Effect of Levocarnitine on the Therapeutic Efficacy of Conventional Therapy in Children with Dilated Cardiomyopathy: Results of a Randomized Trial in 29 Children

Familial dilated cardiomyopathy in a child: a case report

BACKGROUND

Dilated cardiomyopathy (DCM) commonly leads to heart failure (HF) and represents the most common indication for cardiac transplantation in the pediatric population. Clinical manifestations of DCM are mainly the symptoms of heart failure; it is diagnosed by EKG, chest x-ray and echocardiography. For the idiopathic and familial diseases cases of DCM, there are no definite guidelines for treatment in children as they are treated for prognostic improvement.

CASE PRESENTATION

We report the case of a 2-year-old girl diagnosed with dilated cardiomyopathy associated with homozygous mutation in the Myosin Light Chain 3 gene admitted for edema in lower extremities, muscle weakness, lethargy and vomiting, and she was found to be in cardiogenic shock. Chest x-ray showed cardiomegaly and EKG showed first degree atrioventricular block. Echocardiogram showed severe biventricular systolic and diastolic dysfunction. After 70 days of hospitalization, the patient went into cardiac arrest with cessation of electrical and mechanical activity of the heart, despite cardiopulmonary resuscitative efforts.

CONCLUSION

Although rare, pediatric DCM carries a high risk of morbidity and mortality and a lack of curative therapy.

Effect of Carnitine Supplementation in Pediatric Patients with Left Ventricular Dysfunction

Carnitine is an essential amino acid involved in transporting fatty acids across the mitochondrial membrane. Fatty acids are a primary source of energy for the myocardium. Studies in adults demonstrated decreased carnitine levels in the ischemic myocardium, but subsequent exogenous carnitine supplementation showed improvement of myocardial metabolism and left ventricular function. However, only limited data regarding carnitine are available in pediatrics. A single-center retrospective, paired data study was conducted. Patients < 18 years, left ventricular ejection fraction (LVEF) < 55% by echocardiography, and had received at least 7 days of oral or intravenous carnitine supplementation between January 2018 and March 2021 are included in the study. Several endpoints and covariates were collected for each patient: before, one week after, one month after, and 6 months after carnitine supplementation. Univariate analysis consisted of an analysis of variance (ANOVA), followed by an analysis of covariance (ANCOVA) to model LVEF while adjusting for other variables. 44 patients included in the final analyses. LVEF significantly improved from 50.5 to 56.6% (p < 0.01). When LVEF was adjusted for other interventions (mechanical ventilation, afterload reduction, diuretic therapy, spironolactone), the estimated means demonstrated a significant increase from 45.7 to 58.0% (p < 0.01). Free carnitine level increased significantly (p = 0.03), and N-terminal-pro-brain natriuretic peptide (p = 0.03), creatinine (p < 0.01), and lactate (p < 0.01) all significantly decreased over the study period. Carnitine supplementation in pediatric patients with left ventricular systolic dysfunction may be associated with an increase in LVEF and improvement in laboratory markers of myocardial stress and cardiac output.

Multiple-model machine learning identifies potential functional genes in dilated cardiomyopathy

Introduction

Machine learning (ML) has gained intensive popularity in various fields, such as disease diagnosis in healthcare. However, it has limitation for single algorithm to explore the diagnosing value of dilated cardiomyopathy (DCM). We aim to develop a novel overall normalized sum weight of multiple-model MLs to assess the diagnosing value in DCM.

Methods

Gene expression data were selected from previously published databases (six sets of eligible microarrays, 386 samples) with eligible criteria. Two sets of microarrays were used as training; the others were studied in the testing sets (ratio 5:1). Totally, we identified 20 differently expressed genes (DEGs) between DCM and control individuals (7 upregulated and 13 down-regulated).

Results

We developed six classification ML methods to identify potential candidate genes based on their overall weights. Three genes, serine proteinase inhibitor A3 (SERPINA3), frizzled-related proteins (FRPs) 3 (FRZB), and ficolin 3 (FCN3) were finally identified as the receiver operating characteristic (ROC). Interestingly, we found all three genes correlated considerably with plasma cells. Importantly, not only in training sets but also testing sets, the areas under the curve (AUCs) for SERPINA3, FRZB, and FCN3 were greater than 0.88. The ROC of SERPINA3 was significantly high (0.940 in training and 0.918 in testing sets), indicating it is a potentially functional gene in DCM. Especially, the plasma levels in DCM patients of SERPINA3, FCN, and FRZB were significant compared with healthy control.

Discussion

SERPINA3, FRZB, and FCN3 might be potential diagnosis targets for DCM, Further verification work could be implemented.

PPAR agonists attenuate lenalidomide's anti-myeloma activity in vitro and in vivo

Many patients with multiple myeloma (MM) have comorbidities and are treated with PPAR agonists. Immunomodulatory agents (IMiDs) are the cornerstones for MM therapy. Currently, little is known about how co-administration of PPAR agonists impacts lenalidomide treatment in patients with MM. Here, we determined the effects of PPAR agonists on anti-myeloma activities of lenalidomide in vitro and in a myeloma xenograft mouse model. Genetic overexpression and CRISPR/cas9 knockout experiments were performed to determine the role of CRBN in the PPAR-mediated pathway. A retrospective cohort study was performed to determine the correlation of PPAR expression with the outcomes of patients with MM. PPAR agonists down-regulated CRBN expression and reduced the anti-myeloma efficacy of lenalidomide in vitro and in vivo. Co-treatment with PPAR antagonists increased CRBN expression and improved sensitivity to lenalidomide. PPAR expression was higher in bone marrow cells of patients with newly diagnosed MM than in normal control bone marrow samples. High PPAR expression was correlated with poor clinical outcomes. Our study provides the first evidence that PPARs transcriptionally regulate CRBN and that drug-drug interactions between PPAR agonists and IMiDs may impact myeloma treatment outcomes.

Association of Abnormal Serum L-Carnitine Levels with Idiopathic Changes in Left Ventricular Geometry in Pediatric and Adolescent Patients

Background

There is no compelling evidence to prove an association between serum free L-carnitine levels and changes in left ventricular (LV) geometry. The present study aimed to evaluate a possible association between these parameters.

Methods

In a cross-sectional study, 504 outpatients were randomly selected among those registered at Sanandaj Pediatric Heart Clinic (Sanandaj, Iran) during 2014-2020. The patients aged one to 25 years and were presented with cardiac complaints. The serum L-carnitine levels of all patients were evaluated and associated with changes in LV geometry measured by echocardiography. The association was assessed using the Chi squared test, Fisher's exact test, and one-way ANOVA with post hoc Tukey test. Data were analyzed using SPSS software (version 22.0). P≤0.05 was considered statistically significant.

Results

The mean serum L-carnitine levels in the normal, low, and high serum groups were 52.69, 14.16, and 178.67 nmol/dL, respectively. There was a significant statistical association between abnormal serum levels of free L-carnitine and changes in LV geometry (P<0.001).

Conclusion

Our findings are indicative of an association between abnormal serum L-carnitine levels and changes in LV geometry in pediatric and adolescent patients.

Efficacy of L-Carnitine for Dilated Cardiomyopathy: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

L-carnitine mediates the utilization of fatty acids and glucose in the myocardium. The potential of L-carnitine in managing dilated cardiomyopathy (DCM) in patients has been extensively reported, with additional benefits.

OBJECTIVE

This meta-analysis purposed to explore the clinical efficacy of L-carnitine therapy on DCM patients.

METHODS

We searched publications up to May 2020 from several databases including PubMed, Embase, Cochrane Library, Chinese Biomedical (CBM) database, Chinese Science and Technology Periodicals database (VIP), Chinese National Knowledge Infrastructure (CNKI) database, and Wanfang database. Subsequently, publications that met the inclusion criteria were systematically evaluated by two independent reviewers.

RESULTS

A total of 23 RCTs conducted in China with 1455 DCM patients were included in this study. In the meta-analysis, L-carnitine therapy was associated with a considerable improvement in the overall efficacy (RR = 1.28, 95% CI (1.21-1.36), P < 0.0001), left ventricular ejection fraction (LVEF) (MD = 6.16%, 95% CI (4.50, 7.83), P < 0.0001), and cardiac output (CO) (MD = 0.88 L/min, 95% CI (0.51, 1.25), P < 0.0001) as compared to the control group. Moreover, L-carnitine therapy significantly decreased left ventricular end-diastolic dimension (LVEDD) (MD = -2.53, 95% CI (-3.95, -1.12), P = 0.0005), brain natriuretic peptide (BNP) (SMD = -1.71 ng/L, 95% CI (-3.02, -0.40), P = 0.01), and the transforming growth factor-beta (TGF-β1) (MD = -56.78 ng/L, 95% CI (-66.02, -47.53), P < 0.0001).

CONCLUSIONS

L-carnitine potentially enhanced the therapeutic efficiency in DCM patients. Following weaknesses in the evidence due to low methodological quality and high clinical heterogeneity in the included studies, well-designed trials are recommended.

The Changes of T-Wave Amplitude and QT Interval Between the Supine and Orthostatic Electrocardiogram in Children With Dilated Cardiomyopathy

Objectives: Electrocardiogram (ECG) can be affected by autonomic nerves with body position changes. The study aims to explore the ECG changes of children with dilated cardiomyopathy (DCM) when their posture changes. Materials and methods: Sixty-four children diagnosed with DCM were recruited as research group and 55 healthy children as control group. T-wave amplitude and QT interval in ECG were recorded, and their differences between supine and orthostatic ECG were compared in both groups. Subsequently, the children with DCM were followed up and the differences before and after treatment compared. Results: ① Comparisons in differences: Differences of T-wave amplitude in lead II and III, aVF, and V₅ and differences of QT interval in lead II, aVL, aVF, and V₅ were lower in the research group than in the control group. ② Logistic regression analysis and diagnostic test evaluation: The differences of T-wave amplitude in lead III and QT interval in lead aVL may have predictive value for DCM diagnosis. When their values were 0.00 mV and 30 ms, respectively, the sensitivity and specificity of the combined index were 37.5 and 83.6%. ③ Follow-up: In the response group, the T-wave amplitude difference in lead aVR increased and the difference of QT interval in lead V₆ decreased after treatment. In the non-response group, there was no difference before and after treatment. When the combined index of the differences of T-wave amplitude difference in lead aVR and QT interval difference in lead V₆, respectively, were -0.05 mV and 5 ms, the sensitivity and specificity of estimating the prognosis of DCM were 44.4 and 83.3%. Conclusions: The differences of T-wave amplitude and QT interval may have a certain value to estimate DCM diagnosis and prognosis.

[Association of T-wave amplitude on electrocardiogram with left ventricular ejection fraction in children with dilated cardiomyopathy]

OBJECTIVE

To study the association of T-wave amplitude on electrocardiogram (ECG) with left ventricular ejection fraction (LVEF) in children with dilated cardiomyopathy.

METHODS

A retrospective analysis was performed for the clinical data of 44 children who were diagnosed with dilated cardiomyopathy from May 2009 to June 2018. According to LVEF, they were divided into two groups: LVEF ≥50% group (n=26) and LVEF <50% group (n=18). After treatment, 25 children were followed up for 3-42 months (mean 14±9 months). The Guangdong Zhongshan SR-1000A ECG Automatic Analyzer was used to obtain the 12-lead body surface ECG results in the supine position. T-wave amplitude on ECG was evaluated by software and manual measurement.

RESULTS

Compared with the LVEF ≥50% group, the LVEF <50% group had a significant reduction in the T-wave amplitude in leads II, V4, V5 and V6 (P<0.05). The increased-LVEF group (an increase in LVEF > 5% after treatment) had a significant increase in the T-wave amplitude in leads aVR, V5, and V6 after treatment (P<0.05), while the unchanged-LVEF group (an increase in LVEF ≤ 5% after treatment) had a significant reduction in the T-wave amplitude in lead aVR after treatment (P<0.05). The receiver operating characteristic curve analysis showed that the T-wave amplitude in leads II, V4, V5 and V6 had a certain value in predicting LVEF <50% in children with dilated cardiomyopathy (P<0.05). A combination of T-wave amplitude of ≤0.20 mV in lead II, ≤0.40 mV in lead V4, and ≤0.30 mV in leads V5 and V6 had a sensitivity of 88.2% and specificity of 76.0% in the predication of LVEF <50% in children with dilated cardiomyopathy.

CONCLUSIONS

T-wave amplitude on ECG can be used as the indexes for the evaluation of the left ventricular systolic function in children with dilated cardiomyopathy.