A Novel Designed Valved Conduit for RVOT Reconstruction in Grown-up Congenital Heart Patients: a Glimpse Down the Road.

BACKGROUND: A plethora of valves and valve conduits are available for reconstruction of the right ventricular outflow tract (RVOT) for grown-up congenital heart patients. However, for several reasons, the ideal pulmonary valve substitute still remains the subject of debate. In this study, we investigated the preliminary clinical and echocardiographic results after implantation of the RVOT Elan (Vascutek, Renfrewshire, United Kingdom) conduit in adolescents and adults. MATERIAL AND METHODS: Between October 2012 and December 2014, a total of 27 patients (19 males, mean age: 23.7 ± 22.5; range: 9-74 years) received a RVOT Elan conduit for RVOT reconstruction and were prospectively followed up clinically and echocardiographically. Twenty-five patients had previous cardiac surgery. The median number of prior operations per patient was 2 (range: 1-4). Tetralogy of Fallot was the most common diagnosis (n = 7). RESULTS: At a mean follow-up time of 0.9 ± 0.61 years (100% complete), all patients (27 of 27) were alive and in New York Heart Association Class I. Adverse events defined as valve failure, thrombosis, embolism, bleeding, or endocarditis did not occur. Freedom from reoperation in general was 100%. At 1-year follow-up, median peak pressure gradients (Δ Pmax) across the RVOT Elan conduit were 15 ± 3.2; 15.3 ± 2.1Δ, 16 ± 4.8, and 16.3 ± 5.1 mm Hg for the 19 (n = 3), 21 (n = 3), 23 (n = 6), and 25 mm (n = 15) conduit size, respectively. CONCLUSION: The RVOT Elan conduit revealed excellent preliminary clinical and hemodynamic performances independent from the underlying cardiac pathology with insignificant transvalvular gradients and nonturbulent flow characteristics.

Endoscopic Resection of a Giant Left Atrial Appendage.

A 23-year-old woman with a history of arterial hypertension presented to our institution complaining of dyspnea and chest pain. Her workup including echocardiography and magnetic resonance imaging revealed an aneurysm of the left atrial appendage. No thrombus was identified in the aneurysm or left atrial appendage, and the patient was in sinus rhythm. She was started on prophylactic anticoagulation, and surgical resection of the aneurysm was recommended as a definitive treatment of this lesion. The surgery was performed using a minimally invasive left-sided thoracoscopy approach. The entire left atrial appendage including the aneurysm was removed at its base using an articulating endoscopic stapler device. On postoperative echocardiography, no residual left atrial appendage tissue was evident. The patient could be taken off oral anticoagulation and left the hospital in good condition.

Aortic valve/root procedures in patients with an anomalous left circumflex coronary artery and a bicuspid aortic valve: anatomical and technical implications.

An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery from the right coronary sinus of Valsalva encircling the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy in patients with an anomalous left circumflex coronary artery, a bicuspid aortic valve morphology and different aortic valve pathologies.

Characterization of a modified ROCK2 protein that allows use of N6-ATP analogs for the identification of novel substrates.

BACKGROUND: The Rho-associated coiled-coil kinase-2 (ROCK2) is an important signaling transducer in the transmission of extracellular signals effecting organization of the actin cytoskeleton. ROCK2 has been implicated in numerous pathologies and the current focus is on understanding the molecular events that couple ROCK2 activity to biological function. To aid in the search for new ROCK2 substrates, we have developed an analog-sensitive (AS) ROCK2 protein that allows the use of selective ATP analogs that are not efficiently utilized by other protein kinases. RESULTS: The analog sensitive protein, M160A ROCK2, was highly active and could phosphorylate proteins from a cellular homogenate with γ32P-N6 (benzyl)ATP. We show the utility of this approach by identifying a putative ROCK2 substrate, elongation initiation factor-1-α1. We further show that the major site of ROCK2 phosphorylation of EIF1α1 is Thr432. CONCLUSIONS: Our work demonstrates that AS-ROCK2 could be useful in a systematic proteomic approach for identifying novel ROCK2 substrates.

The role of adiponectin signaling in metabolic syndrome and cancer.

The increased prevalence of obesity has mandated extensive research focused on mechanisms responsible for associated clinical complications. Emerging from the focus on adipose tissue biology as a vitally important adipokine is adiponectin which is now believed to mediate anti-diabetic, anti-atherosclerotic, anti-inflammatory, cardioprotective and cancer modifying actions. Adiponectin mediates these primarily beneficial effects via direct signaling effects and via enhancing insulin sensitivity via crosstalk with insulin signaling pathways. Reduced adiponectin action is detrimental and occurs in obesity via decreased circulating levels of adiponectin action or development of adiponectin resistance. This review will focus on cellular mechanisms of adiponectin action, their crosstalk with insulin signaling and the resultant role of adiponectin in cardiovascular disease, diabetes and cancer and reviews data from in vitro cell based studies through animal models to clinical observations.

Valve-sparing reimplantation technique for treatment of neoaortic root dilatation late after the arterial switch operation: raising the bar.

Neoaortic root dilatation can develop during long-term follow-up after an arterial switch operation (ASO). Although few patients require surgical reintervention, significant valve regurgitation is still an important cause of late morbidity. We report on a 15-year-old boy with significant dilatation of the neoaortic root that was treated with the valve-sparing reimplantation technique. There is only one reported case of valve-preserving surgery late after the ASO. Valve preservation is believed to be superior to valve replacement in patients with aortic regurgitation due to better hemodynamic performance and avoidance of anticoagulation therapy.

Adverse results of a decellularized tissue-engineered pulmonary valve in humans assessed with magnetic resonance imaging.

OBJECTIVES: Matrix P® and Matrix P plus® tissue-engineered pulmonary valves (TEPV) were offered as an improvement for pulmonary valve replacement (PVR) because of recellularization by host cells. The high frequency of graft failure gave reason to evaluate the underlying morphological substrate using magnetic resonance imaging (MRI) and histology. METHODS: Between June 2006 and August 2008, 17 Matrix P® and 10 Matrix P plus® TEPVs were implanted in 26 patients with a median age of 12.4 (range: 0.8-38.7, interquartile range: 6.1-18.1) years. The grafts were studied by MRI, and underwent histological examination when explantation was required. RESULTS: Surgical (n = 13) or transcatheter (n = 1) TEPV replacement because of graft failure was needed in 14 cases (52%) 19 (0.5-53) months after implantation. MRI detected significant TEPV stenosis with mild insufficiency (V(max) = 3.7 ± (standard deviation) 0.5 m/s, regurgitant fraction (RGF) = 10 ± 3%) and stenosis with moderate-to-severe insufficiency (V(max) = 3.5 ± 0.8 m/s, RGF = 38 ± 10%) in 6 patients, respectively, and severe insufficiency (RGF = 40%) in 1 patient. In patients with graft failure, MRI showed hyperenhancement and TEPV wall thickening. Histology revealed severe inflammation, increased fibrous tissue and foreign-body reaction against valve leaflets and fascial tissue, while TEPV endothelialization was not detected in any case. CONCLUSIONS: The high frequency of Matrix P® and Matrix P plus® graft failure can be related to inflammation and fibrosis revealed by MRI and histology. Our results do not support the use of these valves for PVR and suggest careful follow-up examinations, including MRI for early detection of graft inflammation and fibrosis.

The MYC-associated protein CDCA7 is phosphorylated by AKT to regulate MYC-dependent apoptosis and transformation.

Cell division control protein A7 (CDCA7) is a recently identified target of MYC-dependent transcriptional regulation. We have discovered that CDCA7 associates with MYC and that this association is modulated in a phosphorylation-dependent manner. The prosurvival kinase AKT phosphorylates CDCA7 at threonine 163, promoting binding to 14-3-3, dissociation from MYC, and sequestration to the cytoplasm. Upon serum withdrawal, induction of CDCA7 expression in the presence of MYC sensitized cells to apoptosis, whereas CDCA7 knockdown reduced MYC-dependent apoptosis. The transformation of fibroblasts by MYC was reduced by coexpression of CDCA7, while the non-MYC-interacting protein Δ(156-187)-CDCA7 largely inhibited MYC-induced transformation. These studies provide insight into a new mechanism by which AKT signaling to CDCA7 could alter MYC-dependent growth and transformation, contributing to tumorigenesis.

Cutaneo-pericardial fistula after transapical aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) represents a therapeutic option of increasing impact for the treatment of high-risk patients with symptomatic, severe aortic valve stenosis. We report here the case of an 86-year old patient with a cutaneo-pericardial fistula after a transapical TAVI procedure.

Serine 396 of PDK1 is required for maximal PKB activation.

Protein kinase B (PKB; also known as Akt) is important for mediating survival and proliferation signals. Following activation, PKB shuttles to various compartments of the cell, including the nucleus, where it phosphorylates an array of targets. PKB is phosphorylated at T308 by its activator PDK1. PDK1 is normally excluded from the nucleus via a nuclear exclusion sequence (NES), and our previous work suggested that nuclear exclusion can be attenuated by IGF-1-induced phosphorylation of S396 proximal to the NES. No studies have been done to test the significance of S396 phosphorylation or the impact of nuclear accumulation of PDK1 on PKB activation. To address these questions, we created isogenic embryonic stem cell (ESC) lines expressing various alleles of PDK1 within a PDK1-/- background. Disruption of the NES domain of PDK1 correlated with elevated PKB phosphorylation at both T308 and S473. In contrast, mutation of S396 to alanine reduced PDK1 nuclear localization and reduced PKB phosphorylation and activation. The loss of phosphorylation of PKB by S396A mutation was rescued by forcing nuclear PDK1 or by conversion of S396 to an aspartic acid. The phosphorylation of the PKB substrate FOXO3alpha was reduced in S396A PDK1 ESC. Other known and suspected PKB substrates, including GSK3 and Raf1, were unaffected. This study therefore reveals that S396 plays a role in the activation of PKB leading to the regulated phosphorylation of some PKB substrates including FOXO3alpha.

Phosphorylation of MEKK3 at threonine 294 promotes 14-3-3 association to inhibit nuclear factor kappaB activation.

The protein kinase MEKK3 is essential for tumor necrosis factor alpha (TNFalpha)- and lipopolysaccharide-induced activation of nuclear factor kappaB, although the mechanism by which TNF receptor 1 and Toll-like receptors regulate MEKK3 is largely unknown. In this study we have identified MEKK3 Thr(294) as a novel site of phosphorylation that regulates MEKK3 binding with 14-3-3. Phosphorylation of MEKK3 at Thr(294) was observed for both endogenous and ectopically expressed MEKK3. Mutation of Thr(294) to alanine abolished 14-3-3-MEKK3 association and incubation with phosphorylated peptides mimicking Thr(P)(294) competed for 14-3-3 binding. Mutation of Thr(294) did not alter Ser(526) phosphorylation within the activation loop. However, expression of T294A MEKK3 elevated TNFalpha-stimulated NF-kappaB transcriptional activity, suggesting that Thr(294) phosphorylation and 14-3-3 binding negatively regulate MEKK3. Stimulation with TNFalpha or lipopolysaccharide caused a rapid decrease in Thr(294) phosphorylation of endogenous MEKK3 and subsequent loss of 14-3-3 association. Thus, this study identifies a potentially important regulatory step in MEKK3 signaling via dephosphorylation of Thr(294), which reduces 14-3-3 binding correlating with MEKK3 pathway activation.

Phosphoinositide-dependent phosphorylation of PDK1 regulates nuclear translocation.

3-phosphoinositide-dependent kinase 1 (PDK1) phosphorylates the activation loop of a number of protein serine/threonine kinases of the AGC kinase superfamily, including protein kinase B (PKB; also called Akt), serum and glucocorticoid-induced kinase, protein kinase C isoforms, and the p70 ribosomal S6 kinase. PDK1 contains a carboxyl-terminal pleckstrin homology domain, which targets phosphoinositide lipids at the plasma membrane and is central to the activation of PKB. However, PDK1 subcellular trafficking to other compartments is not well understood. We monitored the posttranslational modifications of PDK1 following insulin-like growth factor 1 stimulation. PDK1 underwent rapid and transient phosphorylation on S396, which was dependent upon plasma membrane localization. Phosphorylation of S396 was necessary for nuclear shuttling of PDK1, possibly through its influence on an adjacent nuclear export sequence. Thus, mitogen-stimulated phosphorylation of PDK1 provides a means for directed PDK1 subcellular trafficking, with potential implications for PDK1 signaling.

Unravelling the activation mechanisms of protein kinase B/Akt.

Over the past decade, protein kinase B (PKB, also termed Akt) has emerged as an important signaling mediator between extracellular cues and modulation of gene expression, metabolism, and cell survival. The enzyme is tightly controlled and consequences of its deregulation include loss of growth control and oncogenesis. Recent work has better characterized the mechanism of PKB activation, including upstream regulators and secondary binding partners. This minireview refreshes some old concepts with new twists and highlights current outstanding questions.

Multiple phosphoinositide 3-kinase-dependent steps in activation of protein kinase B.

The protein kinase B (PKB)/Akt family of serine kinases is rapidly activated following agonist-induced stimulation of phosphoinositide 3-kinase (PI3K). To probe the molecular events important for the activation process, we employed two distinct models of posttranslational inducible activation and membrane recruitment. PKB induction requires phosphorylation of two critical residues, threonine 308 in the activation loop and serine 473 near the carboxyl terminus. Membrane localization of PKB was found to be a primary determinant of serine 473 phosphorylation. PI3K activity was equally important for promoting phosphorylation of serine 473, but this was separable from membrane localization. PDK1 phosphorylation of threonine 308 was primarily dependent upon prior serine 473 phosphorylation and, to a lesser extent, localization to the plasma membrane. Mutation of serine 473 to alanine or aspartic acid modulated the degree of threonine 308 phosphorylation in both models, while a point mutation in the substrate-binding region of PDK1 (L155E) rendered PDK1 incapable of phosphorylating PKB. Together, these results suggest a mechanism in which 3' phosphoinositide lipid-dependent translocation of PKB to the plasma membrane promotes serine 473 phosphorylation, which is, in turn, necessary for PDK1-mediated phosphorylation of threonine 308 and, consequentially, full PKB activation.

Phosphatidylinositol (3,4,5)P3 is essential but not sufficient for protein kinase B (PKB) activation; phosphatidylinositol (3,4)P2 is required for PKB phosphorylation at Ser-473: studies using cells from SH2-containing inositol-5-phosphatase knockout mice.

Using bone marrow derived mast cells from SH2-containing inositol-5-phosphatase (SHIP) +/+ and minus sign/minus sign mice, we found that the loss of SHIP leads to a dramatic increase in Steel Factor (SF)-stimulated phosphatidylinositol 3,4,5-trisphosphate (PI(3,4,5)P(3)), a substantial reduction in PI(3,4)P(2), and no change in PI(4,5)P(2) levels. We also found that SF-induced activation of protein kinase B (PKB) is increased and prolonged in SHIP -/- cells, due in large part to more PKB associating with the plasma membrane in these cells. Pretreatment of SHIP -/- cells with 25 microm LY294002 resulted in complete inhibition of SF-induced PI(3,4)P(2), while still yielding PI(3,4,5)P(3) levels similar to those achieved in SHIP+/+ cells. This offered a unique opportunity to study the regulation of PKB by PI(3,4,5)P(3), in the absence of PI(3,4)P(2). Under these conditions, PKB activity was markedly reduced compared with that in SF-stimulated SHIP+/+ cells, even though more PKB localized to the plasma membrane. Although phosphoinositide-dependent kinase 1 mediated phosphorylation of PKB at Thr-308 was unaffected by LY294002, phosphorylation at Ser-473 was dramatically reduced. Moreover, intracellular delivery of PI(3,4)P(2) to LY294002-pretreated, SF-stimulated SHIP -/- cells increased phosphorylation of PKB at Ser-473 and increased PKB activity. These results are consistent with a model in which SHIP serves as a regulator of both activity and subcellular localization of PKB.

Identification of a novel phosphorylation site, Ser-170, as a regulator of bad pro-apoptotic activity.

Bad is a pro-apoptotic member of the Bcl-2 family of proteins that is thought to exert a death-promoting effect by heterodimerization with Bcl-X(L), nullifying its anti-apoptotic activity. Growth factors may promote cell survival at least partially through phosphorylation of Bad at one or more of Ser-112, -136, or -155. Our previous work showed that Bad is also phosphorylated in response to cytokines at another site, which we now identify as Ser-170. The functional role of this novel phosphorylation site was assessed by site-directed mutagenesis and analysis of the pro-apoptotic function of Bad in transiently transfected HEK293 and COS-7 cells or by stable expression in the cytokine-dependent cell line, MC/9. In general, mutation of Ser-170 to Ala results in a protein with increased ability to induce apoptosis, similar to the S112A mutant. Mutation of Ser-170 to Asp, mimicking a constitutively phosphorylated site, results in a protein that is virtually unable to induce apoptosis. Similarly, the S112A/S170D double mutant does not cause apoptosis in HEK293 and MC/9 cell lines. These data strongly suggest that phosphorylation of Bad at Ser-170 is a critical event in blocking the pro-apoptotic activity of Bad.