P2272Determinants of left ventricular ATP availability measured in vivo and ex vivo in patients with severe aortic stenosis: correlation of creatine kinase activity with LVEF and ATP diffusion distance
Authors: Peterzan M A , Clarke W T , Lygate C A , Lake H A , Lau J Y C , Johnson E , Rayner J J , Hundertmark M J , Sayeed R A , Petrou M , Krasopoulos G , Srivastava V , Neubauer S , Rodgers C T , Rider O J 
Published: October 2019

Abstract

Introduction
The transition to systolic failure in severe aortic stenosis (AS) increases mortality. There are currently no reliable markers of transition, and the guideline LVEF <50% threshold for intervention in asymptomatic severe AS does not capture all subjects at increased risk. In animal models, reduced ATP delivery capacity through creatine kinase (CK) is important, with modest increases in CK capacity conferring cardioprotection. ATP may also diffuse (independent of CK) from mitochondria to the contractile site. We have performed the first human study to test whether ATP diffusion distance relates to CK activity and whether CK activity is reduced in low LVEF severe AS.

Methods
19 patients with severe AS, LVEF ≥55% (AS-pEF, mean±SD LVEF 63±5%, mean gradient 48±14 mmHg) and 10 with severe AS, LVEF <55% (AS-rEF, LVEF 42±8%, mean gradient 32±11) underwent 31P-MRS for CK rate constant (kf) and phosphocreatine/ATP (PCr/ATP) ratio, and MRI for LV volumes. LV biopsies were taken during AVR and analysed for CK total activity, CK isoforms, total creatine, and citrate synthase (CS) activity. 9 biopsies also underwent serial block face scanning electron microscopy and mitochondria-sarcomere 3D distance distributions were plotted. Results were compared to 24 controls (LVEF 61±4%), of which 4 had LV biopsy (3 severe MS, 1 LA myxoma, MS-pEF). Surgical patients had flow-limiting atheroma excluded with invasive angiography and prior myocardial infarction excluded with late gadolinium enhancement MRI.

Results
When compared to controls, both CK total activity and CS activity were lower in AS-pEF (by 27% and 23% respectively, both p<0.05, Panels A-B). Although PCr/ATP reduced in AS-pEF (by 20%, p<0.001, panel C), kf (panel D) and CK flux estimated by kf × total creatine were not different. CK-MB expression reduced in AS-pEF (19 vs 27% of total CK, p=0.003), reflecting compensatory increases in CK-MM (p=0.26) and CK-BB (p=0.18) in the face of reduced CK activity.
AS-rEF was associated with further reduction in both CK and CS activities (by 32% and 22% respectively, both p<0.05, Panels A-B), but no differences in PCr/ATP, CK kf or relative CK isozyme expression were seen. There were no significant between-group differences in total creatine (Panel E). Overall this suggests that CK reserve and oxidative capacity potentially reduce in pressure overload, with further falls commensurate with systolic dysfunction.
When median mitochondria-sarcomere ATP diffusion distances were plotted against CK total activity a strong positive correlation was observed (r=0.86, p=0.003, Panel F). This suggests a compensatory reduction in diffusion distance develops when CK activity falls.

Conclusions
Transition to failure in severe AS is associated with lower oxidative capacity and maximal ATP delivery capacity through CK. Despite compensatory falls in ATP diffusion distance and altered CK isozyme expression, these changes may underlie susceptibility to EF decline in AS.

Acknowledgement/Funding
British Heart Foundation Clinical Research Training Fellowship (FS/15/80/31803) and Programme Grant (RG/18/12/34040).