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Abstract
AimsInfective endocarditis (IE) is characterized by septic thrombi (vegetations) attached on heart valves, consisting of microbial colonization of the valvular endocardium, that may eventually lead to congestive heart failure or stroke subsequent to systemic embolism. We hypothesized that host defense activation may be directly involved in tissue proteolytic aggression, in addition to pathogenic effects of bacterial colonization.Methods and ResultsIE valve samples collected during surgery (n = 39) were dissected macroscopically by separating vegetations (VG) and the surrounding damaged part of the valve from the adjacent, apparently normal (N) valvular tissue. Corresponding conditioned media were prepared separately by incubation in culture medium. Histological analysis showed an accumulation of platelets and polymorphonuclear neutrophils (PMNs) at the interface between the VG and the underlying tissue. Apoptotic cells (PMNs and valvular cells) were abundantly detected in this area. Plasminogen activators (PA), including urokinase (uPA) and tissue (tPA) types were also associated with the VG. Secreted matrix metalloproteinase (MMP) 9 was also increased in VG, as was leukocyte elastase and myeloperoxidase (MPO). The presence of neutrophil extracellular traps (NETs) associating MPO and externalized nucleosomes, was shown by immunostaining in the VG. Both MPO and cell-free DNA were released in larger amounts by VG than N samples, suggesting bacterial activation of PMNs within the vegetation. Finally, evidence of proteolytic tissue damage was obtained by the release of fragments of extracellular matrix components such as fibrinogen and fibronectin, as well as protease-sensitive receptors such as the uPA receptor.ConclusionOur data obtained using human IE valves suggest that septic vegetations represent an important source of proteases originating from massive leukocyte recruitment and activation of the host plasminergic system. The latter forms a potential therapeutic target to minimize valvular tissue degradation independently from that induced by bacterial proteases.
Highlights
Infective endocarditis (IE) is characterized by vegetative lesions consisting of microbial colonization of a damaged valvular endocardium, or of an intracardiac prosthesis
Our data obtained using human IE valves suggest that septic vegetations represent an important source of proteases originating from massive leukocyte recruitment and activation of the host plasminergic system
Vegetations and Subjacent Tissue Damage For each valve collected, one representative part was chosen for histological characterization, the remaining tissue was macroscopically separated into the damaged part comprising the vegetations (‘‘VG’’) and the adjacent apparently normal tissue (‘‘N’’) for preparation of the conditioned medium (Figure 1A)
Summary
Infective endocarditis (IE) is characterized by vegetative lesions consisting of microbial colonization of a damaged valvular endocardium (native valve IE), or of an intracardiac prosthesis (prosthetic IE). The infected vegetation is the elementary lesion of IE. It is formed by successive appositions of fibrinoplatelet thrombi, incorporating pathogens and leukocytes [3]. The characteristics of the bacterial population that colonizes the vegetation may explain the limited efficacy of antibiotics sometimes observed in the treatment of human IE. After the initial phase of bacterial adhesion and colonization, pathogens proliferate within the forming vegetation. The nonhomogenous distribution of bacteria within the vegetation often leads to formation of ‘‘clusters’’ protected by layers of fibrin which constitute an important morphological feature of the lesion [3]
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