Mechanical dispersion in Fabry disease assessed with speckle tracking echocardiography

Cardiac involvement in Anderson-Fabry disease. The role of advanced echocardiography

Anderson-Fabry disease (AFD) is a lysosomal storage disorder, depending on defects in alpha galactosidase A activity, due to a mutation in the galactosidase alpha gene. Cardiovascular involvement represents the leading cause of death in AFD. Cardiac imaging plays a key role in the evaluation and management of AFD patients. Echocardiography is the first-line imaging modality for the identification of the typical features of AFD cardiomyopathy. Advanced echocardiography that allows assessment of myocardial deformation has provided insights into the cardiac functional status of AFD patients. The present review highlights the value and the perspectives of advanced ultrasound imaging in AFD.

Sphingolipid Metabolism Is Associated with Cardiac Dyssynchrony in Patients with Acute Myocardial Infarction

AIM

Sphingolipids are a class of complex and bioactive lipids that are involved in the pathological processes of cardiovascular disease. Fabry disease is an X-linked storage disorder that results in the pathological accumulation of glycosphingolipids in body fluids and the heart. Cardiac dyssynchrony is observed in patients with Fabry disease and left ventricular (LV) hypertrophy. However, little information is available on the relationship between plasma sphingolipid metabolites and LV remodelling after acute myocardial infarction (AMI). The purpose of this study was to assess whether the baseline plasma sphingomyelin/acid ceramidase (aCD) ratio predicts LV dyssynchrony at 6M after AMI.

METHODS

A total of 62 patients with AMI undergoing primary angioplasty were recruited. Plasma aCD and sphingomyelin were measured prior to primary angioplasty. Three-dimensional echocardiographic measurements of the systolic dyssynchrony index (SDI) were performed at baseline and 6 months of follow-up. The patients were divided into three groups according to the level of aCD and sphingomyelin above or below the median. Group 1 denotes lower aCD and lower sphingomyelin; Group 3 denotes higher aCD and higher sphingomyelin. Group 2 represents different categories of patients with aCD and sphingomyelin. Trend analysis showed a significant increase in the SDI from Group 1 to Group 3. Logistic regression analysis showed that the sphingomyelin/aCD ratio was a significant predictor of a worsening SDI at 6 months.

CONCLUSIONS

AMI patients with high baseline plasma sphingomyelin/aCD ratios had a significantly increased SDI at six months. The sphingomyelin/aCD ratio can be considered as a surrogate marker of plasma ceramide load or inefficient ceramide metabolism. Plasma sphingolipid pathway metabolism may be a new biomarker for therapeutic intervention to prevent adverse remodelling after MI.

Sex Differences in Anderson-Fabry Cardiomyopathy: Clinical, Genetic, and Imaging Analysis in Women

Anderson-Fabry Disease (AFD) is a rare, systemic lysosomal storage disease triggered by mutations in the GLA gene, leading to α-galactosidase A (α-Gal A) deficiency. The disease's X-linked inheritance leads to more severe, early-onset presentations in males, while females exhibit variable, often insidious, manifestations, notably impacting cardiac health. This study aims to examine gender-based AFD cardiac manifestations in correlation with the variant type: classical (CL), late-onset (LO), or variants of uncertain significance (VUS). We analyzed data from 72 AFD patients (53 females, 19 males) referred to the "G. Rodolico" University Hospital, employing enzyme activity measurements, genetic analysis, periodic lyso-Gb3 monitoring, comprehensive medical histories, and advanced cardiac imaging techniques. Statistical analysis was performed using SPSS version 26. Our AFD cohort, with an average age of 45 ± 16.1 years, comprised 12 individuals with hypertrophy (AFD-LVH) and 60 without (AFD-N). Women, representing about 75% of the subjects, were generally older than men (47.2 ± 16.2 vs. 38.8 ± 14.6, p = 0.046). In the female group, 17% had CL variants, 43.3% LO, and 39.6% had VUS, compared to 21.1%, 36.8%, and 31.6% in the male group, respectively. Females exhibited significantly higher α-Gal A values (median 7.9 vs. 1.8 nmol/mL/h, p < 0.001) and lower lyso-Gb3 levels (1.5 [IQR 1.1-1.7] vs. 1.9 [1.5-17.3] nmol/L, p = 0.02). Regarding the NYHA class distribution, 70% of women were in class I and 28% in class II, compared to 84% and 16% of men, respectively. Among women, 7.5% exhibited ventricular arrhythmias (10.5% in men), and 9.4% had atrial fibrillation (10.5% in men). Cardiac MRIs revealed fibrosis in 57% of examined women, compared to 87% of men. Even among patients without LVH, significant differences persisted in α-Gal A and lyso-Gb3 levels (p = 0.003 and 0.04), as well as LVMi (61.5 vs. 77.5 g/sqm, p = 0.008) and GLS values (-20% vs. -17%, p = 0.01). The analysis underscored older age, decreased lyso-Gb3 deposition, reduced hypertrophy, and lesser GLS compromise in females, suggesting later disease onset. Severe cardiac patterns were associated with classic variants, while more nuanced manifestations were noted in those with VUS. Early GLS impairment in males, irrespective of hypertrophy, emphasized the role of subclinical damage in AFD.

Evaluation of left ventricular function of pregnant women with autoimmune diseases using speckle tracking echocardiography

Pregnancy can cause fluctuations in autoimmune diseases (AD) women, which may aggravate the cardiac damage. Maternal heart function is very important for maternal and fetal health. Therefore, early and accurate evaluation of the heart function of AD pregnant women is necessary. This study was aimed to evaluate the left ventricular (LV) function of AD pregnant women using two-dimensional speckle tracking echocardiography (2DSTE). A total of 96 subjects, including 26 non-pregnant AD patients (AD group), 33 AD pregnant women (AD-P group), and 37 healthy pregnant women (H-P group) were conducted. Baseline clinical and conventional echocardiography characteristics of all the subjects were collected. The 2DSTE was performed to acquire layer-specific strain parameters of LV. Compared with H-P group, AD-P group showed no significant differences in GLSmid and GLSepi. However, the GLSendo (24.10 [22.30 to 25.40] vs. 21.70 [19.05 to 25.15], P = 0.023) and ΔGLS (5.50 [4.80 to 6.00] vs. 4.90 [4.20 to 5.80], P = 0.017) were decreased, while the PSD (27 [23 to 32] vs. 32 [24 to 44], P = 0.014) was increased. At the segmental level, there was no significant difference in apex LSmid and LSepi between the two groups, while the AD-P group showed transmural dysfunction in basal and middle segments, and the LSendo in apex segments (32.84 [28.34 to 34.25] vs. 27.97 [21.87 to 33.61], P = 0.021) were significantly decreased. Compared with AD group, AD-P group showed no significant difference in ΔGLS, PSD, and GLS parameters of three layers. For the segmental level, there were no significant differences in the LSepi of the apex segment and the LS in three layers of the basal and middle segments between the two groups, while LSendo (32.69 [29.13 to 35.53] vs. 27.97 [21.87 to 33.60], P = 0.017) and LSmid (24.70 [22.24 to 27.78] vs. 21.32 [16.91 to 26.11], P = 0.023) in apex segments were significantly lower in AD-P group. The anti-SSA/Ro antibody were positive independently correlated with PSD. In conclusion, layer-specific strain parameters and PSD by 2DSTE provide an accurate and reproducible measurement of myocardial function. There are subclinical LV myocardial dysfunction in AD pregnant women. Besides, the positive of anti-SSA/Ro antibody maybe associated with LV myocardial dysfunction.

Cardiac Imaging in Anderson-Fabry Disease: Past, Present and Future

Anderson-Fabrydisease is an X-linked lysosomal storage disorder caused by a deficiency in the lysosomal enzyme α-galactosidase A. This results in pathological accumulation of glycosphingolipids in several tissues and multi-organ progressive dysfunction. The typical clinical phenotype of Anderson-Fabry cardiomyopathy is progressive hypertrophic cardiomyopathy associated with rhythm and conduction disturbances. Cardiac imaging plays a key role in the evaluation and management of Anderson-Fabry disease patients. The present review highlights the value and perspectives of standard and advanced cardiovascular imaging in Anderson-Fabry disease.

Fabry Disease and the Heart: A Comprehensive Review

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by mutations of the GLA gene that result in a deficiency of the enzymatic activity of α-galactosidase A and consequent accumulation of glycosphingolipids in body fluids and lysosomes of the cells throughout the body. GB3 accumulation occurs in virtually all cardiac cells (cardiomyocytes, conduction system cells, fibroblasts, and endothelial and smooth muscle vascular cells), ultimately leading to ventricular hypertrophy and fibrosis, heart failure, valve disease, angina, dysrhythmias, cardiac conduction abnormalities, and sudden death. Despite available therapies and supportive treatment, cardiac involvement carries a major prognostic impact, representing the main cause of death in FD. In the last years, knowledge has substantially evolved on the pathophysiological mechanisms leading to cardiac damage, the natural history of cardiac manifestations, the late-onset phenotypes with predominant cardiac involvement, the early markers of cardiac damage, the role of multimodality cardiac imaging on the diagnosis, management and follow-up of Fabry patients, and the cardiac efficacy of available therapies. Herein, we provide a comprehensive and integrated review on the cardiac involvement of FD, at the pathophysiological, anatomopathological, laboratory, imaging, and clinical levels, as well as on the diagnosis and management of cardiac manifestations, their supportive treatment, and the cardiac efficacy of specific therapies, such as enzyme replacement therapy and migalastat.

Layer-specific strain and dyssynchrony index alteration in new-onset systemic lupus erythematosus patients without cardiac symptoms

Background

Layer-specific speckle-tracking echocardiography (STE) is a noninvasive approach that assesses subclinical left ventricular dysfunction. We aimed to investigate the (I) alteration of layer-specific STE parameters and the dyssynchrony index; and (II) the disease parameters associated with layer-specific STE change in drug-naïve patients with new-onset systemic lupus erythematosus (SLE) without cardiac symptoms.

Methods

Thirty-five drug-naïve patients with new-onset SLE and twenty-five healthy controls were enrolled. All individuals received both conventional echocardiographic and two-dimensional STE assessment. The data of layer-specific global longitudinal strain (GLS), global circumferential strain (GCS), and peak systolic dispersion (PSD) were acquired in layer-specific STE.

Results

All patients had a normal left ventricular ejection fraction (LVEF)(mean LVEF: 58%) and conventional echocardiographic parameters were comparable between patients and controls. Decreased layer-specific GLS and elevated PSD were observed in SLE patients (whole layer GLS: -17.6%±3.0% versus -19.3%±2.6%, P=0.02; endocardial GLS: -20.0%±3.2% versus -22.1%±3.0%, P=0.01; epicardial GLS: -15.6%±2.7% versus -16.8%±2.4%, P=0.04; PSD: 41.0±18.9 versus 28.8±10.1 msec, P=0.007). In contrast, there was no difference in layer-specific GCS at three different levels between patients and controls (P>0.05). More severely impaired GLS was observed in patients with higher disease activity, high-risk antiphospholipid antibody (aPL) profile, or renal involvement. The PSD was increased in patients with higher disease activity or a high-risk aPL profile. Correlational analysis showed that GLS at three layers and PSD correlated with high-sensitivity C-reactive protein (hsCRP) levels (whole GLS: r=0.662, P<0.001; endocardial GLS: r=0.637, P<0.001; epicardial GLS: r=0.658, P<0.001; PSD: r=0.390, P=0.021). PSD correlated with epicardial GLS (r=0.360, P=0.047), when treating the hsCRP level, renal involvement, aPL profile, and disease activity as control variables. Multivariate regression showed the hsCRP level and epicardial GLS were predictors of layer-specific GLS impairment and elevated PSD, respectively.

Conclusions

Drug-naive patients with new-onset SLE are likely to have subclinical GLS impairment and left ventricular dyssynchrony, even in the presence of normal LVEF. SLE-related risk factors are associated with these dysfunctions.