[Aortic root and arch replacement late after ascending aortic replacement for acute aortic dissection; report of a case].

Surgical treatment for acute type A aortic dissection remains controversial, especially when the aortic dissection extends to the aortic root and arch. A 73-year-old woman presented with palpitation. She had previously undergone ascending aorta replacement for acute type A aortic dissection with reinforcement of the proximal and distal aortic stumps using gelatin-resorcinol-formaldehyde (GRF) glue, conducted by a different surgical team 7 years ago. Echocardiography and computed tomography revealed dilatation of both ends of the reconstructed aorta, with aortic valve insufficiency. Hence, we performed Bentall procedure, partial aortic arch replacement, and coronary artery bypass grafting. The postsurgical course was uneventful. Redo operations may be avoidable, if, in the initial operation for acute type A aortic dissection with dissected aortic root and arch, surgery is performed without use of GRF glue for reinforcement of stumps. We recommend to perform the Bentall procedure, partial remodeling procedure, or valve-sparing aortic root replacement for reconstruction of the aortic root and arch replacement for repair of the aortic arch.

Association between toll-like receptor 8 expression and adverse clinical outcomes in patients with enterovirus-associated dilated cardiomyopathy.

BACKGROUND: In recent reports, human toll-like receptor (TLR) 8 mediates the antiviral response by recognizing single-stranded RNA. The inflammatory response against enteroviral (EV) RNA replication may play an important role in dilated cardiomyopathy (DCM). The purpose of this study was to determine whether TLR8 was expressed with EV replication in patients with enterovirus-associated DCM. METHODS: Reverse transcriptase-polymerase chain reaction analysis was performed to screen the detection of myocardial EV RNA in 198 consecutive patients with DCM. Seventy-two EV RNA-positive patients with DCM and 20 control samples constituted the study population of the present study. Levels of TLR8 and myeloid differentiation factor (MyD) 88 adaptor protein mRNA and EV RNA (plus- and minus-strand RNAs) were measured by real-time RT-PCR. Immunohistochemistry was performed to identify the cellular source of these molecules. RESULTS: Toll-like receptor 8 and MyD88 mRNA levels were higher in patients with DCM than in controls (P < .001). Immunostainings of TLR8, MyD88, and EV protein showed localization of these proteins in cardiac myocytes in patients with DCM. After a mean follow-up of 426 days, clinical outcomes (development of heart failure n = 11, cardiac death n = 3) were associated with increased levels of TLR8 and MyD88 (P < .05). Multivariate analysis showed that TLR8 (relative risk 3.2, 95% CI 1.6-6.2) was a strong predictor of heart failure and cardiac death after adjustment for baseline characteristics. CONCLUSION: Toll-like receptor 8 and MyD88 expressions may be involved in the immune response to EV replication in enterovirus-associated DCM. In addition, TLR8 may provide important prognostic information in patients with enterovirus-associated DCM.

A novel activator of C-C chemokine, FROUNT, is expressed with C-C chemokine receptor 2 and its ligand in failing human heart.

BACKGROUND: A novel activator of C-C chemokines, FROUNT, directly binds C-C chemokine receptor (CCR) 2 and plays a central role in the chemokine system. Activation of the chemokine system appears to be involved in the pathogenesis of congestive heart failure (CHF). The purpose of this study was to determine whether FROUNT is expressed with CCR2 and its ligand (CCL2) in failing human heart. METHODS AND RESULTS: We examined endomyocardial biopsy tissues obtained from 71 patients with CHF (HF group) and 20 subjects without CHF (non-HF group). FROUNT, CCR2, and CCL2 mRNA levels were higher in the HF group than in the non-HF group (P < .001). FROUNT mRNA levels were positively correlated with CCR2 and CCL2 mRNA levels in the HF group. FROUNT and CCL2 signal was seen in the cytoplasm of cardiac myocytes in failing hearts. Levels of FROUNT mRNA were negatively correlated with left ventricular ejection fraction. FROUNT, CCR2, and CCL2 mRNA levels were higher in the severe HF subgroup than in the mild HF subgroup. CONCLUSIONS: The expression of FOUNT-mediated CCL2/CCR2 may have important implications in the pathogenesis of CHF. The CCL2/CCR2 pathway via FROUNT may influence the clinical severity of CHF.

Elevated circulating levels of heat shock protein 70 are related to systemic inflammatory reaction through monocyte Toll signal in patients with heart failure after acute myocardial infarction.

BACKGROUND: Recent studies have shown that heat shock protein (HSP) 70 may serve as a "damage signal" to the immune system and could be the endogenous ligand for Toll-like receptor (TLR) 4 mediating synthesis of inflammatory cytokines. AIMS: To explore the relationship between circulating HSP70 levels and activation of monocyte TLR4 and myocardial damage after AMI. METHODS AND RESULTS: This study examined circulating HSP70 and monocyte TLR4 levels in 52 patients with AMI and 20 controls, and analyzed ex vivo inflammatory cytokine productions using HSP70-stimulated monocytes. Circulating HSP70 levels were higher in AMI patients on day 1 after onset than in controls and remained elevated in AMI patients 14 days after onset. HSP70 levels were positively correlated with monocyte TLR4, plasma interleukin-6 and tumor necrosis factor-alpha levels in AMI patients. HSP70 levels 14 days after onset were higher in AMI patients with heart failure (n=15) than in those without heart failure. In our in vitro study, HSP70-stimulated monocytes resulted in dose-dependent TLR4 expression and release of inflammatory cytokines. TLR4 antibody inhibited inflammatory cytokines release. CONCLUSIONS: Elevated circulating levels of HSP70 may be involved in TLR4 signal-mediated immune response and the progression of heart failure after AMI.

Activated toll-like receptor 4 in monocytes is associated with heart failure after acute myocardial infarction.

Peripheral monocytosis may affect the development of heart failure (HF) after acute myocardial infarction (AMI). Activated toll-like receptor (TLR) 4 in monocytes plays an important role in the synthesis of proinflammatory cytokines. We examined TLR4 expression in monocytes, which may be a possible source of proinflammatory cytokines in AMI. Sixty-five patients with AMI and 20 healthy subjects (HS) were studied. Monocytes were isolated from peripheral blood on days 1 and 14 after the onset of AMI. TLR4 levels in monocytes were measured using real-time RT-PCR and flow cytometry. Generation capacity was evaluated by TLR4 levels and cytokine concentrations in the culture medium with lipopolysaccharide (LPS) stimulation. On day 1 after onset, baseline levels of TLR4 and plasma proinflammatory cytokines, notably IL-6 and TNF-alpha, were higher in AMI patients than in HS. These levels remained elevated in AMI patients 14 days after onset. Generation capacities of TLR4 and proinflammatory cytokines (IL-2, IL-6, IL-8, IL-10, GM-CSF and TNF-alpha) were increased in AMI patients compared to HS. LPS-stimulated TLR4 levels were positively correlated with IL-6 and TNF-alpha levels in AMI patients. Baseline TLR4 levels and plasma proinflammatory cytokine (IL-6, GM-CSF and TNF-alpha) levels were higher in AMI patients with HF (n = 22) than in those without HF. Generation capacities of TLR4 and proinflammatory cytokines (IL-6, GM-CSF and TNF-alpha) were greater in AMI patients with HF than in those without HF. Activation of TLR4 through a myocytic inflammatory reaction is associated with HF after AMI. These observations suggest that TLR4 signaling in monocytes may play a role in the development of HF after AMI.

C-reactive protein co-expresses with tumor necrosis factor-alpha in the myocardium in human dilated cardiomyopathy.

BACKGROUND: C-reactive protein (CRP) has recently been reported to be present in cardiac tissue and to stimulate the production of proinflammatory cytokines. Cardiac expression of tumor necrosis factor-alpha (TNF-alpha) plays an important role in the pathogenesis of dilated cardiomyopathy (DCM). AIMS: To determine whether CRP co-expresses with TNF-alpha in the myocardium and to examine its association with clinical features in patients with DCM. METHODS AND RESULTS: Endomyocardial biopsy tissues were obtained from 41 DCM patients and 16 controls by right ventricular endomyocardial biopsy. Levels of CRP and TNF-alpha mRNA were measured by real-time RT-PCR. Immunohistochemistry and in situ hybridization were performed to identify the cellular sources of CRP and TNF-alpha. Both CRP and TNF-alpha mRNA were expressed in myocardium obtained from DCM patients, but not in controls. A positive correlation was found between CRP and TNF-alpha levels. CRP/TNF-alpha double staining was found to be colocalized in the cardiomyocytes of DCM patients. Both forms of mRNA were also expressed in cardiomyocytes. Both CRP and TNF-alpha mRNA levels were negatively correlated with systolic function and positively correlated with left ventricular volume in DCM patients. These mRNA levels were lower in DCM patients treated with a combination of spironolactone and either angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II type 1 receptor blockers (ARBs) than in patients not treated with these drugs. CONCLUSION: Cardiac expression of CRP with TNF-alpha may function as a proinflammatory mediator in DCM and may be related to the clinical severity of DCM. Expression of both of these proteins was decreased in DCM patients receiving spironolactone and either ACEIs or ARBs.

Myocardial osteopontin expression is associated with collagen fibrillogenesis in human dilated cardiomyopathy.

BACKGROUND: Osteopontin (OPN), an extracellular matrix (ECM) protein, plays an important role in myocardial remodeling by promoting collagen synthesis and accumulation in experimental animal models. AIMS: We hypothesized that OPN could be expressed in myocardial tissues and contribute to collagen accumulation and myocardial dysfunction in human dilated cardiomyopathy (DCM). METHODS AND RESULTS: Endomyocardial biopsy tissues were obtained from 51 patients with DCM and 15 controls by right ventricular endomyocardial biopsy. OPN, collagen types I (Col I) and III (Col III) mRNA levels were measured by real-time reverse transcriptase polymerase chain reaction (RT-PCR). The cellular source of OPN was analyzed using immunohistochemistry and in situ hybridization. Myocardial collagen volume fraction (CVF) was determined by digital planimetry. OPN, Col I and Col III mRNA levels were higher in DCM patients than in controls (P<0.01). OPN mRNA levels were positively correlated with Col I levels and CVF in DCM patients (OPN vs. Col I: r=0.60, P<0.01; OPN vs. CVF: r=0.52, P<0.001). Immunostaining of OPN was present in cardiomyocytes from DCM patients. In situ hybridization identified cardiomyocytes as the major source of OPN mRNA transcription in DCM patients. OPN and Col I mRNA levels were highly expressed in the DCM subgroup with large left ventricular (LV) end-systolic diameter (LVESD > or = 54.5 mm) or low LV ejection fraction (LVEF < 29.5%). There was a weak positive correlation between OPN mRNA levels and LV end-systolic diameter (r=0.39, P<0.01). Levels of OPN mRNA were also negatively correlated with LV ejection fraction (r=-0.43, P<0.01). CONCLUSIONS: These results suggest that OPN may play a pivotal role in the development of Col-I-induced cardiac fibrosis and dysfunction in human DCM.

Activated tumour necrosis factor-alpha shedding process is associated with in-hospital complication in patients with acute myocardial infarction.

TACE [TNF-alpha (tumour necrosis factor-alpha)-converting enzyme] plays an essential role in the shedding of TNF-alpha, which could affect the outcome of AMI (acute myocardial infarction). To investigate the clinical significance of the TACE-TNF-alpha system in AMI, we examined TACE-mediated TNF-alpha synthesis in PBMCs (peripheral blood mononuclear cells), which are a possible source of TNF-alpha in AMI. Forty-one patients with AMI and 15 healthy subjects (HS) were enrolled in the present study. PBMCs were isolated from peripheral blood on day 1 and 14 after the onset of AMI. TACE and TNF-alpha mRNA levels and intracellular median fluorescence intensity were measured by real-time RT (reverse transcriptase)-PCR and flow cytometry respectively. TACE-mediated TNF-alpha production was evaluated in cultured PBMCs with PMA, which is known to activate TACE. Spontaneous TACE and TNF-alpha levels were higher in AMI patients than in HS (P<0.001). TACE and TNF-alpha levels in PMA-stimulated PMBCs were markedly increased in AMI patients compared with HS (P<0.001). There was a positive correlation between TACE and TNF-alpha levels in AMI. Although spontaneous and stimulated levels of TACE and TNF-alpha decreased 14 days after the onset of AMI, levels in AMI patients were higher than in HS. In AMI patients with in-hospital complications (n=15; pump failure in ten, recurrent myocardial infarction in one, malignant ventricular arrhythmia in three and cardiac death in one), spontaneous and stimulated levels of TACE and TNF-alpha were higher than in patients without complications (P<0.01). These levels were higher in AMI patients with in-hospital complications 14 days after onset. These results demonstrate that TACE-mediated TNF-alpha maturation in PBMCs may play an important role in poor outcomes from AMI, suggesting that TACE may be a potential target for the inhibition of cellular TNF-alpha production in AMI.

Increased expression of tumor necrosis factor-alpha converting enzyme and tumor necrosis factor-alpha in peripheral blood mononuclear cells in patients with advanced congestive heart failure.

BACKGROUND: Tumor necrosis factor-alpha converting enzyme (TACE) has recently been identified as a metalloproteinase-disintegrin, which converts pro-tumor necrosis factor-alpha (TNF-alpha) to the mature form, and is an important mediator in the pathogenesis of CHF. AIMS: In order to establish the importance of TACE in the regulation of TNF-alpha synthesis in peripheral blood mononuclear cells (PBMC), we analyzed mRNAs and protein-positive cells of both TACE and TNF-alpha in PBMC obtained from patients with congestive heart failure (CHF). METHODS AND RESULTS: PBMC were obtained from 46 patients with CHF and 22 controls. PBMC were activated by phorbol 12-myristate 13-acetate and ionomycin and assessed for TACE and TNF-alpha mRNAs by real-time RT-PCR, intracellular TACE and TNF-alpha levels by flow cytometry, and TNF-alpha secretion by supernatant ELISA. Levels of TACE and TNF-alpha mRNAs, intracellular TACE and TNF-alpha, and supernatant TNF-alpha were higher in CHF than in controls (P<0.001). There was a positive correlation between TACE and TNF-alpha levels in CHF patients (mRNA: r=0.60, P<0.001, intracellular protein levels: r=0.76, P<0.001). When the CHF group was divided into two subgroups by NYHA functional class (I and II vs. III and IV), levels of TACE and TNF-alpha were significantly higher in severe CHF patients (NYHA III or IV) than in mild CHF patients (NYHA I or II) (mRNA: P<0.001; intracellular protein levels: P<0.001). CONCLUSION: These results demonstrate that in patients with CHF, and especially those with severe CHF, TACE expression in PBMC increases with TNF-alpha expression. These observations suggest that TACE in PBMC is an important regulator of TNF-alpha maturation, meaning that TACE may be a potential target for the inhibition of cellular TNF-alpha production in CHF.

Toll-like receptor 4 is expressed with enteroviral replication in myocardium from patients with dilated cardiomyopathy.

Expressions of innate immune response proteins, most notably proinflammatory cytokines, against enteroviral (EV) infection have been documented in the heart of human dilated cardiomyopathy (DCM). Toll-like receptor 4 (TLR4) activates signaling pathways leading to the expression of proinflammatory cytokines implicated the etiology of DCM. We sought to determine whether EV replication activates TLR4-dependent immune response in myocardium obtained from patients with DCM. Endomyocardial biopsy tissues were obtained from 56 patients with DCM and 10 controls. Levels of plus- and minus-strand EV RNA and TLR4 mRNA were measured by real-time RT-PCR. Immunohistochemical analysis was performed to identify the cellular source of EV capsid protein VP1 and TLR4. Both plus- and minus-strand EV RNA were detected in 19 DCM patients (34%). Neither strand of EV RNA was detected in controls. TLR4 mRNA levels were higher in DCM patients than in controls (P<0.001). A positive correlation was found between TLR4 levels and each strand type of EV RNA in EV RNA-positive patients (plus-strand vs TLR4: r=0.69, P<0.001; minus-strand vs TLR4: r=0.65, P=0.002). VP1/TLR4 double staining showed extensive colocalization of VP1 and TLR4 proteins in cytoplasm of cardiac myocytes in myocardium obtained from DCM patients. EV RNA-positive patients showed lower systolic function and larger ventricular volume compared with EV RNA-negative patients left ventricular ejection fraction (LVEF): P=0.002; left ventricular end-systolic diameter (LVESD): P=0.004). The DCM subgroup with high TLR4 levels showed lower LVEF and larger LVESD than the subgroup with TLR4 levels (both P<0.001). This study suggests that myocardial expression of TLR4 associates with EV replication in human DCM. EV RNA and TLR4 mRNA levels may correlate with LV dysfunction in DCM. The expression of TLR4 against EV replication may be involved in the pathogenesis of DCM.

Expression of Toll-like receptor 4 is associated with enteroviral replication in human myocarditis.

Previous studies have demonstrated that inflammatory cytokine expression associated with enteroviral (EV) infection may play an important role in human myocarditis. However, the mechanism of the host immune response against viral pathogens has not been fully understood. The aim of the present study was to determine whether Toll-like receptor 4 (TLR4) and EV RNA are present in human myocarditis. Endomyocardial biopsy samples were obtained from 44 patients with myocarditis and five controls. Levels of plus- and minus-strand EV RNAs and TLR4 mRNA were measured by real-time reverse transcriptase-PCR. Immunohistochemical analysis was performed to identify the cellular source of TLR4 and the EV capsid protein VP1. EV RNA was present in 21 patients with myocarditis and these patients were defined as having either active viral replication ( n =15) or latent viral persistence ( n =6). Neither strand of EV RNA was detected in controls. TLR4 mRNA expression levels were higher in myocarditis patients than in controls (TLR4/glyceraldehyde-3-phosphate dehydrogenase ratio 1.48+/-0.17 compared with 0.08+/-0.06, P <0.001). A positive correlation was found between EV RNA and TLR4 levels (plus-strand vs TLR4: r =0.66, P <0.001; minus-strand vs TLR4: r =0.48, P <0.001). TLR4 immunostaining was observed in infiltrating cells and myocytes in patients with myocarditis. The EV capsid protein VP1 was also found in myocytes. The myocarditis group with EV replication and high levels of TLR4 showed significantly lower systolic function. The present study has shown that increased expression of TLR4 is associated with EV replication and that these RNA levels are related to cardiac dysfunction in human myocarditis.

Increased mRNA expression of tumour necrosis factor-alpha and its converting enzyme in circulating leucocytes of patients with acute myocardial infarction.

Tumour necrosis factor-alpha (TNF-alpha) plays an important role in myocardial damage in acute myocardial infarction (AMI). It has recently been discovered that TNF-alpha-converting enzyme (TACE) cleaves precursor TNF-alpha into its mature form. However, it remains unknown whether TNF-alpha expression is related to TACE expression in circulating leucocytes in AMI. Blood samples were obtained from 37 patients with AMI within 24 h of onset and eight healthy controls. Plasma TNF-alpha levels were measured by ELISA. Total mRNA was then extracted from circulating leucocytes, and the expression levels of TACE and TNF-alpha mRNAs were determined by reverse transcriptase-PCR. Plasma TNF-alpha levels were significantly higher in patients with Killip's classes III and IV AMIs (17.1+/-5.0 pg/ml, n =11) than in those with Killip's classes I and II AMIs (13.7+/-4.2 pg/ml, n =26), or controls (13.0+/-1.7 pg/ml, n =8) ( P <0.05). There was a significant increase in expression (arbitrary units) of TACE and TNF-alpha mRNAs in circulating leucocytes obtained from patients with Killip's classes I and II AMIs [TACE/glyceraldehyde-3-phosphate dehydrogenase (GAPDH), 2.770+/-0.303; TNF-alpha/GAPDH, 2.123+/-0.475] compared with controls (TACE/GAPDH, 1.498+/-0.209; TNF-alpha/GAPDH, 1.283+/-0.274) ( P <0.01). This increase was even greater in patients with Killip's classes III and IV AMIs (TACE/GAPDH, 3.086+/-0.354; TNF-alpha/GAPDH, 2.808+/-0.422) ( P <0.01). Moreover, there was a significant positive relationship between these mRNA expression levels ( r =0.60, P <0.01). The TACE-TNF-alpha system in circulating leucocytes is stimulated and may have a negative impact on clinical outcome in AMI.

Aldosterone synthase (CYP11B2) expression and myocardial fibrosis in the failing human heart.

The pathway of tissue aldosterone production may exist in the heart, and may be an important contributory factor to myocardial fibrosis and cardiac remodelling in the failing heart. CYP11B2 (aldosterone synthase) catalyses the final step of aldosterone production. The aim of the present study was to determine whether CYP11B2 and CYP11B1 (11beta-hydroxylase) are expressed in myocardial tissues, and whether these enzymes contribute to collagen accumulation and myocardial dysfunction in the failing human heart. Endomyocardial tissues were obtained from 23 patients with chronic heart failure (CHF) and 10 controls. CYP11B2 and CYP11B1 mRNA levels were measured by real-time quantitative reverse transcriptase-PCR. The myocardial collagen volume fraction (CVF) was determined by digital planimetry. CYP11B2 mRNA expression was greater in the CHF group than in the controls (P<0.05), while CYP11B1 mRNA was barely expressed in either group. There was a positive correlation between CYP11B2 mRNA levels and CVF (r=0.64, P=0.001). CYP11B2 mRNA was particularly highly expressed in subgroups of CHF patients with a large left ventricular end-systolic diameter (>55 mm) or a low left ventricular ejection fraction (<30%). CYP11B2 mRNA expression and CVF were lower in a CHF subgroup treated with a combination of spironolactone and angiotensin-converting enzyme inhibitors (ACEIs) than in a subgroup not treated with these drugs. In conclusion, this study has shown that increased myocardial expression of CYP11B2 mRNA is associated with increased myocardial fibrosis and with the severity of left ventricular dysfunction in human CHF. In addition, CYP11B2 expression and cardiac fibrosis are found to be decreased in CHF patients on drug therapy comprising spironolactone combined with ACEIs.