Paolo Biglioli

Circulating microRNAs are new and sensitive biomarkers of myocardial infarction

Aims Circulating microRNAs (miRNAs) may represent a novel class of biomarkers; therefore, we examined whether acute myocardial infarction (MI) modulates miRNAs plasma levels in humans and mice. Methods and results Healthy donors (n = 17) and patients (n = 33) with acute ST-segment elevation MI (STEMI) were evaluated. In one cohort (n = 25), the first plasma sample was obtained 517 ± 309 min after the onset of MI symptoms and after coronary reperfusion with percutaneous coronary intervention (PCI); miR-1, -133a, -133b, and -499-5p were ∼15- to 140-fold control, whereas miR-122 and -375 were ∼87–90% lower than control; 5 days later, miR-1, -133a, -133b, -499-5p, and -375 were back to baseline, whereas miR-122 remained lower than control through Day 30. In additional patients (n = 8; four treated with thrombolysis and four with PCI), miRNAs and troponin I (TnI) were quantified simultaneously starting 156 ± 72 min after the onset of symptoms and at different times thereafter. Peak miR-1, -133a, and -133b expression and TnI level occurred at a similar time, whereas miR-499-5p exhibited a slower time course. In mice, miRNAs plasma levels and TnI were measured 15 min after coronary ligation and at different times thereafter. The behaviour of miR-1, -133a, -133b, and -499-5p was similar to STEMI patients; further, reciprocal changes in the expression levels of these miRNAs were found in cardiac tissue 3–6 h after coronary ligation. In contrast, miR-122 and -375 exhibited minor changes and no significant modulation. In mice with acute hind-limb ischaemia, there was no increase in the plasma level of the above miRNAs. Conclusion Acute MI up-regulated miR-1, -133a, -133b, and -499-5p plasma levels, both in humans and mice, whereas miR-122 and -375 were lower than control only in STEMI patients. These miRNAs represent novel biomarkers of cardiac damage.

Atrial fibrillation after isolated coronary surgery affects late survival.

Background— Atrial fibrillation (AF) after coronary artery bypass graft surgery is a difficult problem and a continuing source of morbidity and mortality. However, the prognostic implications of postoperative AF are still in dispute. Our aim was to ascertain the impact of AF after coronary artery bypass graft on postoperative survival and to assess its prognostic role in cause-specific mortality. Methods and Results— We conducted a prospective observational study of 1832 patients undergoing isolated coronary artery bypass graft between January 2000 and December 2005 at 2 cardiac surgery centers in northern Italy. Patients affected by postoperative AF were identified and followed up until death or study end (April 30, 2007). A total of 570 patients (31%) developed AF after coronary surgery. Patients affected by postoperative AF experienced a longer hospital stay (7 days [25th to 75th percentile, 7 to 10 days] versus 7 days [25th to 75th percentile, 6 to 8 days]; P<0.001). Hospital mortality also was higher in AF patients (3.3% versus 0.5%; P<0.001). On discharge, 1806 patients were alive; 143 were lost to follow-up. The remaining 1663 were followed up for a median of 51 months (25th to 75th percentile, 41 to 63 months); 126 of them died after a median of 14 months (25th to 75th percentile, 5 to 32 months). Long-term mortality rates were significantly higher for patients with postoperative AF (2.99 per 100 person-years; 95% confidence interval, 2.33 to 3.84; 61 deaths) compared with those without the arrhythmia (1.34 per 100 person-years; 95% confidence interval, 1.05 to 1.71; 65 deaths), with an adjusted hazard ratio of 2.13 (P<0.001) and 2.56 (P=0.001) when also accounting for the prescription of warfarin at discharge. With Cox regression, patients with AF were shown to be at higher risk of dying from embolism (adjusted hazard ratio, 4.33; 95% confidence interval, 1.78 to 10.52) but not from other causes. Conclusions— Postoperative AF affects early and late mortality after isolated coronary artery bypass graft surgery. Patients affected by AF are at higher risk of fatal embolic events. Careful postoperative surveillance with a specific antiarrhythmic and antithrombotic prophylaxis, aimed at reducing AF and its complications, is recommended.

Vascular Endothelial Growth Factor Modulates Skeletal Myoblast Function

Vascular endothelial growth factor (VEGF) expression is enhanced in ischemic skeletal muscle and is thought to play a key role in the angiogenic response to ischemia. However, it is still unknown whether, in addition to new blood vessel growth, VEGF modulates skeletal muscle cell function. In the present study immunohistochemical analysis showed that, in normoperfused mouse hindlimb, VEGF and its receptors Flk-1 and Flt-1 were expressed mostly in quiescent satellite cells. Unilateral hindlimb ischemia was induced by left femoral artery ligation. At day 3 and day 7 after the induction of ischemia, Flk-1 and Flt-1 were expressed in regenerating muscle fibers and VEGF expression by these fibers was markedly enhanced. Additional in vitro experiments showed that in growing medium both cultured satellite cells and myoblast cell line C2C12 expressed VEGF and its receptors. Under these conditions, Flk-1 receptor exhibited constitutive tyrosine phosphorylation that was increased by VEGF treatment. During myogenic differentiation Flk-1 and Flt-1 were down-regulated. In a modified Boyden Chamber assay, VEGF enhanced C2C12 myoblasts migration approximately fivefold. Moreover, VEGF administration to differentiating C2C12 myoblasts prevented apoptosis, while inhibition of VEGF signaling either with selective VEGF receptor inhibitors (SU1498 and CB676475) or a neutralizing Flk-1 antibody, enhanced cell death approximately 3.5fold. Finally, adenovirus-mediated VEGF165 gene transfer inhibited ischemia-induced apoptosis in skeletal muscle. These results support a role for VEGF in myoblast migration and survival, and suggest a novel autocrine role of VEGF in skeletal muscle repair during ischemia. (Am J Pathol 2003, 163:1417–1428)

Biological effects of off-pump vs. on-pump coronary artery surgery: focus on inflammation, hemostasis and oxidative stress

Cardiopulmonary bypass (CPB) has been recognized as a cause of complex systemic inflammatory response, which significantly contributes to several adverse postoperative complications. In the last few years, off-pump coronary artery bypass grafting has gained widespread diffusion as an alternative technique to conventional on-pump coronary artery bypass grafting. Surgeons supporting off-pump surgery state that the avoidance of the CPB and myocardial ischemia-reperfusion significantly reduces the postoperative systemic inflammatory response and other biological derangements and, possibly, may improve the clinical outcomes. We review, here, the available evidence concerning possible differences between off-pump and on-pump procedures in terms of inflammation, hemostasis and oxidative stress. Consistent differences in the involvement of these systems are observed, but they are limited to the final steps of the surgical procedures and the early hours after. These findings suggest that the global surgical trauma may be as important, or even more, as the CPB in terms of systemic inflammatory and coagulation-fibrinolytic pathway activation. Further studies are needed in order to confirm this hypothesis.

Epigenetic Histone Modification and Cardiovascular Lineage Programming in Mouse Embryonic Stem Cells Exposed to Laminar Shear Stress

Experimental evidence indicates that shear stress (SS) exerts a morphogenetic function during cardiac development of mouse and zebrafish embryos. However, the molecular basis for this effect is still elusive. Our previous work described that in adult endothelial cells, SS regulates gene expression by inducing epigenetic modification of histones and activation of transcription complexes bearing acetyltransferase activity. In this study, we evaluated whether SS treatment could epigenetically modify histones and influence cell differentiation in mouse embryonic stem (ES) cells. Cells were exposed to a laminar SS of 10 dyne per cm2/s−1, or kept in static conditions in the presence or absence of the histone deacetylase inhibitor trichostatin A (TSA). These experiments revealed that SS enhanced lysine acetylation of histone H3 at position 14 (K14), as well as serine phosphorylation at position 10 (S10) and lysine methylation at position 79 (K79), and cooperated with TSA, inducing acetylation of histone H4 and phosphoacetylation of S10 and K14 of histone H3. In addition, ES cells exposed to SS strongly activated transcription from the vascular endothelial growth factor (VEGF) receptor 2 promoter. This effect was paralleled by an early induction of cardiovascular markers, including smooth muscle actin, smooth muscle protein 22-&agr;, platelet-endothelial cell adhesion molecule-1, VEGF receptor 2, myocyte enhancer factor-2C (MEF2C), and &agr;-sarcomeric actin. In this condition, transcription factors MEF2C and Sma/MAD homolog protein 4 could be isolated from SS-treated ES cells complexed with the cAMP response element-binding protein acetyltransferase. These results provide molecular basis for the SS-dependent cardiovascular commitment of mouse ES cells and suggest that laminar flow may be successfully applied for the in vitro production of cardiovascular precursors.

Off-pump versus on-pump coronary artery bypass: meta-analysis of currently available randomized trials

BACKGROUND Off-pump coronary artery bypass (OPCAB) challenges the conventional on-pump coronary artery bypass grafting (CABG) as the standard of surgical therapy for coronary disease. The aim of this study is to assess the differences in clinical outcomes between CABG and OPCAB by meta-analysis of data published in randomized trials. METHODS A literature search (Medline, Pubmed, Cochrane Controlled Trials Register, and the Cochrane Medical Editors Trial Amnesty of unpublished clinical trials) was done for the period starting from January 1990 until May 2002 and was supplemented with a manual bibliographic review for all peer-reviewed English language publications. A systematic overview (meta-analysis) of the randomized trials was done to define the risk of the composite end point (death, stroke, or myocardial infarction) in CABG versus OPCAB. RESULTS A literature search yielded nine comparable randomized studies, for a total of 1090 patients, of whom 558 and 532 were randomly assigned to CABG and OPCAB, respectively. Meta-analysis of these studies showed a trend, albeit not statistically significant, toward reduction in the risk of the composite end point for patients who had OPCAB (odds ratio 0.48; 95% confidence interval 0.21 to 1.09; p = 0.08). CONCLUSIONS Cumulative analysis of the few prospective randomized studies currently available found a potential clinical benefit of OPCAB, indicating that the avoidance of extracorporeal circulation might result in improved clinical outcomes. Further evidence, however, from large randomized trials is needed to assess potential advantages of OPCAB in terms of early outcomes.

High-Mobility Group Box 1 Protein in Human and Murine Skin: Involvement in Wound Healing

High-mobility group box 1 (HMGB1) protein is a multifunctional cytokine involved in inflammatory responses and tissue repair. In this study, it was examined whether HMGB1 plays a role in skin wound repair both in normoglycemic and diabetic mice. HMGB1 was detected in the nucleus of skin cells, and accumulated in the cytoplasm of epidermal cells in the wounded skin. Diabetic human and mouse skin showed more reduced HMGB1 levels than their normoglycemic counterparts. Topical application of HMGB1 to the wounds of diabetic mice enhanced arteriole density, granulation tissue deposition, and accelerated wound healing. In contrast, HMGB1 had no effect in normoglycemic mouse skin wounds, where endogenous HMGB1 levels may be adequate for optimal wound closure. Accordingly, inhibition of endogenous HMGB1 impaired wound healing in normal mice but had no effect in diabetic mice. Finally, HMGB1 had a chemotactic effect on skin fibroblasts and keratinoyctes in vitro. In conclusion, lower HMGB1 levels in diabetic skin may play an important role in impaired wound healing and this defect may be overcome by the topical application of HMGB1.

Shear Stress–Mediated Chromatin Remodeling Provides Molecular Basis for Flow-Dependent Regulation of Gene Expression

&NA; Shear stress (SS), the tangential component of hemodynamic forces, modulates the expression of several genes in endothelial cells. However, no information is available about its effect on chromatin structure, which plays a key role in gene transcription. In this study, a link between SS and chromatin remodeling was established in human umbilical vein endothelial cells (HUVECs). HUVECs were exposed to SS of 10 dyne/cm2 per second, in the presence or absence of the histone deacetylase inhibitor trichostatin A, and assayed for histone H3 and histone H4 modifications. SS induced histone H3 serine phosphorylation at position 10 (S10) and lysine acetylation at position 14 (K14) but required trichostatin A to induce H3 phosphoacetylation and H4 acetylation. The phosphatidylinositol 3‐kinase inhibitor wortmannin and the mitogen‐activated protein kinase inhibitor PD98059 decreased SS‐dependent histone H3 phosphorylation, without affecting its acetylation; the p38 inhibitor SB203580 reduced both H3 phosphorylation and acetylation, whereas the protein kinase A inhibitor PKI‐tide reduced histone H3 acetylation. Remarkably, the abrogation of histone acetylation inhibited SS‐dependent c‐fos expression. SS also activated ribosomal S6 kinase‐2 and mitogenand stress‐activated kinase‐1 protein kinases and promoted the formation of a cAMP‐responsive element‐binding protein (CREB)/CREB‐binding protein complex, providing the molecular basis for the increase in histone acetyltransferase activity observed in HUVECs exposed to SS. Finally, the effect of SS on chromatin remodeling was examined. In HUVECs exposed to SS, chromatin within c‐fos and c‐jun promoters was specifically immunoprecipitated by an antibody against acetylated histone H3 on K14. These results indicate that SS induces posttransduction modifications of histones; this is an early step toward the flow‐dependent regulation of gene expression. (Circ Res. 2003;93:155‐161.)

Impact of left ventricular systolic function on clinical and echocardiographic outcomes following transcatheter aortic valve implantation for severe aortic stenosis

BACKGROUND This study aimed to evaluate the impact of baseline left ventricular (LV) systolic function on clinical and echocardiographic outcomes following transcatheter aortic valve implantation (TAVI). Survival of patients undergoing TAVI was also compared with that of a population undergoing surgical aortic valve replacement. METHODS One hundred forty-seven consecutive patients (mean age=80±7 years) undergoing TAVI in 2 centers were included. Mean follow-up period was 9.1±5.1 months. RESULTS At baseline, 34% of patients had impaired LV ejection fraction (LVEF) (<50%) and 66% had normal LVEF (≥50%). Procedural success was similar in these 2 groups (94% vs 97%, P=.41). All patients achieved improvement in transvalvular hemodynamics. At follow-up, patients with a baseline LVEF<50% showed marked LV reverse remodeling, with improvement of LVEF (from 37%±8% to 51%±11%). Early and late mortality rates were not different between the 2 groups, despite a higher rate of combined major adverse cardiovascular events (MACEs) in patients with a baseline LVEF<50%. The predictors of cumulative MACEs were baseline LVEF (HR=0.97, 95% CI=0.94-0.99) and preoperative frailty (HR=4.20, 95% CI=2.00-8.84). In addition, long-term survival of patients with impaired or normal LVEF was comparable with that of a matched population who underwent surgical aortic valve replacement. CONCLUSIONS TAVI resulted in significant improvement in LV function and survival benefit in high-risk patients with severe aortic stenosis, regardless of baseline LVEF. Patients with a baseline LVEF<50% were at higher risk of combined MACEs.

p66ShcA Modulates Tissue Response to Hindlimb Ischemia

Background—Oxidative stress plays a pivotal role in ischemia and ischemia/reperfusion injury. Because p66ShcA-null (p66ShcA−/−) mice exhibit both lower levels of intracellular reactive oxygen species and increased resistance to cell death induced by oxidative stress, we investigated whether tissue damage that follows acute ischemia or ischemia/reperfusion was altered in p66ShcA−/− mice. Methods and Results—Unilateral hindlimb ischemia was induced by femoral artery dissection, and ischemia/reperfusion was induced with an elastic tourniquet. Both procedures caused similar changes in blood perfusion in p66ShcA wild-type (p66ShcAwt) and p66ShcA−/− mice. However, significant differences in tissue damage were found: p66ShcAwt mice displayed marked capillary density decrease and muscle fiber necrosis. In contrast, in p66ShcA−/− mice, minimal capillary density decrease and myofiber death were present. When apoptosis after ischemia was assayed, significantly lower levels of apoptotic endothelial cells and myofibers were found in p66ShcA−/− mice. In agreement with these data, both satellite muscle cells and endothelial cells isolated from p66ShcA−/− mice were resistant to apoptosis induced by simulated ischemia in vitro. Lower apoptosis levels after ischemia in p66ShcA−/− cells correlated with decreased levels of oxidative stress both in vivo and in vitro. Conclusions—p66ShcA plays a crucial role in the cell death pathways activated by acute ischemia and ischemia/reperfusion, indicating p66ShcA as a potential therapeutic target for prevention and treatment of ischemic tissue damage.