by ATF5 or as part of an integrated cellular stress response by ATF4. A deeper understanding of these stress responses is crucial for the identification of novel therapeutic targets in atherosclerosis.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University hospital Bonn

Serum levels of the endoplasmic-reticulum-stress chaperone GRP78 identify patients with coronary artery disease and predict mortality

Background

Endoplasmic-reticulum-stress (ER Stress) and associated chaperones like the main ER-Stress moderator GRP78 (glucose-regulated-protein, 78kDa) are involved in the pathogenesis of coronary artery disease (CAD). In addition to their intracellular localization and effects, secretion and extracellular properties of chaperones, including GRP78, were recently described. However, a diagnostic or prognostic relevance of serum ER-chaperones in patients with CAD has not been established yet.

Purpose

To investigate the significance of serum GRP78 in patients undergoing coronary angiography for suspected CAD.

Methods

Serum concentration of GRP78 was measured by ELISA in 789 patients with indication for coronary angiography (both ACS and CCS). CAD was defined as &gt;50% stenosis in any major coronary artery. Clinical endpoint was one-year all-cause mortality.

Results

Mean age was 70.8±11.9 years and 65% of patients were male. 192 (24%) patients presented with acute coronary syndrome (ACS). CAD was found in 72.4% of patients. Mean GRP78 serum concentration was 2492 ng/ml. Increased levels of GRP78 (&gt; median) were associated with diabetes (29.9% vs. 23.1%, p=0.03), a higher BMI (28.9±7.1 kg/m2 vs. 27.0±6.0 kg/m2, p&lt;0.0001) and chronic kidney disease (CKD: 23.3% vs. 17.1%, p=0.03). There was no difference regarding age or sex.

GRP78 levels were increased in patients with CAD when compared to patients without CAD (2640 ng/ml [95% CI: 2415–2864] vs. 2178 ng/ml [95% CI: 1893–2463], p=0.013, Fig A). Interestingly, GRP78 levels were lower in patients with ACS than in patients with CCS (2284 ng/ml [95% CI: 1944–2642] vs. 2822 [95% CI: 2531–3113], p=0.018, Fig B). To further elucidate these findings, we analyzed available proteomics of patients with hypertrophic cardiomyopathy undergoing septal ablation as a model for a planned myocardial infarction (PMI)1. Coronary sinus blood samples drawn 10 and 60 min after PMI showed a downregulation of GRP78 levels compared to baseline.

Finally, we assessed prognostic relevance of GRP78 in patients with CAD. Increased GRP78 levels were associated with lower one-year mortality (5.3% vs. 10.6% vs. p=0.016). Increased GRP78 levels were associated with reduced one-year mortality in both continuous (HR: 0.48 [95% CI: 0.25–0.92]) and categorial analyses stratified by median GRP78. After adjusting for age, sex, BMI, diabetes, CKD and ACS, GRP78 remained an independent predictor of one-year mortality (HR: 0.51 [0.26–0.96], p=0.039).

Conclusion

GRP78 serum levels are generally elevated in patients with CAD but downregulated during ACS. Reduced levels are associated with increased one-year mortality. These results support previous findings that GRP78 secretion is a protective mechanism in cardiovascular diseases. Further mechanistic studies are warranted to foster our understanding of the effects of extracellular GRP78 and to aid in the identification of modifying therapeutic targets.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University hospital Bonn

The endoplasmic reticulum (ER) chaperone GRP78 is secreted during ER Stress and alleviates endothelial cell inflammation

Introduction

Glucose-Regulated Protein 78kD (GRP78) is a chaperone and the main regulator of the ER-stress response. Upon ER Stress, GRP78 activates the unfolded protein response (UPR), which aims to clear unfolded proteins and restore ER homeostasis. A prolonged activation of the UPR triggers inflammation, thus contributing to the progression of cardiovascular diseases. Recently, extracellular secretion of GRP78 was described. However, the pathophysiological relevance of secreted GRP78 in atherosclerosis and endothelial cell inflammation remains to be elucidated.

Aim

Aim of this study is to investigate the role of GRP78 secretion in endothelial cells.

Methods and results

First, we sought to investigate if vascular cells secrete GRP78 during ER Stress. Human coronary artery endothelial cells (HCAEC) were treated with the ER stress inductor tunicamycin for up to 48h. After ER Stress induction, Western Blot and ELISA experiments detected an increased intracellular GRP78 expression. Intriguingly, prolonged ER Stress also promoted extracellular secretion of GRP78. Proteomic analysis confirmed that after ER-Stress induction, GRP78 is one of the most highly upregulated extracellular proteins (2.43-fold). Co-incubation with Brefeldin A, an inhibitor of ER-Golgi protein transport, abolished extracellular secretion (Fig.1). Hence, ER-Stress-induced GRP78 secretion is an actively regulated process.

Next, the effect of GRP78 containing conditioned medium (CM) on HCAEC was analyzed. Treatment with GRP78 containing CM decreased GRP78 mRNA expression in target cells (0.35-fold vs. control [+BFA], p&lt;0.0001). Furthermore, it increased viability (93.0% vs. 79.6%, p=0.017) and decreased formation of reactive oxygen species (0.78-fold). Moreover, expression of markers of vascular inflammation and ER Stress (e.g., NF-κB and CHOP) was decreased when compared to control CM with additional BFA treatment.

However, ER Stress induced by tunicamycin exhibits deleterious effects on donor cells and is therefore not feasible for in vivo usage. Thus, we utilized Bip protein inducer x (Bix), a recently described small-molecule activator of GRP78. Treatment with Bix also promoted expression of GRP78 and general UPR activation (e.g., ATF4, XBP1). Moreover, in contrast to tunicamycin, Bix treatment did not impair viability of HCAEC.

After treatment with Bix-induced CM, apoptosis (0.77-fold vs. 1.64-fold, p&lt;0.0001) and expression of markers of vascular inflammation (e.g., Il-6) were significantly decreased compared to control CM. Furthermore, presence of GRP78 was able to promote proliferation and viability.

Conclusion

Endothelial ER Stress promotes GRP78 secretion. Presence of GRP78 in conditioned medium ameliorates subsequent ER Stress and endothelial inflammation, which play a critical role in atherogenesis. Modification of GRP78 secretion by Bix might be a feasible and innovative therapeutic option for vascular inflammation and endothelial regeneration.

Funding Acknowledgement

Type of funding sources: None.

Unravelling the role of SOCS3 in aortic valve stenosis

Background

Calcific aortic valve stenosis (CAVD) is the most prevalent heart valve disease worldwide and, in advanced stages, leads to clinical deterioration and poor prognosis. Until now, no medical treatment is available. Thought to be a merely degenerative disease, we now know that disease initiation and progression are actively regulated by immune cell infiltration, chronic inflammation, osteogenic differentiation of valvular interstitial cells (VIC) and endothelial-to-mesenchymal transition (EndMT) of valvular endothelial cells (VEC). Suppressor of Cytokine Signaling 3 (SOCS3) is known to be a key regulator of inflammation. It promotes the polarisation of macrophages to an inflammatory phenotype and thus, contributes to disease progression in atherosclerosis. In CAVD, not only inflammation but also heterotopic bone formation leads to the thickening and obstruction of the aortic valve cusps and as SOCS3 is one of the main regulators of physiological bone formation, it could play a critical role in the progression of CAVD.

Purpose

We hypothesize that SOCS3 plays a crucial role during calcification of the aortic valve through regulation of EndMT, calcification of valvular interstitial cells and macrophage polarization.

Methods and results

In initial screening experiments, we investigated SOCS3-protein expression in explanted human aortic valves from patients undergoing surgical aortic valve replacement. SOCS3 is expressed in both stenotic and non-stenotic valve tissues. Immunofluorescence-staining of human aortic valves shows the co-localisation of SOCS3 with the interstitial cell-marker Vimentin and SOCS1, which is known to regulate macrophage-polarisation together with SOCS3 (Fig. 1). Staining of the macrophage-marker CD68 revealed its co-localisation with calcified areas of the aortic valve cusp. We validated our findings in our in vitro model of VIC calcification using two different calcifying conditions. Upregulation of RUNX2 and BMP2 verified successful osteogenic differentiation of VICs. During osteogenic differentiation for 7 days, SOCS3 and SOCS1 are significantly upregulated (Fig. 2A).

We were able to induce EndMT by stimulating VEC with either TNFα or TGFβ/IL1β in vitro. We show that EndMT leads to the loss of endothelial cell markers like eNOS and VWF and to an upregulation of interstitial cell markers (such as Vimentin and α-SMA) and markers of EndMT (SNAI2). During EndMT, we were also able to observe a significant upregulation of SOCS1 and SOCS3 after 7 days (Fig. 2B). Ongoing knockdown experiments will help to elucidate the role of SOCS1 and SOCS3 during initiation and progression of CAVD.

Conclusion

We aim towards a better understanding of SOCS3 and its role in inflammation and calcification as hallmarks of the pathogenesis of CAVD. Since Zoledronic acid has been shown to induce a decreased expression of SOCS3 in macrophages, this might present as a possible treatment strategy to target SOCS3 therapeutically.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Deutsche Forschungsgemeinschaft