Author + information
- Received June 18, 2018
- Revision received November 8, 2018
- Accepted December 2, 2018
- Published online March 4, 2019.
- Marion Morvan, BSa,∗,
- Dimitri Arangalage, MD, PhDa,b,c,∗,
- Grégory Franck, PhDa,∗,
- Fanny Perez, MDa,
- Léa Cattan-Levy, MDa,b,
- Isabelle Codogno, BSb,
- Marie-Paule Jacob-Lenet, PhDa,
- Catherine Deschildre, BSa,
- Christine Choqueux, BSa,
- Guillaume Even, BSa,
- Jean-Baptiste Michel, MD, PhDa,
- Magnus Bäck, MD, PhDd,
- David Messika-Zeitoun, MD, PhDa,b,c,
- Antonino Nicoletti, PhDa,c,
- Giuseppina Caligiuri, MD, PhDa,b,†∗∗ ( and )
- Jamila Laschet, PhDa,c,†∗ (, )@Inserm
- aNational Institute of Health and Medical Research U1148, Paris, France
- bDepartment of Cardiology, Bichat Hospital, Paris, France
- cFaculty of Medicine Paris-Diderot, University Paris Diderot, Sorbonne Paris Cité, Paris, France
- dDepartment of Cardiology, Karolinska University Hospital, Stockholm, Sweden
Background Intraleaflet hematomas are associated with advanced stages of aortic valve calcification and suspected to be involved in disease progression. However, the mechanism by which the entry of blood cells into the valves affects the biology of aortic valvular interstitial cells (VICs) remains to be elucidated.
Objectives This study sought to evaluate the putative link between intraleaflet hematoma and aortic valve calcification and to assess its pathophysiological implications.
Methods The spatial relationship between calcium deposits and intraleaflet hematomas was analyzed by whole-mount staining of calcified and noncalcified human aortic valves, obtained in the context of heart transplantation and from patients who underwent surgical valve replacement. Endothelial microfissuring was evaluated by en face immunofluorescence and scanning electron microscopic analyses of the fibrosa surface. Red blood cell (RBC) preparations were used in vitro to assess, by immunofluorescence microscopy and Alizarin red staining, the potential impact of intraleaflet hematomas on phenotypic changes in VICs.
Results Intraleaflet hematomas, revealed by iron deposits and RBCs into the fibrosa, secondary to endothelial microfissuring, were consistently found in noncalcified valves. The contact of primary VICs derived from these valves with RBCs resulted in a global inflammatory and osteoblastic phenotype, reflected by the up-regulation of interleukin-6, interleukin-1β, bone sialoprotein, osteoprotegerin, receptor activator of nuclear factor kappa B, bone morphogenic protein 2, and muscle segment homeobox 2, the production of osteocalcin, and the formation of calcium deposits.
Conclusions The acquisition of an osteoblastic phenotype in VICs that come into contact with the senescent RBCs of intraleaflet hematomas may play a critical role in the initiation of calcium deposition into the fibrosa of human aortic valves.
↵∗ Drs. Morvan, Arangalage, and Franck are joint first authors and contributed equally to this work.
↵† Drs. Caligiuri and Laschet are joint senior authors and contributed equally to this work.
This work was supported by the Fondation de France (FDF 2013 00038582) and by the French Government through the National Research Agency (ANR) Program Investissements d’Avenir (ANR-16-RHUS-0003_STOP-AS, and ANR16-RHUS-00010_iVASC). The GENERAC study was supported by grants from the Assistance Publique–Hôpitaux de Paris (PHRC National 2005 and 2010 and PHRC regional 2007). Dr. Franck has received research grants from the Fondation Lefoulon-Delalande and the European Union PRESTIGE program (2017-1-0032). Drs. Perez and Cattan-Levy have received grants from the Fédération Française de Cardiologie (FFC). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received June 18, 2018.
- Revision received November 8, 2018.
- Accepted December 2, 2018.
- 2019 American College of Cardiology Foundation
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