RGD-Based Fluorescence to Assess Placental Angiogenesis

Normal fetal growth and placental development depend on active angiogenesis occurring at the fetomaternal interface throughout pregnancy. Nevertheless, reliable in vivo methods to assess placental angiogenesis are still missing. Here, we describe a quantitative and noninvasive in vivo method to specifically measure placental neovascularization in the gravid mouse. This method uses a technique based on the measurement of a fluorescent molecule Angiostamp700 that targets the alpha v beta 3 (αvβ3) integrin, a protein that is highly expressed by endothelial cells during the neovascularization and by trophoblast cells during invasion of the maternal decidua. Due to this noninvasive method, quantification of the fetomaternal angiogenic activity and information regarding the outcome of pregnancy are now possible.

EG-VEGF maternal levels predict spontaneous preterm birth in the second and third trimesters in pregnant women with risk factors for placenta-mediated complications

Prediction of spontaneous preterm birth in asymptomatic women remains a great challenge for the public health system. The aim of the study was to determine the informational value of EG-VEGF circulating levels for prediction of spontaneous preterm birth in the second and third trimesters in pregnant women at high risk for placenta-mediated complications. A prospective multicenter cohort study including 200 pregnant patients with five-serum sampling per patient. Women with spontaneous preterm birth have higher concentrations of serum EG-VEGF than uncomplicated patients at 24 weeks, 28 weeks and 32 weeks (p = 0.03, 0.02 and < 0.001). The areas under the curve reached 0.9 with 100% sensitivity at 32 weeks for the prediction of spontaneous preterm birth. Serum EG-VEGF concentrations could be considered as a reliable biomarker of spontaneous preterm birth in high-risk for placenta-mediated complications pregnant women.

NLRP7 Enhances Choriocarcinoma Cell Survival and Camouflage in an Inflammasome Independent Pathway

Background: Gestational choriocarcinoma (GC) is a highly malignant trophoblastic tumor that often develops from a complete hydatidiform mole (HM). NLRP7 is the major gene responsible for recurrent HM and is involved in the innate immune response, inflammation and apoptosis. NLRP7 can function in an inflammasome-dependent or -independent pathway. Recently, we have demonstrated that NLRP7 is highly expressed in GC tumor cells and contributes to their tumorigenesis. However, the underlying mechanisms are still unknown. Here, we investigated the mechanism by which NLRP7 controls these processes in malignant (JEG-3) and non-tumor (HTR8/SVneo) trophoblastic cells. Cell survival, dedifferentiation, camouflage, and aggressiveness were compared between normal JEG-3 cells or knockdown for NLRP7, JEG-3 Sh NLRP7. In addition, HTR8/SVneo cells overexpressing NLRP7 were used to determine the impact of NLRP7 overexpression on non-tumor cells. NLRP7 involvement in tumor cell growth and tolerance was further characterized in vivo using the metastatic mouse model of GC. Results: We demonstrate that NLRP7 (i) functions in an inflammasome-dependent and -independent manners in HTR8/SVneo and JEG-3 cells, respectively; (ii) differentially regulates the activity of NF-κB in tumor and non-tumor cells; (iii) increases malignant cell survival, dedifferentiation, and camouflage; and (iv) facilitates tumor cells colonization of the lungs in the preclinical model of GC. Conclusions: This study demonstrates for the first time the mechanism by which NLRP7, independently of its inflammasome machinery, contributes to GC growth and tumorigenesis. The clinical relevance of NLRP7 in this rare cancer highlights its potential therapeutic promise as a molecular target to treat resistant GC patients.

Assessment of absolute coronary flow and microvascular resistance reserve in patients with severe aortic stenosis

Introduction

The development of left ventricular hypertrophy in patients with severe aortic stenosis (AS) is accompanied by adaptive coronary flow regulation, both in epicardial and microvascular compartment, which ultimately lead to a chronic ischemic insult even in the absence of obstructive coronary artery disease. Intracoronary continuous thermodilution of saline through a dedicated infusion catheter is a novel tool that allows to measure absolute coronary flow and microvascular resistance at rest and during hyperemia and to calculate both coronary flow reserve (CFR) and Microvascular Resistance Reserve (MRR)

Purpose

We aimed to assess absolute coronary flow, microvascular resistance, CFR and MRR in patients with AS, by continuous intracoronary thermodilution, comparing these hemodynamic findings with a propensity-score matched contemporary cohort of patients without AS.

Methods

Absolute coronary blood flow and microvascular resistance were measured by continuous thermodilution in 29 patients with AS and compared to 15 controls matched for age, gender, diabetes mellitus and functional severity of epicardial coronary lesions. Myocardial work, total myocardial mass and LAD-specific mass were quantified by echocardiography and cardiac-CT.

Results

Patients with AS presented a significantly positive LV remodeling with lower global longitudinal strain and higher global work index compared to controls (p&lt;0.02). Total LV myocardial mass and LAD-specific myocardial mass were significantly higher in patients with AS. Compared to matched controls, absolute resting flow in the LAD was significantly higher in the AS cohort (86 [66–107] ml/min vs 68 [52–75] ml/min, p=0.036), resulting, in lower CFR (2.30±0.69 vs 2.89±0.77, p=0.005) and MRR (2.73±0.74 vs 3.53±0.95, p=0.005) in the AS cohort compared to controls (Figure 1). No differences were found in hyperemic flow and resting and hyperemic resistances. Interestingly, hyperemic myocardial perfusion (calculated as the ratio between the absolute coronary flow in the LAD and the mass subtended by the vessel, expressed in mL/min/g), but not resting, was significantly lower in the AS group (1.9 [1.5–2.5] ml/min/g vs 2.3 [2–3.1] ml/min/g p=0.036).

Conclusions

In patients with severe aortic stenosis and non-obstructive coronary artery disease, with the progression of LVH, the compensatory mechanism of increased resting flow maintains an adequate perfusion at rest, but not during hyperemia (Figure 2). As consequence, both CFR and MRR are significantly impaired.

Funding Acknowledgement

Type of funding sources: None.

Repeatability of bolus and continuous thermodilution for assessing coronary microvasculatory function

Introduction

The bolus thermodilution-derived index of microcirculatory resistance (IMR) has emerged over years as the standard of reference to invasively define coronary microvascular dysfunction (CMD). However, the technique still presents some limitations, mainly related to the fact that manual injection of saline bolus accounts for some variance in the measurements. Continuous intracoronary thermodilution has been recently introduced as a tool to directly quantify absolute coronary flow and microvascular resistance both at rest and during hyperemia and has shown to be safe and operator independent. Microvascular resistance reserve (MRR), derived from continuous thermodilution, has been validated as novel index specific for microcirculation and independent from myocardial mass.

Purpose

To compare head-to-head the intra-observer repeatability of bolus and continuous thermodilution for assessing microvascular function.

Methods

Patients undergoing coronary angiography in the absence of obstructive coronary artery disease were prospectively enrolled. Bolus and continuous intracoronary thermodilution measurements were performed in duplicates in the left anterior descending artery (LAD). Patients were randomly assigned in a 1:1 ratio to undergo first bolus thermodilution or first continuous thermodilution assessment.

Results

A total of 102 patients were enrolled. Average FFR was 0.86±0.06. Coronary Flow Reserve (CFR) calculated with continuous thermodilution (CFRthermo) was significantly lower than bolus thermodilution-derived CFR (CFRbolus) (2.63±0.65 and 3.29±1.17, respectively, p&lt;0.001). CFRthermo showed a lower variability and a higher agreement than CFRbolus (variability 12.74±10.41% vs 31.26±24.85%, respectively, p&lt;0.001; ICC= 0.78 (0.70–0.85) and 0.48 (0.32–0.62), respectively, p&lt;0.001, Figure 1). Both MRR and IMR showed a good agreement (ICC 0.81 (0.74–0.87) and 0.80 (0.71–0.86)) but the variability of the MRR was significantly lower (12.44±10.06% vs 24.24±19.27, respectively, p&lt;0.001, Figure 1). Reproducibility data of all indices derived from duplicated measurements of bolus and continuous thermodilution are reported in Table 2.

Conclusion

Continuous intracoronary thermodilution has a higher repeatability than bolus thermodilution in the assessment of CMD.

Funding Acknowledgement

Type of funding sources: None.

Impact of aortic regurgitation on long-term outcomes in heart failure with preserved ejection fraction

Background

Aortic Regurgitation (AR) may aggravate the clinical course in patients with heart failure and preserved ejection fraction (HFpEF) by increasing filling pressures and triggering LV remodelling.

Objective

To assess AR's prevalence and long-term prognostic implications in patients with HFpEF.

Methods

The study population consisted of 458 consecutive patients (age 77.5±9.2 y, 57.9% females) hospitalized with de novo or worsened HFpEF. Patients with more than moderate aortic and/or mitral valve disease were excluded. Data on cardiovascular death, HF re-hospitalization and their composite (MACE) were collected.

Results

Out of 309 (67.5%) patients with any AR, 156 (34.0%) and 153 (33.5%) had mild-AR and moderate-AR, respectively. The remaining 149 (32.5%) individuals had no-AR. Patients with versus without AR were significantly older with larger LV and LA volumes and a higher prevalence of diastolic dysfunction (all p&lt;0.05). During a median follow-up of 33±25 months, a total of 114 patients (24.9%) died from cardiovascular causes, 126 patients (27.5%) were re-hospitalized for HF, while 272 (59.4%) had the composite endpoint (MACE). In multivariable Cox regression analysis, any AR emerged as an only independent predictor of MACE (HR=1.90, 95% CI 1.26–2.87, p=0.002). Mild-AR and Moderate AR increased the risk of MACE by 77% and 92%, respectively, compared to the No-AR (Figure).

Conclusions

In patients with HFpEF, mild-to-moderate AR is highly prevalent, and it seems to identify individuals with worse long-term outcomes. This suggests that even mild AR should be considered a high-risk prognostic marker in patients with HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Saline-induced coronary hyperemia with continuous intracoronary thermodilution is mediated by intravascular hemolysis

Objectives

To test whether local hemolysis is a potential mechanism of saline-induced coronary hyperemia.

Background

Absolute coronary flow can be measured by intracoronary continuous thermodilution of saline through the lateral side holes of a dedicated infusion cathete. A saline infusion rate at 15–20 mL/min induces an immediate, steady-state, maximal microvascular vasodilation. The mechanism of this hyperemic response remains unclear.

Methods

Twelve patients undergoing left and right catheterization were included. The left coronary artery and the coronary sinus were selectively cannulated. Absolute resting and hyperemic coronary flow were measured by continuous intracoronary thermodilution. Arterial and venous samples were collected from the coronary artery and the coronary sinus in five phases: baseline (BL); resting flow measurement (Rest, saline infusion at 10 mL/min); hyperemia (Hyperemia,saline infusion at 20 mL/min); post-hyperemia (Post-Hyperemia, two minutes after the cessation of saline infusion); and control phase (Control, during infusion of saline through the guide catheter at 30 mL/min).

Results

Hemolysis was visually detected only in the centrifugated venous blood samples collected during the Hyperemia phase. As compared to Rest, during Hyperemia both LDH (131.50±21.89 U/dL [Rest] and 258.33±57.40 U/dL [Hyperemia], p&lt;0.001) and plasma free hemoglobin (PFHb, 4.92±3.82 mg/dL [Rest] and 108.42±46.58 mg/dL [Hyperemia], p&lt;0.001) significantly increased in the coronary sinus. The percentage of hemolysis was significantly higher during the Hyperemia phase (0.04±0.02% [Rest] vs 0.89±0.34% [Hyperemia], p&lt;0.001).

Conclusions

Saline-induced hyperemia through a dedicated intracoronary infusion catheter is associated with hemolysis. Vasodilatory compounds released locally, like ATP, are likely ultimately responsible for localized microvascular vasodilation.

Funding Acknowledgement

Type of funding sources: None.

Improvement in angina pectoris after percutaneous coronary interventions in focal and diffuse coronary artery disease

Objective

To investigate the effect of PCI on patient-reported outcomes in focal and diffuse coronary artery disease (CAD) as defined by the pullback pressure gradient (PPG).

Background

Improvements in fractional flow reserve (FFR) following PCI are associated with freedom from angina. CAD patterns influence the FFR change after stenting. Therefore, CAD patterns might be essential to assess the likelihood of PCI success in terms of angina relief.

Methods

This is a sub-analysis of the TARGET-FFR randomized clinical trial (NCT03259815). The 7-item Seattle Angina Questionnaire (SAQ-7) and EuroQol five-level EQ-5D questionnaire (EQ-5D-5L) were administered at baseline and three months after PCI. The PPG index was calculated from manual pre-PCI FFR pullbacks and the median PPG value was used to define focal and diffuse CAD.

Results

103 patients (51 with focal and 52 with diffuse disease) were analyzed. There were no differences in baseline characteristics between patients with focal and diffuse CAD. Patients with focal disease had larger increases in FFR with PCI than those with diffuse disease (0.30±0.14 units vs 0.19±0.12 units, p&lt;0.001). Patients who underwent PCI to focal CAD had significantly higher SAQ-7 summary scores at follow-up compared to those with diffuse CAD (87.1±20.3 vs. 75.6±24.4, mean difference 11.5 [95% CI 2.8 to 20.3], p=0.01). Following PCI, residual angina was present in 39.8% of all patients but was significantly lower among those with treated focal CAD (27.5% vs 51.9%, p-value=0.020).

Conclusion

Persistent angina after PCI was almost twice as common in patients with diffuse CAD as defined by the pre-PCI PPG. Patients with focal disease reported greater improvement in angina and quality of life with PCI. The likelihood of successful angina relief from PCI can be predicted by the baseline pattern of CAD.

Funding Acknowledgement

Type of funding sources: None.

Microvascular dysfunction in patients with diabetes mellitus: assessment of absolute coronary flow and microvascular resistance reserve

Background

Coronary microvascular dysfunction (CMD) is an early feature of diabetic cardiomyopathy, which usually precedes the onset of systolic and diastolic dysfunction (DDF). Continuous intracoronary thermodilution allows an accurate and reproducible assessment of absolute coronary blood flow and microvascular resistance thus allowing the evaluation of coronary flow reserve (CFR) and Microvascular Resistance Reserve (MRR), a novel index specific for microvascular function, which is independent from the myocardial mass. In the present study we compared absolute coronary flow and resistance, CFR and MRR assessed by continuous intracoronary thermodilution in diabetic versus non-diabetic patients. Left atrial reservoir strain (LASr), an early marker of DDF was compared between the two groups.

Methods

In this observational retrospective study, 108 patients with suspected angina and non-obstructive coronary artery disease (NOCAD) consecutively undergoing elective coronary angiography (CAG) from September 2018 to June 2021 were enrolled. The invasive functional assessment of microvascular function was performed in the left anterior descending artery (LAD) with intracoronary continuous thermodilution. Patients were classified according to the presence of DM. Absolute resting and hyperemic coronary flow (in mL/min) and resistance (in WU) were compared between the two cohorts. FFR was measured to assess coronary epicardial lesions, while CFR and MRR were calculated to assess microvascular function. LAS, assessed by speckle tracking echocardiography, was used to detect early myocardial structural changes potentially associated with microvascular dysfunction.

Results

The median FFR value was 0.83 [0.79–0.87] without any significant difference between the two groups. Absolute resting and hyperemic flow in the left anterior descending coronary were similar between diabetic and non-diabetic patients. Similarly, resting and hyperemic resistances did not change significantly between the two groups. In the DM cohort the CFR and MRR were significantly lower compared to the control group (CFR=2.4±0.6 and 2.9±0.8; MRR=2.8±0.9 and 3.5±1 for diabetic and non-diabetic patients respectively, [p&lt;0.05 for both], Figure 1 and 2). Likewise, diabetic patients had a significantly lower reservoir, contractile and conductive LAS (all p&lt;0.05).

Conclusions

Compared with non-diabetic patients, CFR and MRR were lower in patients with DM and non-obstructive epicardial coronary arteries, while both resting and hyperemic coronary flow and resistance were similar. LASr was lower in diabetic patients, confirming the presence of a subclinical DDF associated to the microcirculatory impairment. Continuous intracoronary thermodilution-derived indexes provide a reliable and operator-independent assessment of coronary macro- and microvasculature and might potentially facilitate widespread clinical adoption of invasive physiologic assessment of suspected microvascular disease.

Funding Acknowledgement

Type of funding sources: None.

POS1165 ASSOCIATION OF LDHD RARE VARIANTS WITH EARLY-ONSET GOUT IN TWO FAMILIES WITH AN ADDITIONAL ASSOCIATION OF RHBG VARIANT IN ONE

Background

Elevated lactate is known to favor urine urate reabsorption by the URAT1 urate/anion exchanger. Autosomal recessive gout caused by pathogenic variant in the LDHD gene encoding for D-lactate deshydrogenase has been recently identified in a large consanguineous Bedouin-Israeli kindred (1).

Objectives

We report here on two families in whom early-onset gout was linked to other variants leading to deficient D-LDH enzymes.

Methods

Studies of the two families were approved by appropriate Ethics committees. Whole exome sequencing (WES) was used to identify the genetic cause of familial gout. Dosages of D-lactate were performed on immediately frozen serum and urine samples by ELISA, using a D-lactate colorimetric assay kit (Abcam ab83429).

Results

Family 1 was Melanesian, living in the Lifou island of New Caledonia. The two index patients were two sisters who developed gout at the age of 13 and 16 years respectively. When seen at the ages of 25 and 27 years, they both had severe gout with frequent polyarticular flares, and multiple tophi and destructive arthropathies in the earliest age of onset one. WES, performed on the 2 affected sisters, their non-consanguine parents, and an unaffected brother, showed that the 2 affected sisters carried homozygous rare variant in DLDH gene (NM_153486.3: c.206 C>T; rs1035398551). This variant was at heterozygote level in both parents and absent in the unaffected brother. It was considered as probably damaging according to in silico prediction software. No association with any other gene was found.

The c.206C>T variant in LDHD was searched by Sanger sequencing method in 13 other extended family members. One 23 year-old brother of the two diseased sisters with atypical MTP flares, high uricemia and double contours at US examination of his MTPs, carried the c.206 C>T variant at the homozygous level. Three other heterozygous patients were found; two of whom were male with late-onset gout, the third one being a non-menopausal female with no gout. No variant carrier was found in the other 9 genotyped family members. The 3 homozygous patients for the c.206 C>T variant had very high hyperuricemia (range 738-834 was searched by Sanger sequencing method in 13 other extended family members. One 23 year-old brother of the two diseased sisters with atypical MTP flares, high uricemia and double contours at US examination of had very low or no D-lactate in plasma and urine. L-lactate blood and urine levels were normal in all subjects.

Family 2 was Vietnamese, living in a remote area of central Vietnam. The two affected children suffered from an extremely severe, destructive gout, which started at the age of 21 years in a daughter and at the age of 9 in her youngest brother, who had developed for the last 3 years, dysarthria, night shakes, memory loss, urine incontinence and an inability to read and count and died at the age of 34, a few months after being seen by us. WES was performed in the two probands, their father and mother (who denied consanguinity), and an unaffected brother. An undescribed variant in LDHD (NM_153486.3: c.1363dupG) was identified in homozygous level in the 2 juvenile gout patients and at the heterozygous level in their 2 parents and unaffected brother. This variant led to a frameshift followed by a stop codon p.(AlaGly432fsTer58). In addition, the two juvenile gout patients were homozygous for an undescribed frameshift (NR_046115.1: c.1064dup) variant of the RHBG gene encoding for a Rhesus Blood Group family ammonium transporter. The two parents carried the heterozygous variant which was not identified in the non-gout brother.

Conclusion

We report on 2 families in whom autosomal recessive juvenile gout was due to rare or undescribed, damaging LDHD gene variants. In addition, we observed in the Vietnamese family, an additional non-described frameshift homozygous variant in RHBG, the pathophysiological role of which deserves to be investigated.

References

[1]Drabkin M et al. Hyperuricemia and gout caused by missense mutation in D-lactate dehydrogenase. J Clin Invest. 2019;129:5163-5168

Disclosure of Interests

Thomas Bardin Consultant of: leo Pharma, Yves-Marie Ducrot: None declared, Quang Nguyen: None declared, Emmanuel Letavernier: None declared, Hang-Korng Ea: None declared, Frederic Touzain: None declared, Duc Minh Do: None declared, Julien Corot: None declared, Yan Barguil: None declared, Antoine Biron: None declared, Pascal Richette: None declared, Corinne Collet: None declared

Performance of non-invasive myocardial work to predict the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF)

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Dr. Paolisso, Dr. Esposito, Dr. Fabbricatore are supported by a research grant from the CardioPaTh PhD Program of University of Naples Federico II

Background

Non-invasive myocardial work (MW) is a validated index of left ventricular (LV) systolic performance, incorporating afterload and myocardial metabolism. The role of MW in predicting the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF) is still unknown.

Purpose

To investigate the diagnostic performance of MW to predict the first de novo HFpEF hospitalization in ambulatory individuals with preserved LVEF.

Methods

Twenty-nine patients with trans-thoracic echocardiography performed at least 6 months before the first HFpEF hospitalization were compared with 29 matched controls. MW was derived as the area of pressure-strain loop using speckle-tracking and brachial artery blood pressure. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were collected. First HFpEF hospitalization and its combination with cardiovascular death (MACE) and all-cause of death (MAE) were assessed.

Results

At baseline, future HFpEF patients showed lower GWI, GCW, GWE and higher GWW than controls (all p &lt; 0.05).  At admission versus baseline, GWE significantly decreased, and GWW increased in the HFpEF group (p &lt; 0.05), whereas no significant difference was observed in the controls over time. GWW, with a cut-off of 170 mmHg%, showed the largest AUC to predict first HFpEF hospitalization (AUC = 0.80, 95% CI 0.69–0.91, p &lt; 0.001), MACE (AUC = 0.80, 95% CI 0.66–0.90, p &lt; 0.001) and MAE (AUC = 0.79, 95% CI 0.62–0.88, p = 0.001). GWW &gt; 170 mmHg% was associated with a 4-fold increase of MACE (HR = 4.5, 95% CI 1.59–13.12, p = 0.005) and a 3-fold higher risk of MAE (HR = 2.9, 95% CI 1.24–6.6, p = 0.014).

Conclusions

In ambulatory patients with preserved LVEF and risk factors, GWW showed high accuracy to predict the first HFpEF hospitalization and its combination with mortality. The GWW routine assessment may be clinically helpful in patients with dyspnea. Abstract Figure 1: Serial changes of LARs, LV GLS  Abstract Figure 2:Kaplan–Meier survival curves fo

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

BACKGROUND

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions are associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using calcium modifying techniques such as Rotational Atherectomy (RA) or Intravascular Lithotripsy (IVL) has been advocated. Studies comparing these technologies are lacking. We aimed to compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either RA or IVL.

METHODS

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥ 0.90.

RESULTS

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65 ± 0,13 RA and 0,67 ± 0,11 IVL). After PCI, in-stent pressure gradients were significantly lower in the IVL group (0.032 ± 0.026 vs 0.043 ± 0.026 in the RA group, p = 0.024). The proportions of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p = 0.669).

CONCLUSIONS

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Role of NLRP7 in Normal and Malignant Trophoblast Cells

Gestational choriocarcinoma (CC) is an aggressive cancer that develops upon the occurrence of abnormal pregnancies such as Hydatidiform moles (HMs) or upon non-molar pregnancies. CC cells often metastasize in multiple organs and can cause maternal death. Recent studies have established an association between recurrent HMs and mutations in the Nlrp7 gene. NLRP7 is a member of a new family of proteins that contributes to innate immune processes. Depending on its level of expression, NLRP7 can function in an inflammasome-dependent or independent pathway. To date, the role of NLRP7 in normal and in malignant human placentation remains to be elucidated. We have recently demonstrated that NLRP7 is overexpressed in CC trophoblast cells and may contribute to their acquisition of immune tolerance via the regulation of key immune tolerance-associated factors, namely HLA family, βCG and PD-L1. We have also demonstrated that NLRP7 increases trophoblast proliferation and decreases their differentiation, both in normal and tumor conditions. Actual findings suggest that NLRP7 expression may ensure a strong tolerance of the trophoblast by the maternal immune system during normal pregnancy and may directly affect the behavior and aggressiveness of malignant trophoblast cells. The proposed review summarizes recent advances in the understanding of the significance of NLRP7 overexpression in CC and discusses its multifaceted roles, including its function in an inflammasome-dependent or independent pathways.

Transcriptomic Characterization of Postmolar Gestational Choriocarcinoma

The human placenta shares properties with solid tumors, such as rapid growth, tissue invasion, cell migration, angiogenesis, and immune evasion. However, the mechanisms that drive the evolution from premalignant proliferative placental diseases—called hydatidiform moles—to their malignant counterparts, gestational choriocarcinoma, as well as the factors underlying the increased aggressiveness of choriocarcinoma arising after term delivery compared to those developing from hydatidiform moles, are unknown. Using a 730-gene panel covering 13 cancer-associated canonical pathways, we compared the transcriptomic profiles of complete moles to those of postmolar choriocarcinoma samples and those of postmolar to post-term delivery choriocarcinoma. We identified 33 genes differentially expressed between complete moles and postmolar choriocarcinoma, which revealed TGF-β pathway dysregulation. We found the strong expression of SALL4, an upstream regulator of TGF-β, in postmolar choriocarcinoma, compared to moles, in which its expression was almost null. Finally, there were no differentially expressed genes between postmolar and post-term delivery choriocarcinoma samples. To conclude, the TGF-β pathway appears to be a crucial step in the progression of placental malignancies. Further studies should investigate the value of TGF- β family members as biomarkers and new therapeutic targets.

Angiography vs physiology-based deferral of revascularization in patients with reduced left ventricular ejection fraction: a 10-year clinical follow-up

Background

Deferring percutaneous coronary intervention (PCI) in patients with non-ischemic coronary stenoses based on fractional flow reserve (FFR) and preserved left ventricular ejection fraction (LVEF) is associated with favorable long-term clinical outcomes. In patients with reduced LVEF, the role of reversible/residual ischemia in deferring revascularization is still debated.

Purpose

To investigate whether FFR provides additive clinical benefit compared to coronary angiography in deferring revascularization in patients with intermediate coronary stenoses and reduced LVEF.

Methods

Among 4577 coronary angiographies performed between 2002 and 2010, consecutive patients with reduced LVEF (≤50%) and at least one intermediate coronary stenosis [diameter stenosis (DS)% 40–70%] in whom revascularization was deferred based either on FFR (FFR-guided) or angiography (Angiography-guided) were screened. The primary endpoint of the study was cumulative incidence of death at 10 years.

Results

A total of 843 patients were included (209 in the FFR-guided and 634 in the Angio-guided group). Median clinical follow-up was 7.1 years (IQR 3.2–11.2 years). After 1:1 propensity score matching, baseline characteristics between the two groups were similar. All-cause death at 10 years was significantly lower in the FFR-guided compared with the Angiography-guided group (94 [45%] vs 115 [55%], HR 0.72 [95% CI 0.55–0.95], p&lt;0.05). Similarly, the incidence of major adverse cardiovascular and cerebrovascular events (MACCE, composite of all-cause death, myocardial infarction, any revascularization and stroke) was lower in the FFR guided group (125 [60%] vs 140 [67%], HR 0.77 [95% CI 0.61–0.98], p&lt;0.05).

Conclusions

In patients with reduced LVEF and associated coronary artery disease, deferring revascularization of intermediate stenoses based on FFR is associated with lower incidence of death and MACCE at 10 years.

Funding Acknowledgement

Type of funding sources: None.

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

Background

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions is associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using dedicated calcium modifying techniques such as RA or IVL has been advocated. Studies comparing these technologies are lacking.

Objectives

To compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either rotational atherectomy (RA) or intravascular lithotripsy (IVL).

Methods

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad, calculated as the difference between the vFFR at the proximal minus distal edge of the stent). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥0.90.

Results

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65±0,13 RA and 0,67±0,11 IVL). After PCI, in-stent pressure gradient was significantly lower in the IVL group (0.032±0.026 vs 0.043±0.026 in the RA group, p=0.024). The proportion of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p=0.669)

Conclusions

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Funding Acknowledgement

Type of funding sources: None. In stent gradients after RA and IVL

Baseline troponin-T is powerful predictor of mortality after coronary bifurcation stenting

Introduction

Considerable progress has been made in the treatment of coronary bifurcation stenosis. Anatomical characteristics of the lesion, however, fail to give information about the functional significance of the bifurcation stenosis. There is no study that systematically establishes the baseline functional significance of coronary stenosis and its effect on procedural and clinical outcomes.

Methods

Patients with significant angiographically bifurcation lesions defined as diameter stenosis &gt;50% in main vessel and/or side branch were included. FFR was performed in main vessel (MV) and side branch (SB) before and after percutaneous coronary intervention (PCI). If FFR was ≤0.80 the lesion was considered functionally significant, and patients underwent PCI. For the group with FFR &gt;0.80 – intervention was deferred. All patients were followed-up for vital status every 3 months. Cox regression analysis was performed to identify independent predictors of all-cause and cardiovascular death. The local ethics committee approved the study and patients signed informed consent for participation into registry.

Results

For mean follow-up of 38±18 months (median 40, IQR 23–55 months) all-cause mortality was numerically lower: 8.5% (n=7/82) in deferred group and 12.6% in stented group (n=11/76, p=0.387). The cardiac mortality was also numerically lower, but statistically not significant (9.8%, n=8/82 vs. 11.5%, n=10/88, p=0.714). On multivariate model, independent predictors were mitral regurgitation &gt;1st degree – HR=1.778 (CI 1.100–2.874, p=0.019); dyslipidemia HR=0.765 (CI 0.594–0.985, p=0.038); hemoglobin concentration – HR=0.976 (CI 0.964–0.988, p&lt;0.001); pre-PCI serum troponin ≥0.010 ng/ml – HR=2.702 (CI 1.451–5.032, p=0.002). On multivariate analysis, the following factors were identified as independent predictors of cardiac mortality: age – HR=1.035 (CI 1.009–1.062, p=0.009); diabetes – HR=1.789 (CI 1.089–2.962, p=0.024); dyslipidemia treated with statin – HR=0.667 (CI 0.515–0.863, p=0.002); LV posterior wall thickness – HR=1.230 (CI 1.062–1.424, p=0.006); mitral regurgitation more than 1st degree – HR=1.763 (CI 1.065–2.917, p=0.027); troponin pre-PCI ≥0.010 ng/ml – HR=2.498 (CI 1.228–5.081, p=0.011); true bifurcation lesion – HR=1.820 (CI 1.026–3.229, p=0.040); SBBARI score &lt;10% – HR=1.715 (CI 1.049–2.804, p-0.031).

Conclusion

Baseline high-sensitive troponin T value is a strong predictor for both all cause and cardiac mortality in patients undergoing coronary bifurcation lesion PCI.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Alexandrovska University Hospital

Evidence-Based View of Safety and Effectiveness of Prokineticin Receptors Antagonists during Pregnancy

Endocrine gland derived vascular endothelial growth factor (EG-VEGF) is a canonical member of the prokineticin (PROKs) family. It acts via the two G-protein coupled receptors, namely PROKR1 and PROKR2. We have recently demonstrated that EG-VEGF is highly expressed in the human placenta; contributes to placental vascularization and growth and that its aberrant expression is associated with pregnancy pathologies including preeclampsia and fetal growth restriction. These findings strongly suggested that antagonization of its receptors may constitute a potential therapy for the pregnancy pathologies. Two specific antagonists of PROKR1 (PC7) and for PROKR2 (PKRA) were reported to reverse PROKs adverse effects in other systems. In the view of using these antagonists to treat pregnancy pathologies, a proof of concept study was designed to determine the biological significances of PC7 and PKRA in normal pregnancy outcome. PC7 and PKRA were tested independently or in combination in trophoblast cells and during early gestation in the gravid mouse. Both independent and combined treatments uncovered endogenous functions of EG-VEGF. The independent use of antagonists distinctively identified PROKR1 and PROKR2-mediated EG-VEGF signaling on trophoblast differentiation and invasion; thereby enhancing feto-placental growth and pregnancy outcome. Thus, our study provides evidence for the potential safe use of PC7 or PKRA to improve pregnancy outcome.

Early mandibular morphological differences in patients with FGFR2 and FGFR3-related syndromic craniosynostoses: A 3D comparative study

Syndromic craniosynostoses are defined by the premature fusion of one or more cranial and facial sutures, leading to skull vault deformation, and midfacial retrusion. More recently, mandibular shape modifications have been described in FGFR-related craniosynostoses, which represent almost 75% of the syndromic craniosynostoses. Here, further characterisation of the mandibular phenotype in FGFR-related craniosynostoses is provided in order to confirm mandibular shape modifications, as this could contribute to a better understanding of the involvement of the FGFR pathway in craniofacial development. The aim of our study was to analyse early mandibular morphology in a cohort of patients with FGFR2- (Crouzon and Apert) and FGFR3- (Muenke and Crouzonodermoskeletal) related syndromic craniosynostoses. We used a comparative geometric morphometric approach based on 3D imaging. Thirty-one anatomical landmarks and eleven curves with sliding semi-landmarks were defined to model the shape of the mandible. In total, 40 patients (12 with Crouzon, 12 with Apert, 12 with Muenke and 4 with Crouzonodermoskeletal syndromes) and 40 age and sex-matched controls were included (mean age: 13.7 months ±11.9). Mandibular shape differed significantly between controls and each patient group based on geometric morphometrics. Mandibular shape in FGFR2-craniosynostoses was characterized by open gonial angle, short ramus height, and high and prominent symphysis. Short ramus height appeared more pronounced in Apert than in Crouzon syndrome. Additionally, narrow inter-condylar and inter-gonial distances were observed in Crouzon syndrome. Mandibular shape in FGFR3-craniosynostoses was characterized by high and prominent symphysis and narrow inter-gonial distance. In addition, narrow condylar processes affected patients with Crouzonodermoskeletal syndrome. Statistical analysis of variance showed significant clustering of Apert and Crouzon, Crouzon and Muenke, and Apert and Muenke patients (p < 0.05). Our results confirm distinct mandibular shapes at early ages in FGFR2- (Crouzon and Apert syndromes) and FGFR3-related syndromic craniosynostoses (Muenke and Crouzonodermoskeletal syndromes) and reinforce the hypothesis of genotype-phenotype correspondence concerning mandibular morphology.

Quantifying coronary microvascular disease: assessing absolute microvascular resistance reserve (MRR) by continuous coronary thermodilution

Background and aim

Hyperemic absolute coronary blood flow (in mL/min) can be safely and reproducibly measured with intracoronary continuous thermodilution of saline at room temperature at an infusion rate of 20 mL/min. This study aims at assessing whether continuous thermodilution can also measure resting flow and microvascular resistance.

Methods and results

In 87 coronary arteries (58 patients) with angiographic non-significant stenoses absolute flow was assessed by continuous thermodilution of saline at infusion rates of 10 mL/min and 20 mL/min using a pressure/temperature sensored guide wire, a dedicated infusion catheter and a dedicated software. In addition, in 26 arteries, average peak velocity (APV) was measured simultaneously using an intracoronary Doppler-wire.

There was no significant difference between Pd/Pa at baseline and during saline infusion at 10 mL/min, (0.95±0.053 vs 0.94±0.054, respectively (p=0.53) and there was no significant difference in APV at baseline and during the infusion of saline at 10 mL/min (22.2±8.40 vs 23.2±8.39 cm/s, respectively, p=0.63), thus indicating presence of resting coronary blood flow during the infusion of 10 mL/min of saline.

In contrast, at an infusion rate of 20 mL/min, a significant decrease in Pd/Pa was observed compared to baseline: (0.85±0.089 vs 0.95±0.053, respectively, p&lt;0.001) and a significant increase in APV was observed (22.2±8.4 cm/s to 57.8±25.5 cm/s, respectively, p&lt;0.001). The coronary flow reserve (CFR) calculated by thermodilution and by Doppler flow velocity were similar (2.73±0.85 vs 2.72±1.07, respectively) and their individual values correlated closely (r=0.87, 95% CI 0.72–0.94, p&lt;0,001). Microvascular resistance (Rμ), defined as the distal coronary pressure divided by the absolute flow was calculated both at rest (Rμ-rest) and during hyperemia (Rμ-hyper). Microvascular Resistance Reserve (MRR), is calculated as the ratio of Rμ-rest and Rμ-hyper and showed a good correlation with the analogous Doppler-derived parameter (using the APV instead of absolute flow). Mean doppler and thermodilution derived MRR were similar (3.32±1.50 vs 3.23±1.16) and values correlated closely (r=0.91, 95% CI 0.81 - 0.96, p&lt;0.001; Bland-Altman analysis: mean bias = 0.071, limit of agreement −1.195 to 1.338).

Conclusion

Absolute coronary blood flow (in mL/min) can be measured by continuous thermodilution both at rest and during hyperemia. This allows accurate, reproducible, and operator-independent direct volumetric calculation of CFR and MRR. The latter is a quantitative metric which is specific for microvascular function and independent from myocardial mass.

Doppler and Thermodilution derived MRR

Funding Acknowledgement

Type of funding source: None