Annabelle Dupont

von Willebrand Factor as a Biological Sensor of Blood Flow to Monitor Percutaneous Aortic Valve Interventions

RATIONALE Percutaneous aortic valve procedures are a major breakthrough in the management of patients with aortic stenosis. Residual gradient and residual aortic regurgitation are major predictors of midterm and long-term outcome after percutaneous aortic valve procedures. We hypothesized that (1) induction/recovery of high molecular weight (HMW) multimers of von Willebrand factor defect could be instantaneous after acute changes in blood flow, (2) a bedside point-of-care assay (platelet function analyzer-closure time adenine DI-phosphate [PFA-CADP]), reflecting HMW multimers changes, could be used to monitor in real-time percutaneous aortic valve procedures. OBJECTIVE To investigate the time course of HMW multimers changes in models and patients with instantaneous induction/reversal of pathological high shear and its related bedside assessment. METHODS AND RESULTS We investigated the time course of the induction/recovery of HMW multimers defects under instantaneous changes in shear stress in an aortic stenosis rabbit model and in patients undergoing implantation of a continuous flow left ventricular assist device. We further investigated the recovery of HMW multimers and monitored these changes with PFA-CADP in aortic stenosis patients undergoing transcatheter aortic valve implantation or balloon valvuloplasty. Experiments in the aortic stenosis rabbit model and in left ventricular assist device patients demonstrated that induction/recovery of HMW multimers occurs within 5 minutes. Transcatheter aortic valve implantation patients experienced an acute decrease in shear stress and a recovery of HMW multimers within minutes of implantation which was sustained overtime. In patients with residual high shear or with residual aortic regurgitation, no recovery of HMW multimers was observed. PFA-CADP profiles mimicked HMW multimers recovery both in transcatheter aortic valve implantation patients without aortic regurgitation (correction) and transcatheter aortic valve implantation patients with aortic regurgitation or balloon valvuloplasty patients (no correction). CONCLUSIONS These results demonstrate that variations in von Willebrand factor multimeric pattern are highly dynamic, occurring within minutes after changes in blood flow. It also demonstrates that PFA-CADP can evaluate in real time the results of transcatheter aortic valve procedures.

Quantitative Mass Spectrometry Analysis Using PAcIFIC for the Identification of Plasma Diagnostic Biomarkers for Abdominal Aortic Aneurysm

Background Abdominal aortic aneurysm (AAA) is characterized by increased aortic vessel wall diameter (>1.5 times normal) and loss of parallelism. This disease is responsible for 1–4% mortality occurring on rupture in males older than 65 years. Due to its asymptomatic nature, proteomic techniques were used to search for diagnostic biomarkers that might allow surgical intervention under nonlife threatening conditions. Methodology/Principal Findings Pooled human plasma samples of 17 AAA and 17 control patients were depleted of the most abundant proteins and compared using a data-independent shotgun proteomic strategy, Precursor Acquisition Independent From Ion Count (PAcIFIC), combined with spectral counting and isobaric tandem mass tags. Both quantitative methods collectively identified 80 proteins as statistically differentially abundant between AAA and control patients. Among differentially abundant proteins, a subgroup of 19 was selected according to Gene Ontology classification and implication in AAA for verification by Western blot (WB) in the same 34 individual plasma samples that comprised the pools. From the 19 proteins, 12 were detected by WB. Five of them were verified to be differentially up-regulated in individual plasma of AAA patients: adiponectin, extracellular superoxide dismutase, protein AMBP, kallistatin and carboxypeptidase B2. Conclusions/Significance Plasma depletion of high abundance proteins combined with quantitative PAcIFIC analysis offered an efficient and sensitive tool for the screening of new potential biomarkers of AAA. However, WB analysis to verify the 19 PAcIFIC identified proteins of interest proved inconclusive save for five proteins. We discuss these five in terms of their potential relevance as biological markers for use in AAA screening of population at risk.

Frequency of Abdominal Aortic Aneurysm in Patients Undergoing Coronary Artery Bypass Grafting

The aims of this study were to clarify the prevalence and the risk factors for unsuspected abdominal aortic aneurysm (AAA) in patients who underwent coronary artery bypass grafting for severe coronary artery disease and to identify the most at risk patients for AAA. Among 217 patients (189 men, mean age 64 +/- 11 years), asymptomatic AAAs, as prospectively identified by echocardiography, were found in 15 patients (6.9%). All patients with AAAs were men and smokers or past smokers. Factors significantly associated by univariate analysis with asymptomatic AAA presence were smoking (p = 0.003), symptomatic peripheral artery disease (p = 0.006), significant carotid artery stenosis (p = 0.007), and larger femoral and popliteal diameters (p = 0.008 and p = 0.0012, respectively). The other classic demographic, clinical, and biologic features were equally distributed among patients. In conclusion, in patients who underwent coronary artery bypass grafting who were men and aged <75 years with smoking histories, the prevalence of AAA was as high as 24% when they had concomitant peripheral arterial disease and/or carotid artery stenosis (vs 4.4% in the absence of either condition, p = 0.007), justifying consideration of AAA screening in this subgroup of in-hospital patients.

Application of Saturation Dye 2D-DIGE Proteomics to Characterize Proteins Modulated by Oxidized Low Density Lipoprotein Treatment of Human Macrophages

Macrophages are believed to play a crucial role in atherogenesis and atherosclerotic plaque progression, mainly through their role in the accumulation of large amounts of cholesteryl ester and foam cell formation after the uptake into the arterial intima of oxidized LDL (oxLDL) particles known to be proatherogenic. The aim of this study was to use a differential proteomic approach to identify the response of human monocyte-derived macrophages after treatment with oxLDL for 24 h. Mass spectrometry analysis (MALDI-TOF) of 2D-DIGE gels made it possible to identify 9 intracellular and 3 secreted proteins that were up-regulated, 11 intracellular and 1 secreted proteins that were down-regulated, and 2 secreted proteins that were induced. This methodological approach not only confirmed the differential expression levels of proteins known to be regulated by oxLDL in macrophages, such as catalase and pyruvate kinase, but also identified oxLDL modulation of other proteins for the first time, including heat shock proteins (HSP) and Actin cytoskeletal proteins. Semiquantitative Western blot confirmed their role. The HSPs identified included heat shock cognate 71 kDa protein (Hsc70), 75 kDa glucose-regulated protein (GRP75), heat shock 70 kDa protein (Hsp70), and 60 kDa (Hsp60) proteins. These highly conserved intracellular protein chaperones, commonly seen in atherosclerotic plaques, appear to participate in protection against cellular stress. Interestingly, oxLDL also modulated several F-Actin capping proteins involved in Actin polymerization and motility: gelsolin, CapG, and CapZ. In conclusion, we have demonstrated the effects of oxLDL in the modulation of several proteins in human macrophages and established a functional profile of the human macrophage during the atherosclerotic process.

M1 and M2 macrophage proteolytic and angiogenic profile analysis in atherosclerotic patients reveals a distinctive profile in type 2 diabetes

This study aimed to investigate atherosclerotic mediators’ expression levels in M1 and M2 macrophages and to focus on the influence of diabetes on M1/M2 profiles. Macrophages from 36 atherosclerotic patients (19 diabetics and 17 non-diabetics) were cultured with interleukin-1β (IL-1β) or IL-4 to induce M1 or M2 phenotype, respectively. The atherosclerotic mediators’ expression was evaluated by quantitative reverse transcription-polymerase chain reaction (RT-PCR). The results showed that M1 and M2 macrophages differentially expressed mediators involved in proteolysis and angiogenesis processes. The proteolytic balance (matrix metalloproteinase-9 (MMP-9)/tissue inhibitor of metalloproteinase-1 (TIMP-1), MMP-9/plasminogen activator inhibitor-1 (PAI-1) and MMP-9/tissue factor pathway inhibitor-2 (TFPI-2) ratios) was higher in M1 versus M2, whereas M2 macrophages presented higher angiogenesis properties (increased vascular endothelial growth factor/TFPI-2 and tissue factor/TFPI-2 ratios). Moreover, M1 macrophages from diabetics displayed more important proangiogenic and proteolytic activities than non-diabetics. This study reveals that M1 and M2 macrophages could differentially modulate major atherosclerosis-related pathological processes. Moreover, M1 macrophages from diabetics display a deleterious phenotype that could explain the higher plaque vulnerability observed in these subjects.

Arterial Pulsatility and Circulating von Willebrand Factor in Patients on Mechanical Circulatory Support

BACKGROUND The main risk factor for bleeding in patients with continuous-flow mechanical circulatory support (CF-MCS) is the acquired von Willebrand factor (VWF) defect related to the high shear-stress forces developed by these devices. Although a higher bleeding rate has been reported in CF-MCS recipients who had reduced pulsatility, the relation between pulsatility and the VWF defect has never been studied. OBJECTIVES The purpose of this study was to investigate the relation between pulsatility and VWF under CF-MCS. METHODS We assessed the effect of 2 CF-MCS on VWF multimer degradation in a mock circulatory loop (model 1). Using these devices, we investigated in a dose-effect model (model 2) 3 levels of pulsatility in 3 groups of swine. In a cross-over model (model 3), we studied the effects of sequential changes of pulsatility on VWF. We reported the evolution of VWF multimerization in a patient undergoing serial CF-MCS and/or pulsatile-MCS. RESULTS We demonstrated the proteolytic degradation of VWF multimers by high shear CF-MCS in a circulatory loop without pulsatility. We observed both in swine models and in a patient that the magnitude of the VWF degradation is modulated by the pulsatility level in the high shear-stress level condition, and that the restoration of pulsatility is a trigger for the endothelial release of VWF. CONCLUSIONS We demonstrated that the VWF defect reflects the balance between degradation induced by the shear stress and the endothelial release of new VWF triggered by the pulsatility. This modulation of VWF levels could explain the relationship between pulsatility and bleeding observed in CF-MCS recipients. Preservation of pulsatility may be a new target to improve clinical outcomes of patients.

Abdominal Aortic Aneurysm in Patients with Coronary Artery Disease: A Review Article

Abdominal Aortic Aneurysm (AAA) is defined as a localized and permanent dilatation of the abdominal aorta, beyond 50% of the normal aorta diameter (Schermerhorn, 2009). The prevalence of AAA ranges from 1.3% to 8.9% in men and 1% to 2.2% in women (Sakalihasan et al., 2005; Singh et al., 2001). Incidence of AAA is on the rise in parallel with a globally ageing population, higher clinical suspicion and improved accuracy of imaging methods (Best et al., 2003; Prisant & Mondy, 2004). AAA is an important problem for public health, since AAA rupture is the tenth leading cause of death in American white men 65 to 74 years of age (Upchurch & Schaub, 2006). Most AAA remain asymptomatic until rupture occurs. Half of the patients with a ruptured AAA reach the hospital alive, with an additional operative mortality of 30-60%. On the contrary, an elective AAA repair, recommended in most patients with an abdominal aortic diameter exceeding 50-55 mm or rapid growth (> 1 cm/y), is associated with a mortality risk of 2% to 6% (Kurvers at al., 2003; Sakalihasan et al., 2005). Health organizations recently recommended one-time screening for AAA by ultrasonography for men aged between 65 and 75 years with a smoking history, thereby reducing AAA related mortality rates by 50% (Cosford & Leng, 2007; Ehlers et al., 2008; Ferket et al., 2011; Moxon et al., 2010; Takagi et al., 2010). However, they advised against screening in men below 65 and over 75 years, and in women, since the number of AAArelated deaths that can be prevented by screening these populations is too small. AAA and atherosclerosis share several risk factors, such as male sex, age, smoking and arterial hypertension (Forsdahl et al., 2009). In population – based studies, AAA is independently associated with pre – existing coronary arterial disease (CAD) (Golledge et al., 2006; Kent et al., 2010). The high prevalence of CAD among patients with AAA is well known, with an impact on short term survival after AAA repair (Falk et al., 1997). Indeed, coronary investigation is often required prior to aortic surgery, finding a concomitant CAD prevalence of 31% to 90% (Kioka et al., 2002; Sukhija et al., 2004; Van Kuijk et al., 2009). In contrast, the opposite relationship, namely the prevalence of AAA among patients with CAD, has been explored only in some recent cohorts or in subgroups of patients. The possibility that AAA could be more prevalent in this population, as compared with the general population, has been suggested by these previous studies, with limited, incomplete

Real-Time Monitoring of von Willebrand Factor in the Catheterization Laboratory: The Seatbelt of Mini-Invasive Transcatheter Aortic Valve Replacement?

Significant paravalvular regurgitation (PVR) remains a relatively frequent (4% to 9%) and deleterious complication of transcatheter aortic valve replacement (TAVR), even with the latest generation of bioprosthesis. Although mini-invasive TAVR without general anesthesia or transesophageal echocardiography (TEE) is progressively becoming the predominant approach, identification and grading of PVR in the catheterization laboratory remain an important and challenging clinical issue. The authors discuss how a recently reported blood biomarker reflecting the von Willebrand factor activity, that is, the closure time with adenosine diphosphate, can be successfully applied during the TAVR procedure to detect and monitor PVR in real time, with an excellent negative predictive value. This point-of-care testing performed directly in the catheterization laboratory may improve the diagnosis of PVR and rationalize the decision of whether or not to perform corrective measures. They further discuss how such a test could be a substitute for the multimodal approach combining TEE, hemodynamics, and cine-angiography, and help to secure the transition to the mini-invasive approach and facilitate the expanding indications of less invasive procedures to lower-risk patients without jeopardizing procedural and clinical outcomes.