Sabato Sorrentino

Down-regulation of miR-23b induces phenotypic switching of vascular smooth muscle cells in vitro and in vivo

AIMSnPhenotypic switch of vascular smooth muscle cells (VSMCs) plays a key role in the pathogenesis of different vascular diseases, such as atherosclerosis and restenosis after coronary intervention. MicroRNAs have been identified as key regulators of VSMC biology. The miR-23b is highly expressed in VSMCs and it is involved in differentiation, proliferation, and migration of several non-vascular cell types. However, the role of miR-23b in vascular disease is currently unknown. Thus, the aim of the present study was to evaluate the role of miR-23b on VSMC phenotypic switch in vitro and after vascular injury in vivo.nnnMETHODS AND RESULTSnTo determine the changes of miR-23b expression in the injured arterial wall, we used the standard rat carotid artery balloon injury model. In vivo studies demonstrated that miR-23b is down-regulated after vascular injury. Gain-of-function studies showed that overexpression of miR-23b inhibited VSMC proliferation and migration, whereas the opposite effect was obtained with the in vitro inhibition of miR-23b. We further demonstrated that miR-23b can significantly promote the expression of VSMC marker genes such as smooth muscle α-actin (ACTA2) and smooth muscle myosin heavy chain (MYH11). Overexpression of miR-23b in balloon-injured arteries by Ad-miR-23b markedly decreased neointimal hyperplasia. Finally, miR-23b specifically suppresses urokinase-type plasminogen activator, SMAD family member 3, and transcription factor forkhead box O4 (FoxO4) expression in phenotypically modulated VSMCs. By luciferase reporter assay, we validated the transcription factor FoxO4 as a direct target of miR-23b in VSMCs.nnnCONCLUSIONSnWe identify miR-23b as a novel regulator of VSMC phenotypic switch in vitro and following vascular injury in vivo.

Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis

Patent foramen ovale (PFO) is a common finding that has been reported in 10% to 35% of persons (1, 2). The presence of PFO increases the risk for cardioembolic cerebrovascular accidents, such as stroke transient ischemic attacks (TIA), but most persons with PFOs remain asymptomatic and do not develop serious complications (2). Among young persons with a cryptogenic stroke, the prevalence of PFO is high (3), and approximately half have no apparent underlying causes (4). Because PFO may be a nest of thrombus formation or the conduit for paradoxical embolism (1, 5, 6), percutaneous closure was introduced to prevent recurrent stroke in high-risk persons (7). Until 2017, evidence and guideline recommendations did not support the routine use of PFO closure (812): Individual randomized controlled trials suggested no benefit of closure over medical therapy alone (1113), and meta-analyses of the trials showed no statistically significant reductions in recurrent stroke but possible increased risks for adverse effects (1417). In late 2017, the results of 2 new randomized trialsCLOSE (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence) and REDUCE (Gore Helex Septal Occluder/Gore Cardioform Septal Occluder for Patent Foramen Ovale Closure in Stroke Patients)as well as a long-term analysis of the RESPECT (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment) trial changed the landscape of evidence (1820). We undertook this systematic review to summarize the new evidence and compare risks for recurrent cerebrovascular events and adverse events in adults with PFO and cryptogenic stroke who received treatment with PFO closure versus those who received medical therapy alone. Methods We developed a protocol for the review on 5 June 2017 and registered it at PROSPERO (www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017074686) on 8 August 2017. Data Sources and Searches We searched PubMed, Scopus, and Google Scholar electronic databases from 1 December 2004 through 14 September 2017 using the following keywords and corresponding MeSH (Medical Subject Headings) terms: PFO closure, cryptogenic stroke, patent foramen ovale, and randomized controlled trial. We also checked the reference lists of eligible studies and screened scientific abstracts and relevant Web sites (www.clinicaltrialresults.org, www.escardio.org, www.tctmd.com, https://accscientificsession.acc.org, and https://exhibitatsessions.org). Further details on search sources are reported in Appendix Table 1. Appendix Table 1. Information on Search Sources Study Selection Two investigators (J.S and S.D.R.) independently screened search records to identify eligible trials. No disagreements occurred. Inclusion criteria were randomized controlled trials of patients with PFO and cryptogenic stroke that compared an intervention with a percutaneous PFO closure device versus medical therapy alone and reported at least 1 of the following outcomes: stroke or TIA (main outcome) or new-onset atrial fibrillation (AF) or atrial flutter (AFL). Exclusion criteria were duplicate publications, trials published in a language other than English, and studies in which the end point measure was not specified (at least stroke or TIA, or AF or AFL). Data Extraction and Quality Assessment Two reviewers (J.S. and S.D.R.) independently extracted data about study characteristics and event rates from full articles. Two investigators (S.D.R. and A.P.) independently assessed study quality for each trial by using the Cochrane Risk of Bias Tool (http://methods.cochrane.org/bias/assessing-risk-bias-included-studies). The following domains were evaluated: randomization method; allocation concealment; blinding of patient, investigator, and outcome adjudication committee; reporting bias; attrition bias; and any other potential sources of bias, such as those related to trial designs, or the risk for contamination or crossover between the groups. The assessment was done at the study level and focused on the main study outcome (stroke or TIA). Disagreements were resolved by consensus. Data Synthesis and Analysis We focused our primary summary of data on trials evaluating closure devices that are currently available commercially and used data extracted from the original primary publications (11, 12, 18, 19) because the longer-term follow-up data for 1 trial were deemed less complete because of poor retention (20). We based our primary analyses on the composite end point of stroke or TIA. We analyzed ischemic stroke and death as secondary end points and the new onset of AF or AFL, major bleeding, and serious adverse events as safety end points. We used the risk difference (RD) with 95% CI as the summary measure. The random-effects model with the HartungKnappSidikJonkman method to estimate tau was used to compute estimates for the summary effect (21, 22). We used the treatment group correction for continuity described by Sweeting and colleagues (23) when one of the study groups had zero events. We used the double arcsine transformation when both treatment groups of a study reported zero events (24). Heterogeneity was assessed by using the Cochran Q test by means of a chi-square function. P values below 0.10 were considered indicative of heterogeneity. I 2 values were calculated to estimate variation among studies attributable to heterogeneity. Meta-analysis results were displayed with forest plots in which the measure of effect (RD) for each study is represented by a square and the area of each square is proportional to study weight. A metaregression analysis was performed to examine the potential effect of interatrial shunt (IAS) size on ischemic stroke. Subgroup and sensitivity analyses were conducted using recently published long-term follow-up data (rather than the original shorter-term follow-up data) for 1 trial (20) and fixed-effects (MantelHaenszel) and random-effects (HedgesOlkin and SidikJonkman) models (22, 25, 26). Analyses were performed by using Open Meta-Analyst and R (The R Foundation). Role of the Funding Source The funding bodies had no role in the studys design, conduct, review, or reporting or the decision to submit the manuscript for publication. Results Of 114 screened records, we identified 5 trials that compared PFO closure with medical therapy (Figure 1) (1113, 1820). We excluded 1 of these studies from our primary synthesis because it evaluated a device that was removed from the market because of low procedural success and a high risk for complications (13). Another trial (12) recently reported long-term results (20), which we used only in our sensitivity analyses. Figure 1. Evidence search and selection. CLOSURE I= Evaluation of the STARFlex Septal Closure System in Patients with a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale; RCT= randomized controlled trial; RESPECT= Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment. Characteristics of the trials are presented in Tables 1 and 2 and Appendix Tables 2 and 3. All trials were multicenter, open-label superiority studies, and all except CLOSE were funded by industry. The RESPECT trial (funded by St. Jude Medical) randomly assigned 980 patients to receive either PFO closure with the Amplatzer PFO Occluder (St. Jude Medical) plus antiplatelet therapy or medical treatment alone (12). Mean follow-up was 2.6 years for the initial publication; recently, results of a prolonged follow-up (median, 5.9 years) were published (20). Between 2000 and 2009, the PC-Trial (Randomized Clinical Trial Comparing the Efficacy of Percutaneous Closure of PFO With Medical Treatment in Patients With Cryptogenic Embolism), funded by St. Jude Medical, randomly assigned 414 patients to undergo PFO closure with the Amplatzer PFO Occluder plus antiplatelet therapy or receive medical treatment at the physicians discretion. Mean follow-up was 4.0 years (11). The CLOSE study, funded by the French Ministry of Health, was a multicenter, open-label, 3-group superiority trial with blinded event adjudication. The trial was designed to enroll 900 patients with a 1:1:1 randomization to receive transcatheter PFO closure with any approved implantable medical device plus long-term antiplatelet therapy, long-term oral anticoagulation, or long-term antiplatelet therapy (18). Mean follow-up was 5.32.0 years. The open-label REDUCE study (funded by W.L. Gore and Associates) assessed the efficacy and safety of PFO closure using a Gore septal occluder device (Helex or Cardioform) in 664 patients with a history of cryptogenic stroke randomly assigned in a 2:1 proportion (19). Mean follow-up was 3.2 years. Table 1. Characteristics of Trials of PFO Closure in Adults With PFO and Cryptogenic Stroke Table 2. Characteristics of Patients in PFO Closure Trials Appendix Table 2. Definition of Large IAS Appendix Table 3. Effective PFO Closure Across All Studies Risk-of-bias assessments are reported in Appendix Figure 1. All trials used an adequate method of randomization and allocation concealment. Blinding of patients and caregivers was not possible because no sham procedure was performed in the medical treatment group in any of the trials. End point adjudication committees were blinded to the treatment strategy in all trials. Risk of selection, detection, attrition, and reporting bias was judged as low. Risk of performance bias was present. Appendix Figure 1. Study quality assessment. Quality assessment was performed at the trial level for the primary study outcome. The funding sources are listed on the right. CLOSE = Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence; PC-Trial = Randomized Clinical Trial Comparing the Efficacy of Percutaneous Closure of PFO With Medical Treatment in Patients With Crypt

The instantaneous wave-free ratio (iFR) for evaluation of non-culprit lesions in patients with acute coronary syndrome and multivessel disease

BACKGROUNDnAdenosine administration is currently required for evaluation of stenosis severity with fractional flow reserve (FFR). The instantaneous wave-free ratio (iFR) was recently introduced as an adenosine-free alternative in patients with stable CAD. The aim of the present study was to replicate the findings of previous iFR studies using an independent calculation algorithm and to evaluate the iFR for the assessment of non-culprit vessels in patients with acute coronary syndrome (ACS).nnnMETHODS AND RESULTSn53 patients with ACS (65%) and at least one non-culprit intermediate lesion and 29 (35%) with stable CAD were included. A total of 123 stenoses were evaluated with both FFR and iFR. Classification match of iFR in ACS was not inferior to stable CAD (79.5% in ACS and 84.4% in CAD; p=0.497). Accordingly, no difference was observed in iFR/FFR correlation between ACS and stable CAD (r=0.66 in ACS vs. r=0.69 in CAD). Overall, a significant correlation was found between iFR and FFR (r=0.68; p<0.001) with a good diagnostic efficiency at ROC analysis (area under the curve: 0.87). In addition, neither the localization of the stenosis within the coronary tree (p=0.147) nor the time interval from the acute event (p=0.550) significantly influenced the concordance of iFR with FFR.nnnCONCLUSIONSnThe iFR is a promising method for the assessment of non-culprit lesion severity in patients with acute coronary syndrome.

Exosomal miRNAs in Heart Disease

Micro-RNAs (miRNAs) are small noncoding RNAs involved in the posttranscriptional regulation of gene expression. Exosomes have recently emerged as novel elements of intercellular communication in the cardiovascular system. Exosomal miRNAs could be key players in intercellular cross-talk, particularly during different diseases such as myocardial infarction (MI) and heart failure (HF). This review addresses the functional role played by exosomal miRNAs in heart disease and their potential use as new biomarkers.

The duration of balloon inflation affects the luminal diameter of coronary segments after bioresorbable vascular scaffolds deployment.

BackgroundAdequate expansion is critical to achieve optimal Bioresorbable Vascular Scaffolds (BVS) apposition to the vessel wall. However, compared to metallic stents, BVS present different mechanical properties. Hence, slow deployment and maintenance of balloon inflation for at least 30” is recommended for BVS implantation. However, since no evidences are available demonstrating the superiority of a longer balloon dilatation time, the implantation technique is highly variable among different centers.MethodsA total of 24 BVS-treated lesions were included in the present analysis. After BVS deployment at 12 atmosphere (ATM) the balloon was rapidly deflated and scaffold expansion was documented with an angiogram. The same balloon was then inflated again and kept at 12 ATM for 30”. Finally, a further angiogram was obtained to evaluate BVS expansion. Quantitative coronary angiography (QCA) was performed at each step.ResultsA significant increase of minimal luminal diameter (MLD)-to-reference scaffold diameter (RSD) ratio (MLD to RSD Ration, MR-Ratio) from 0.70u2009±u20090.10 after initial stent deployment to 0.79u2009±u20090.10 after the 30”-long balloon dilation was observed (pu2009<u20090.001). Of note, this result was consistent across all sub-segments, as well as across almost all lesion subgroups. A substantial reduction in the prevalence of residual stenosis from 29xa0% to 17xa0% was registered after the 30”-long dilation.ConclusionsOur results strongly support the maintenance of balloon inflation for at least 30” during BVS deployment to achieve optimal scaffold expansion and minimize the occurrence of residual stenosis.

Impact of intracoronary adenosine administration during primary PCI: A meta-analysis.

BACKGROUNDnAim of the present study was to evaluate all randomized trials, comparing intracoronary adenosine versus placebo in STEMI patients undergoing primary PCI.nnnMETHODS AND RESULTSnPubMed, the Cochrane Library and ISI Web of Knowledge electronic databases were scanned for eligible studies up to February 23rd 2015. The summary measure used was risk ratio (RR) with 95% confidence intervals. A total of 13 studies were eligible, including 1487 patients. Incidence of ST resolution was significantly higher in the IC adenosine group than in the placebo group (RR = 1.20 [1.05–1.38]; p = 0.008). At metaregression, a significant correlation was found between the magnitude of the adenosine-related effect on ST resolution and the mean ischemic time (p = 0.011) or the percentage of patients with the LAD as the infarct-related artery (p = 0.03). Furthermore, we found a larger increase in LVEF (p = 0.02) with a parallel reduction in the incidence of heart failure (HF) (RR = 0.50 [0.28–0.89]; p = 0.02) in the IC adenosine group. Finally, IC adenosine administration was associated with a significantly lower incidence of major adverse cardiac events (MACE) both at short- (RR = 0.62 [0.39–0.98] p = 0.04) and long-term (RR = 0.61 [0.39–0.95] p = 0.03).nnnCONCLUSIONSnThis is the first meta-analysis demonstrating a clinical benefit for IC adenosine in hard endpoints, such as adverse cardiovascular events, in patients undergoing primary PCI.

miR-125a-5p Modulates Phenotypic Switch of Vascular Smooth Muscle Cells by Targeting ETS-1

MicroRNAs are key regulators of vascular smooth muscle cells (VSMCs) phenotypic switch, one of the main events responsible for bare metal in-stent restenosis after percutaneous coronary intervention. miR-125a-5p is an important modulator of differentiation, proliferation, and migration in different cell types; however, its role in VSMCs is still unknown. The aim of this study was to evaluate the role of miR-125a-5p in VSMCs phenotypic switch. Our results suggest that miR-125a-5p is highly expressed in VSMCs, but it is down-regulated after vascular injury in vivo. Its overexpression is sufficient to reduce VSMCs proliferation and migration, and it is able to promote the expression of selective VSMCs markers such as alpha smooth muscle actin, myosin heavy chain 11, and smooth muscle 22 alpha. Interestingly, miR-125a-5p directly targets ETS-1, a transcription factor implicated in cell proliferation and migration and is crucial in PDGF-BB pathway in VSMCs. Thus, miR-125a-5p in this context inhibits PDGF-BB pathway and is therefore a potential regulator of VSMCs phenotypic switch.

A novel quick and easy test for radial artery occlusion with the laser Doppler scan.

We report the results of a laser Doppler scan (PeriScan PIM III, Perimed AB, Jarfalla, Sweden) showing an ominous reduction of left-hand vascularization upon manual occlusion of the ipsilateral ulnar artery ([Fig.xa01B][1]) compared with the resting condition ([Fig.xa01A][1]), after a percutaneous

Hindlimb Ischemia Impairs Endothelial Recovery and Increases Neointimal Proliferation in the Carotid Artery

Peripheral ischemia is associated with higher degree of endothelial dysfunction and a worse prognosis after percutaneous coronary interventions (PCI). However, the role of peripheral ischemia on vascular remodeling inxa0remote districts remains poorly understood. Here we show that the presence of hindlimb ischemia significantly enhances neointima formation and impairs endothelial recovery in balloon-injured carotid arteries. Endothelial-derived microRNAs are involved in the modulation of these processes. Indeed, endothelial miR-16 is remarkably upregulated after vascular injury in the presences of hindlimb ischemia and exerts a negative effect on endothelial repair through the inhibition of RhoGDIα and nitric oxide (NO) production. We showed that the repression of RhoGDIα by means of miR-16 induces RhoA, with consequent reduction of NO bioavailability. Thus, hindlimb ischemia affects negative carotid remodeling increasing neointima formation after injury, while systemic antagonizzation of miR-16 is able to prevent these negative effects.

DIAGNOSTIC PERFORMANCE OF IFR FOR EVALUATION OF INTERMEDIATE LEFT MAIN CORONARY ARTERY STENOSES

Coronary angiography presents several limitations for the evaluation of left main (LMCA) stenoses, due to several reasons: short length, frequent overlapping with side branches, lack of a reference segment, reverse tapering. Fractional flow reserve (FFR) is a useful tool for functional evaluation of