LXR-beta signalling is a key mediator in the pathogenesis of aortic valve stenosis and its prevention by saringosterol
Authors: Noethel M , Schmidt A , Mulder M T , Vanmierlo T , Friedrichs S , Schmidt S V , Voortman G , Goody P , Zimmer S , Nickenig G , Luetjohann D , Jehle J 
Published: October 2022

Abstract

Background
Cholesterol metabolism contributes as a risk factor for aortic valve stenosis (AS), but pharmacological approaches remained unsatisfying. The liver-X-receptor (LXR) is a key regulator in cholesterol metabolism, though its clinical use is limited due to unwanted side effects. The seaweed-derived oxysterol saringosterol is an agonist of the LXRβ, promising a more favourable tolerability.

Purpose
This study aimed to better understand the pathophysiology of aortic valve stenosis and to assess the potential of saringosterol as a targeted pharmacotherapy.

Methods
Tissue samples from aortic valves were collected from patients with AS or aortic valve regurgitation (AR). Transcriptomics were performed and gene ontology (GO) analysis was used to determine pathways and genes that are relevant to AS, and then validated using qPCR.
In vivo, mice received a wire-induced aortic valve stenosis and were either fed a diet supplemented with saringosterol or control diet. Haemodynamic characteristics were assessed using echocardiography. Additionally, hepatic concentrations of saringosterol, expression of LXRβ regulated genes as well as aortic valve thickness and composition were assessed.
In vitro, human aortic valve interstitial cells (VIC) were cultured in a procalcifing medium and stimulated with saringosterol to investigate the underlying molecular mechanisms.

Results
Transcriptomic analysis of AS samples revealed the regulation of several GO-terms related to cholesterol- or lipid metabolism. Many of the genes identified were regulated by LXRβ, suggesting its pathophysiological relevance in AS. We validated this assumption by performing qPCR from aortic valves for the most prominent downstream targets of LXRβ, ABCA1 and ABCG1, with both being differentially regulated.
In vivo, treatment with saringosterol for six weeks resulted in a significant accumulation of saringosterol in liver tissue as well as induction of LXRβ-regulated genes. Furthermore, treatment with saringosterol strikingly reduced the development of AS after wire injury as assessed by echocardiographic and histological measurements.
In vitro, the differentiation of VIC into osteoblastic and myofibroblastic phenotypes was abolished by saringosterol, which reduced the expression of the procalcifying mediators RUNX-2 and ACTA-2 in a dose-dependent manner.

Conclusion
We identified LXRβ-signalling as a key regulator in the pathophysiology of AS. Transcriptomic analyses revealed that cholesterol metabolism was altered in human AS, and many of the genes involved were linked to the LXRβ. In a murine model, we demonstrated that oral application of saringosterol induced LXRβ-activity and mitigated the development of AS. In vitro experiments demonstrated that saringosterol prevents adverse cell differentiation of VIC, which provides a mechanistic explanation.

Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): BONFOR Universität Bonn