Cholesterol crystal induced inflammation and mechanical cardiac valve injury: Implications for transcatheter aortic-valve replacement
2021
The process of cardiac valve sclerosis and stenosis in non-rheumatic disease is related
to inflammation via the innate immune system similar to atherosclerosis. Cardiac
valve composition shares many features with arterial tissue. Cholesterol infiltration
in the valve matrix results in cholesterol crystal formation and deposition that causes
mechanical injury and triggers inflammation. Sclerotic human valve specimens as well
as valves from atherosclerotic rabbit models reveal presence of cholesterol crystals and
macrophage infiltration as seen in atherosclerosis. Lipid lowering by combination of
simvastatin and ezetimibe demonstrates cholesterol reduction in valves only if used in
a preventive manner. However, once the valve is infiltrated by cholesterol and crystals
form in the tissue matrix, these become very difficult to extract and lipid lowering
is no longer very effective. Furthermore, cholesterol crystals serve as a nidus for
calcium phosphate deposition that distorts and stiffens the valve tissue leading to valve
dysfunction. During Transcatheter Aortic Valve Replacement (TAVR) procedures,
crystals can complicate the procedure by release of crystalline particles causing ischemic
cerebral events and rupturing balloons.
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