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Göbel S, Braun AS, Hahad O, von Henning U, Brandt M, Keller K, Gaida MM, Gori T, Schultheiss HP, Escher F, Münzel T, Wenzel P. Etiologies and predictors of mortality in an all-comer population of patients with non-ischemic heart failure. Clin Res Cardiol 2024; 113:737-749. [PMID: 38224373 PMCID: PMC11026225 DOI: 10.1007/s00392-023-02354-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Despite progress in diagnosis and therapy of heart failure (HF), etiology and risk stratification remain elusive in many patients. METHODS The My Biopsy HF Study (German clinical trials register number: DRKS22178) is a retrospective monocentric study investigating an all-comer population of patients with unexplained HF based on a thorough workup including endomyocardial biopsy (EMB). RESULTS 655 patients (70.9% men, median age 55 [45/66] years) with non-ischemic, non-valvular HF were included in the analyses. 489 patients were diagnosed with HF with reduced ejection fraction (HFrEF), 52 patients with HF with mildly reduced ejection fraction (HFmrEF) and 114 patients with HF with preserved ejection fraction (HFpEF). After a median follow-up of 4.6 (2.5/6.6) years, 94 deaths were enumerated (HFrEF: 68; HFmrEF: 8; HFpEF: 18), equating to mortality rates of 3.3% and 11.6% for patients with HFrEF, 7.7% and 15.4% for patients with HFmrEF and 5.3% and 11.4% for patients with HFpEF after 1 and 5 years, respectively. In EMB, we detected a variety of putative etiologies of HF, including incidental cardiac amyloidosis (CA, 5.8%). In multivariate logistic regression analysis adjusting for age, sex and comorbidities only CA, age and NYHA functional class III + IV remained independently associated with all-cause mortality (CA: HRperui 3.13, 95% CI 1.5-6.51; p = 0.002). CONCLUSIONS In an all-comer population of patients presenting with HF of unknown etiology, incidental finding of CA stands out to be independently associated with all-cause mortality. Our findings suggest that prospective trials would be helpful to test the added value of a systematic and holistic work-up of HF of unknown etiology.
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Affiliation(s)
- S Göbel
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - A S Braun
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
| | - O Hahad
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - U von Henning
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
| | - M Brandt
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - K Keller
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - M M Gaida
- Institute of Pathology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Mainz, Germany
- TRON, Translational Oncology at the University Medical Center Mainz, Mainz, Germany
| | - T Gori
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - H P Schultheiss
- Institute of Cardiac Diagnostics and Therapy (IKDT), Berlin, Germany
| | - F Escher
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - T Münzel
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - P Wenzel
- Cardiology I - Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.
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2
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Kanaoka K, Onoue K, Terasaki S, Nakai M, Iwanaga Y, Miyamoto Y, Saito Y. Changes in Cardiac Function Following Fulminant Myocarditis. Circ Heart Fail 2024; 17:e010840. [PMID: 38572641 PMCID: PMC11008446 DOI: 10.1161/circheartfailure.123.010840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/26/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The natural history of myocardial dysfunction in patients with fulminant myocarditis is poorly understood. This study aims to evaluate changes in cardiac function in patients with fulminant myocarditis using a nationwide registry in Japan. METHODS This retrospective cohort study included patients with biopsy-proven fulminant myocarditis and available for left ventricular ejection fraction (LVEF). We described the LVEF on admission, at discharge, and 1 year after discharge. We divided patients into 2 groups based on LVEF at discharge (reduced ejection fraction of <50% or preserved ejection fraction of ≥50%) and analyzed changes in LVEF and prognosis according to groups. RESULTS We included 214 patients (the median [first-third quartiles] age of the cohort was 48 [35-62] years, and 63 [38%] were female). Of 153 patients available for LVEF at 1 year, the median (first-third quartiles) LVEF increased from 33% (21-45%) on admission to 59% (49-64%) at discharge and further to 61% (55-66%) at 1 year. Of 153 patients, 45 (29%) and 22 (14%) had LVEF <50% at discharge and at 1 year, respectively. Comparisons between patients with LVEF <50% and those with LVEF ≥50% demonstrated that the former group had a higher adjusted probability of death or heart transplantation (hazard ratio, 8.19 [95% CI, 2.13-31.5]; P=0.002). CONCLUSIONS Some patients with fulminant myocarditis had left ventricular dysfunction in the chronic phase. Patients with reduced left ventricular function at discharge had a worse prognosis than those with preserved left ventricular function. REGISTRATION URL: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000045352; Unique identifier: UMIN000039763.
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Affiliation(s)
- Koshiro Kanaoka
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan (K.K., K.O., S.T., Y.S.)
- Department of Medical and Health Information Management (K.K., M.N., Y.I.), National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenji Onoue
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan (K.K., K.O., S.T., Y.S.)
| | - Satoshi Terasaki
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan (K.K., K.O., S.T., Y.S.)
| | - Michikazu Nakai
- Department of Medical and Health Information Management (K.K., M.N., Y.I.), National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Clinical Research Support Center, University of Miyazaki Hospital, Japan (M.N.)
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management (K.K., M.N., Y.I.), National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiro Miyamoto
- Open Innovation Center (Y.M.), National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan (K.K., K.O., S.T., Y.S.)
- Nara Prefecture Seiwa Medical Center, Nara, Japan (Y.S.)
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3
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Wang J, Zhang X, Yang X, Yu H, Bu M, Fu J, Zhang Z, Xu H, Hu J, Lu J, Zhang H, Zhai Z, Yang W, Wu X, Wang Y, Tong Q. Revitalizing myocarditis treatment through gut microbiota modulation: unveiling a promising therapeutic avenue. Front Cell Infect Microbiol 2023; 13:1191936. [PMID: 37260696 PMCID: PMC10229058 DOI: 10.3389/fcimb.2023.1191936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/24/2023] [Indexed: 06/02/2023] Open
Abstract
Numerous studies have demonstrated that gut microbiota plays an important role in the development and treatment of different cardiovascular diseases, including hypertension, heart failure, myocardial infarction, arrhythmia, and atherosclerosis. Furthermore, evidence from recent studies has shown that gut microbiota contributes to the development of myocarditis. Myocarditis is an inflammatory disease that often results in myocardial damage. Myocarditis is a common cause of sudden cardiac death in young adults. The incidence of myocarditis and its associated dilated cardiomyopathy has been increasing yearly. Myocarditis has gained significant attention on social media due to its association with both COVID-19 and COVID-19 vaccinations. However, the current therapeutic options for myocarditis are limited. In addition, little is known about the potential therapeutic targets of myocarditis. In this study, we review (1) the evidence on the gut-heart axis, (2) the crosslink between gut microbiota and the immune system, (3) the association between myocarditis and the immune system, (4) the impact of gut microbiota and its metabolites on myocarditis, (5) current strategies for modulating gut microbiota, (6) challenges and future directions for targeted gut microbiota in the treatment of myocarditis. The approach of targeting the gut microbiota in myocarditis is still in its infancy, and this is the study to explore the gut microbiota-immune system-myocarditis axis. Our findings are expected to pave the way for the use of gut microbiota as a potential therapeutic target in the treatment of myocarditis.
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Affiliation(s)
- Jingyue Wang
- Department of Cardiovascular Medicine, The First Hospital of Jilin University, Changchun, China
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Xianfeng Zhang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Xinyu Yang
- Department of Cardiovascular Medicine, The First Hospital of Jilin University, Changchun, China
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Hang Yu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Mengmeng Bu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Jie Fu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Zhengwei Zhang
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Hui Xu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Jiachun Hu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Jinyue Lu
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Haojian Zhang
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Zhao Zhai
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Wei Yang
- Department of Cardiovascular Medicine, The First Hospital of Jilin University, Changchun, China
| | - Xiaodan Wu
- Department of Cardiovascular Medicine, The First Hospital of Jilin University, Changchun, China
| | - Yan Wang
- State Key Laboratory of Bioactive Substance and Function of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Qian Tong
- Department of Cardiovascular Medicine, The First Hospital of Jilin University, Changchun, China
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4
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Youn JC, Kim D, Cho JY, Cho DH, Park SM, Jung MH, Hyun J, Cho HJ, Park SM, Choi JO, Chung WJ, Yoo BS, Kang SM. Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment. INTERNATIONAL JOURNAL OF HEART FAILURE 2023; 5:66-81. [PMID: 37180564 PMCID: PMC10172080 DOI: 10.36628/ijhf.2023.0011] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/17/2023] [Accepted: 03/27/2023] [Indexed: 05/16/2023]
Abstract
The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.
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Affiliation(s)
- Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang Min Park
- Department of Cardiology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
| | - Mi-Hyang Jung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Junho Hyun
- Division of Cardiology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun-Jai Cho
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seong-Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wook-Jin Chung
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Byung-Su Yoo
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok-Min Kang
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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5
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Harding D, Chong MHA, Lahoti N, Bigogno CM, Prema R, Mohiddin SA, Marelli-Berg F. Dilated cardiomyopathy and chronic cardiac inflammation: Pathogenesis, diagnosis and therapy. J Intern Med 2023; 293:23-47. [PMID: 36030368 DOI: 10.1111/joim.13556] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Dilated cardiomyopathy (DCM) is typically defined by left ventricular dilation and systolic dysfunction in the absence of a clear precipitant. Idiopathic disease is common; up to 50% of patients with DCM have no cause found despite imaging, genetic and biopsy assessments. Treatment remains focused on managing symptoms, reducing the risk of sudden cardiac death and ameliorating the structural and electrical complications of disease progression. In the absence of aetiology-specific treatments, the condition remains associated with a poor prognosis; mortality is approximately 40% at 10 years. The role of immune-mediated inflammatory injury in the development and progression of DCM was first proposed over 30 years ago. Despite the subsequent failures of three large clinical trials of immunosuppressive treatment (ATTACH, RENEWAL and the Myocarditis Treatment Trial), evidence for an abnormal adaptive immune response in DCM remains significant. In this review, we summarise and discuss available evidence supporting immune dysfunction in DCM, with a specific focus on cellular immunity. We also highlight current clinical and experimental treatments. We propose that the success of future immunosuppressive treatment trials in DCM will be dependent on the deep immunophenotyping of patients, to identify those with active inflammation and/or an abnormal immune response who are most likely to respond to therapy.
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Affiliation(s)
- Daniel Harding
- Centre for Biochemical Pharmacology, William Harvey Research Institute, London, UK
| | - Ming H A Chong
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Nishant Lahoti
- Conquest Hospital, East Sussex Healthcare NHS Trust, St Leonards-on-Sea, UK
| | - Carola M Bigogno
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Roshni Prema
- University Hospital, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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6
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Rinkūnaitė I, Šimoliūnas E, Alksnė M, Bartkutė G, Labeit S, Bukelskienė V, Bogomolovas J. Genetic Ablation of Ankrd1 Mitigates Cardiac Damage during Experimental Autoimmune Myocarditis in Mice. Biomolecules 2022; 12:biom12121898. [PMID: 36551326 PMCID: PMC9775225 DOI: 10.3390/biom12121898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/05/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Myocarditis (MC) is an inflammatory disease of the myocardium that can cause sudden death in the acute phase, and dilated cardiomyopathy (DCM) with chronic heart failure as its major long-term outcome. However, the molecular mechanisms beyond the acute MC phase remain poorly understood. The ankyrin repeat domain 1 (ANKRD1) is a functionally pleiotropic stress/stretch-inducible protein, which can modulate cardiac stress response during various forms of pathological stimuli; however, its involvement in post-MC cardiac remodeling leading to DCM is not known. To address this, we induced experimental autoimmune myocarditis (EAM) in ANKRD1-deficient mice, and evaluated post-MC consequences at the DCM stage mice hearts. We demonstrated that ANKRD1 does not significantly modulate heart failure; nevertheless, the genetic ablation of Ankrd1 blunted the cardiac damage/remodeling and preserved heart function during post-MC DCM.
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Affiliation(s)
- Ieva Rinkūnaitė
- Department of Biological Models, Institute of Biochemistry, Life Sciences Center, Vilnius University, LT-10257 Vilnius, Lithuania
| | - Egidijus Šimoliūnas
- Department of Biological Models, Institute of Biochemistry, Life Sciences Center, Vilnius University, LT-10257 Vilnius, Lithuania
| | - Milda Alksnė
- Department of Biological Models, Institute of Biochemistry, Life Sciences Center, Vilnius University, LT-10257 Vilnius, Lithuania
| | - Gabrielė Bartkutė
- Department of Biological Models, Institute of Biochemistry, Life Sciences Center, Vilnius University, LT-10257 Vilnius, Lithuania
| | - Siegfried Labeit
- DZHK Partner Site Mannheim-Heidelberg, Medical Faculty Mannheim, University of Heidelberg, 68167 Mannheim, Germany
- Myomedix GmbH, 69151 Neckargemünd, Germany
| | - Virginija Bukelskienė
- Department of Biological Models, Institute of Biochemistry, Life Sciences Center, Vilnius University, LT-10257 Vilnius, Lithuania
| | - Julius Bogomolovas
- Department of Medicine, School of Medicine, University of California, San Diego (UCSD), La Jolla, CA 92093, USA
- Correspondence:
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7
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Genetic Association between Polymorphisms of Interleukin-32 and Dilated Cardiomyopathy in Chinese Han Population. DISEASE MARKERS 2022; 2022:5946290. [PMID: 36505098 PMCID: PMC9733993 DOI: 10.1155/2022/5946290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/05/2022]
Abstract
Background Dilated cardiomyopathy is a primary myocardial disease and one of the critical causes of heart failure. It is the most common indication for heart transplantation worldwide, and most idiopathic dilated cardiomyopathies are sporadic and multifactorial. Evidence has supported that several inflammatory cytokines and immune responses are involved in its pathological process. Interleukin-32 is a proinflammatory cytokine and is elevated during the worsening cardiac function. Herein, we evaluated the correlation between interleukin-32 gene polymorphisms (rs12934561 and rs28372698) and the susceptibility to dilated cardiomyopathy. Methods We enrolled 418 dilated cardiomyopathy patients and 437 healthy controls. The polymerase chain reaction-restriction fragment length polymorphism method was used for genotyping the two single-nucleotide polymorphisms (SNPs), and SPSS software was used for statistical analyses. Results The C allele and CC genotype frequencies of rs12934561 were remarkably elevated in dilated cardiomyopathy patients compared to controls (both P < 0.001). The A allele and AA genotype frequencies of rs28372698 significantly decreased in dilated cardiomyopathy patients (P = 0.004 and P = 0.02, respectively). Compared to TT/TC genotype carriers of rs12934561, CC homozygotes presented an increased risk of dilated cardiomyopathy when the left ventricular ejection fraction no more than 30% (P = 0.02). Conclusions The IL-32 gene polymorphisms might implicate in DCM risk in the Chinese Han population, and rs12934561 could be a potential forecasting factor for screening high-risk population for DCM.
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8
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Chudý M, Goncalvesová E. Prediction of Left Ventricular Reverse Remodelling: A Mini Review on Clinical Aspects. Cardiology 2022; 147:521-528. [PMID: 36103841 PMCID: PMC9808636 DOI: 10.1159/000526986] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/29/2022] [Indexed: 01/07/2023]
Abstract
Improvement of left ventricular ejection fraction (LVEF) in patients after the first manifestation of heart failure with reduced ejection fraction (HFrEF) has currently been observed more frequently than it was years ago. This appears to be due to the early initiation of comprehensive HF therapy. According to these observations, a new HF syndrome category, heart failure with improved ejection fraction (HFimpEF), was introduced. In this short review, we present definitions of reverse remodelling, myocardial remission, and myocardial recovery. We provide an overview of clinical research aimed at evaluating reverse remodelling in different populations of patients with HFrEF. Clinical and imaging characteristics and biomarkers identified as predictors of reverse remodelling and improvement of the LVEF are discussed. We also briefly address the current views on the management of patients with HFimpEF. In-depth study and knowledge of the molecular mechanisms underlying the reverse remodelling process may lead to the identification of new individualized therapeutic approaches for HFrEF.
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9
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Yin Z, Zhang J, Xu S, Liu J, Xu Y, Yu J, Zhao M, Pan W, Wang M, Wan J. The role of semaphorins in cardiovascular diseases: Potential therapeutic targets and novel biomarkers. FASEB J 2022; 36:e22509. [PMID: 36063107 DOI: 10.1096/fj.202200844r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/24/2022] [Accepted: 08/09/2022] [Indexed: 12/17/2022]
Abstract
Semaphorins (Semas), which belongs to the axonal guidance molecules, include 8 classes and could affect axon growth in the nervous system. Recently, semaphorins were found to regulate other pathophysiological processes, such as immune response, oncogenesis, tumor angiogenesis, and bone homeostasis, through binding with their plexin and neuropilin receptors. In this review, we summarized the detailed role of semaphorins and their receptors in the pathological progression of various cardiovascular diseases (CVDs), highlighting that semaphorins may be potential therapeutic targets and novel biomarkers for CVDs.
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Affiliation(s)
- Zheng Yin
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Jishou Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Shuwan Xu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Jianfang Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Yao Xu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Junping Yu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Mengmeng Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Wei Pan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Menglong Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Jun Wan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China.,Cardiovascular Research Institute, Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
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10
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Neurological Manifestations of Myocarditis. Curr Neurol Neurosci Rep 2022; 22:363-374. [PMID: 35588043 PMCID: PMC9117837 DOI: 10.1007/s11910-022-01203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The present review discusses the neurological complications associated with myocarditis of different etiologies. RECENT FINDINGS Myocarditis can be idiopathic or caused by different conditions, including toxins, infections, or inflammatory diseases. Clinical findings are variable and range from mild self-limited shortness of breath or chest pain to hemodynamic instability which may result in cardiogenic shock and death. Several neurologic manifestations can be seen in association with myocarditis. Tissue remodeling, fibrosis, and myocyte dysfunction can result in heart failure and arrhythmias leading to intracardiac thrombus formation and cardioembolism. In addition, peripheral neuropathies, status epilepticus, or myasthenia gravis have been reported in association with specific types of myocarditis. Multiple studies suggest the increasing risk of neurologic complications in patients with myocarditis. Neurologists should maintain a high suspicion of myocarditis in cases presenting with both cardiovascular and neurological dysfunction without a clear etiology.
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11
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Mirna M, Paar V, Topf A, Kraus T, Sotlar K, Aigner A, Ewe A, Watzinger S, Podesser BK, Hackl M, Pistulli R, Hoppe UC, Kiss A, Lichtenauer M. A new player in the game: treatment with antagomiR-21a-5p significantly attenuates histological and echocardiographic effects of experimental autoimmune myocarditis. Cardiovasc Res 2022; 118:556-572. [PMID: 33483746 DOI: 10.1093/cvr/cvab015] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 01/09/2021] [Indexed: 12/16/2022] Open
Abstract
AIMS Myocarditis is associated with formidable symptoms and increased risk of adverse outcomes. Current approaches mostly rely on symptomatic treatments, warranting novel concepts for clinical practice. The aim of this study was to investigate the microRNA (miRNA) expression profile of Balb/c mice with experimental autoimmune myocarditis (EAM), choose a representative miRNA to antagonize after review of available literature and test its effects on myocardial inflammation in vitro and in vivo. METHODS AND RESULTS Phase 1: EAM was induced in 12 male Balb/c mice, 10 animals served as controls. After sacrifice, next-generation sequencing (NGS) of the miRNA expression profile was performed. Based on these results, H9C2 cells and human ventricular cardiac fibroblasts exposed to lipopolysaccharide (LPS) were treated with the selected candidate antagomiR-21a-5p. Phase 2: EAM was induced in 48 animals. Thereof, 24 animals were either treated with antagomiR-21a-5p or negative control oligonucleotide in a nanoparticle formulation. Transthoracic echocardiography (TTE) was performed on Days 0, 7, 14, and 21. Histopathological examination was performed after sacrifice. Phase 1: EAM resulted in a significant up-regulation of 27 miRNAs, including miR-21a-5p (log2FC: 2.23, adj. P = 0.0026). Transfection with antagomiR-21a-5p resulted in a significant reduction of TNFα, IL-6, and collagen I in vitro. Phase 2: Treatment with antagomiR-21a-5p, formulated in polymeric nanoparticles for systemic injection, significantly attenuated myocardial inflammation (P = 0.001) and fibrosis (P = 0.013), as well as myocardial 'hypertrophy' on TTE. CONCLUSIONS Silencing of miR-21a-5p results in a significant reduction of the expression of pro-inflammatory cytokines in vitro, as well as a significant attenuation of inflammation, fibrosis and echocardiographic effects of EAM in vivo.
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Affiliation(s)
- Moritz Mirna
- Department of Cardiology, University Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Vera Paar
- Department of Cardiology, University Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Albert Topf
- Department of Cardiology, University Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Theo Kraus
- University Institute of Pathology, Paracelsus Medical University of Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Karl Sotlar
- University Institute of Pathology, Paracelsus Medical University of Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Achim Aigner
- Rudolf-Boehm-Institut for Pharmacology und Toxicology, Clinical Pharmacology, University of Leipzig, Faculty of Medicine, Haertelstraße 16-18, 04107 Leipzig, Germany
| | - Alexander Ewe
- Rudolf-Boehm-Institut for Pharmacology und Toxicology, Clinical Pharmacology, University of Leipzig, Faculty of Medicine, Haertelstraße 16-18, 04107 Leipzig, Germany
| | - Simon Watzinger
- Ludwig Boltzmann Institute for Cardiovascular Research at Center for Biomedical Research, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria
| | - Bruno K Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research at Center for Biomedical Research, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria
| | | | - Rudin Pistulli
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert-Schweitzer-Strasse 33, 48149 Muenster, Germany
| | - Uta C Hoppe
- Department of Cardiology, University Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Attila Kiss
- Ludwig Boltzmann Institute for Cardiovascular Research at Center for Biomedical Research, Medical University of Vienna, Waehringerguertel 18-20, 1090 Vienna, Austria
| | - Michael Lichtenauer
- Department of Cardiology, University Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria
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12
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Kragholm KH, Lindgren FL, Zaremba T, Freeman P, Andersen NH, Riahi S, Pareek M, Køber L, Torp-Pedersen C, Søgaard P, Hagendorff A, Tayal B. Mortality and ventricular arrhythmia after acute myocarditis: a nationwide registry-based follow-up study. Open Heart 2021; 8:openhrt-2021-001806. [PMID: 34675133 PMCID: PMC8532546 DOI: 10.1136/openhrt-2021-001806] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/01/2021] [Indexed: 12/20/2022] Open
Abstract
Objective Incidence and severity of acute myocarditis vary significantly in previous reports and there is a lack of epidemiological studies on the short-term risks of mortality, heart failure and ventricular arrhythmias in patients with acute myocarditis. Therefore, study aims were to examine 90-day risks of mortality, heart failure (HF) and ventricular arrhythmias in patients with acute myocarditis in comparison to age-matched and sex-matched background population controls. Methods In this nationwide register-based follow-up study of patients hospitalised with myocarditis between 2002 and 2018 in Denmark, 90-day risks of all-cause mortality, HF, ventricular arrhythmias (ventricular tachycardia, ventricular fibrillation (VF)), cardiac arrest and implantable cardioverter-defibrillator (ICD) implantation were compared with age-matched and sex-matched controls from the background population (1:5 matching). Absolute risks standardised to the age, sex and comorbidity distribution of the entire study population were derived from multivariable Cox regression. Results A total of 2523 patients hospitalised with myocarditis were included. Median age was 48 years (Q1–Q3: 30–69) and 67.7% were men. Comorbidity burden was more pronounced among patients with myocarditis relative to controls. Standardised 90-day all-cause mortality risk was 4.9% for patients with acute myocarditis versus 0.3% for controls (p<0.001). Ninety-day standardised risks for other endpoints were 7.5% versus 0.1% for HF, 1.9% versus <0.1% for VF/VF/arrest risk and 1.6% versus <0.1% for ICD implantation (all p<0.001). Conclusions In this large nationwide register-based follow-up study, patients hospitalised with myocarditis had significantly higher 90-day risks of all-cause mortality, HF, ventricular arrhythmias, cardiac arrest and ICD implantation compared with background population controls.
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Affiliation(s)
- Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark .,Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Tomas Zaremba
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Phillip Freeman
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Sam Riahi
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Manan Pareek
- Department of Cardiology, Nordsjællands Hospital, Hillerod, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Bhupendar Tayal
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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13
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Tscholl V, Wielander D, Kelch F, Stroux A, Attanasio P, Tschöpe C, Landmesser U, Roser M, Huemer M, Heidecker B, Nagel P. Benefit of a wearable cardioverter defibrillator for detection and therapy of arrhythmias in patients with myocarditis. ESC Heart Fail 2021; 8:2428-2437. [PMID: 33887109 PMCID: PMC8318510 DOI: 10.1002/ehf2.13353] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/04/2021] [Accepted: 03/29/2021] [Indexed: 12/20/2022] Open
Abstract
Aims Myocarditis may lead to malignant arrhythmias and sudden cardiac death. As of today, there are no reliable predictors to identify individuals at risk for these catastrophic events. The aim of this study was to evaluate if a wearable cardioverter defibrillator (WCD) may detect and treat such arrhythmias adequately in the peracute setting of myocarditis. Methods and results In this observational, retrospective, single centre study, we reviewed patients presenting to the Charité Hospital from 2009 to 2017, who were provided with a WCD for the diagnosis of myocarditis with reduced ejection fraction (<50%) and/or arrhythmias. Amongst 259 patients receiving a WCD, 59 patients (23%) were diagnosed with myocarditis by histology. The mean age was 46 ± 14 years, and 11 patients were women (19%). The mean WCD wearing time was 86 ± 63 days, and the mean daily use was 20 ± 5 h. During that time, two patients (3%) had episodes of sustained ventricular tachycardia (VT; four total) corresponding to a rate of 28 sustained VT episodes per 100 patient‐years. Consequently, one of these patients underwent rhythm stabilization through intravenous amiodarone, while the other patient received an implantable cardioverter defibrillator. Two patients (3.4%) were found to have non‐sustained VT. Conclusions Using a WCD after acute myocarditis led to the detection of sustained VT in 2/59 patients (3%). While a WCD may prevent sudden cardiac death after myocarditis, our data suggest that WCD may have impact on clinical management through monitoring and arrhythmia detection.
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Affiliation(s)
- Verena Tscholl
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Dennis Wielander
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Felicitas Kelch
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Andrea Stroux
- Institute for Biometry and Clinical Epidemiology and Berlin Institute of Health (BIH), Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Attanasio
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Carsten Tschöpe
- Berlin Institute of Health at Charite (BIH)- Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charité - University Medicine Berlin, Campus Virchow Clinic, Augustenburgerplatz 1, 13353, Berlin, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany.,Berlin Institute of Health at Charite (BIH)- Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Charité - University Medicine Berlin, Campus Virchow Clinic, Augustenburgerplatz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Mattias Roser
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Martin Huemer
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Bettina Heidecker
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Patrick Nagel
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Germany
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14
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Kimura Y, Okumura T, Morimoto R, Kazama S, Shibata N, Oishi H, Araki T, Mizutani T, Kuwayama T, Hiraiwa H, Kondo T, Murohara T. A clinical score for predicting left ventricular reverse remodelling in patients with dilated cardiomyopathy. ESC Heart Fail 2021; 8:1359-1368. [PMID: 33471966 PMCID: PMC8006712 DOI: 10.1002/ehf2.13216] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/12/2020] [Accepted: 01/05/2021] [Indexed: 12/31/2022] Open
Abstract
Aims Left ventricular reverse remodelling (LVRR) is a well‐established predictor of a good prognosis in patients with dilated cardiomyopathy (DCM). The prediction of LVRR is important when developing a long‐term treatment strategy. This study aimed to assess the clinical predictors of LVRR and establish a scoring system for predicting LVRR in patients with DCM that can be used at any institution. Methods and results We consecutively enrolled 131 patients with DCM and assessed the clinical predictors of LVRR. LVRR was defined as an absolute increase in left ventricular ejection fraction (LVEF) from ≥10% to a final value of >35%, accompanied by a decrease in left ventricular end‐diastolic dimension (LVEDD) ≥ 10% on echocardiography at 1 ± 0.5 years after a diagnosis of DCM. The mean patient age was 50.1 ± 11.9 years. The mean LVEF was 32.2 ± 9.5%, and the mean LVEDD was 64.1 ± 12.5 mm at diagnosis. LVRR was observed in 45 patients (34%) at 1 ± 0.5 years. In a multivariate analysis, hypertension [odds ratio (OR): 6.86; P = 0.002], no family history of DCM (OR: 10.45; P = 0.037), symptom duration <90 days (OR: 6.72; P < 0.001), LVEF <35% (OR: 13.66; P < 0.0001), and QRS duration <116 ms (OR: 5.94; P = 0.005) were found to be independent predictors of LVRR. We scored the five independent predictors according to the ORs (1 point, 2 points, 1 point, 2 points, and 1 point, respectively), and the total LVRR predicting score was calculated by adding these scores. The LVRR rate was stratified by the LVRR predicting score (0–2 points: 0%; 3 points: 6.7%; 4 points: 17.4%; 5 points: 48.2%; 6 points: 79.2%; and 7 points: 100%). The cut‐off value of the LVRR predicting score was >5 in receiver‐operating characteristic curve analysis (area under the curve: 0.89; P < 0.0001; sensitivity: 87%; specificity: 78%). An LVRR predicting score of >5 was an independent predictor compared with the presence of late gadolinium enhancement on cardiovascular magnetic resonance or the severity of fibrosis on endomyocardial biopsy (OR: 11.79; 95% confidence interval: 2.40–58.00; P = 0.002). Conclusions The LVRR predicting score using five predictors including hypertension, no family history of DCM, symptom duration <90 days, LVEF <35%, and QRS duration <116 ms can stratify the LVRR rate in patients with DCM. The LVRR predicting score may be a useful clinical tool that can be used easily at any institution.
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Affiliation(s)
- Yuki Kimura
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shingo Kazama
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Naoki Shibata
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hideo Oishi
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Araki
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Takashi Mizutani
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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15
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Tajiri K, Imanaka-Yoshida K, Tsujimura Y, Matsuo K, Hiroe M, Aonuma K, Ieda M, Yasutomi Y. A New Mouse Model of Chronic Myocarditis Induced by Recombinant Bacille Calmette-Guèrin Expressing a T-Cell Epitope of Cardiac Myosin Heavy Chain-α. Int J Mol Sci 2021; 22:E794. [PMID: 33466825 PMCID: PMC7829923 DOI: 10.3390/ijms22020794] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 12/12/2022] Open
Abstract
Dilated cardiomyopathy (DCM) is a potentially lethal disorder characterized by progressive impairment of cardiac function. Chronic myocarditis has long been hypothesized to be one of the causes of DCM. However, owing to the lack of suitable animal models of chronic myocarditis, its pathophysiology remains unclear. Here, we report a novel mouse model of chronic myocarditis induced by recombinant bacille Calmette-Guérin (rBCG) expressing a CD4+ T-cell epitope of cardiac myosin heavy chain-α (rBCG-MyHCα). Mice immunized with rBCG-MyHCα developed chronic myocarditis, and echocardiography revealed dilation and impaired contraction of ventricles, similar to those observed in human DCM. In the heart, CD62L-CD4+ T cells were increased and produced significant amounts of IFN-γ and IL-17 in response to cardiac myosin. Adoptive transfer of CD62L-CD4+ T cells induced myocarditis in the recipient mice, which indicated that CD62L-CD4+ T cells were the effector cells in this model. rBCG-MyHCα-infected dendritic cells produced proinflammatory cytokines and induced MyHCα-specific T-cell proliferation and Th1 and Th17 polarization. This novel chronic myocarditis mouse model may allow the identification of the central pathophysiological and immunological processes involved in the progression to DCM.
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Affiliation(s)
- Kazuko Tajiri
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, Tsukuba 305-0843, Japan;
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Japan; (K.A.); (M.I.)
| | - Kyoko Imanaka-Yoshida
- Department of Pathology and Matrix Biology, Mie University Graduate School of Medicine, Tsu 514-8507, Japan;
- Mie University Matrix Biology Research Center, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Yusuke Tsujimura
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, Tsukuba 305-0843, Japan;
- Leprosy Research Center, National Institute of Infectious Diseases, Higashimurayama 189-0002, Japan
| | - Kazuhiro Matsuo
- Department of Research and Development, Japan BCG Laboratory, Kiyose 204-0022, Japan;
| | - Michiaki Hiroe
- Department of Cardiology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan;
| | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Japan; (K.A.); (M.I.)
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba 305-8575, Japan; (K.A.); (M.I.)
| | - Yasuhiro Yasutomi
- Tsukuba Primate Research Center, National Institutes of Biomedical Innovation, Health and Nutrition, Tsukuba 305-0843, Japan;
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16
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Hazebroek MR, Henkens MTHM, Raafs AG, Verdonschot JAJ, Merken JJ, Dennert RM, Eurlings C, Abdul Hamid MA, Wolffs PFG, Winkens B, Brunner-La Rocca HP, Knackstedt C, van Paassen P, van Empel VPM, Heymans SRB. Intravenous immunoglobulin therapy in adult patients with idiopathic chronic cardiomyopathy and cardiac parvovirus B19 persistence: a prospective, double-blind, randomized, placebo-controlled clinical trial. Eur J Heart Fail 2021; 23:302-309. [PMID: 33347677 PMCID: PMC8048650 DOI: 10.1002/ejhf.2082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/16/2020] [Accepted: 12/17/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS Previous uncontrolled studies suggested a possible benefit of intravenous immunoglobulin (IVIg) in parvovirus B19 (B19V)-related dilated cardiomyopathy (DCM). This randomized, double-blind, placebo-controlled, single-centre trial investigated the benefits of IVIg beyond conventional therapy in idiopathic chronic DCM patients with B19V persistence. METHODS AND RESULTS Fifty patients (39 men; mean age 54 ± 11 years) with idiopathic chronic (>6 months) DCM on optimal medical therapy, left ventricular ejection fraction (LVEF) <45%, and endomyocardial biopsy (EMB) B19V load of >200 copies/µg DNA were blindly randomized to either IVIg (n = 26, 2 g/kg over 4 days) or placebo (n = 24). The primary outcome was change in LVEF at 6 months after randomization. Secondary outcomes were change in functional capacity assessed by 6-min walk test (6MWT), quality of life [Minnesota Living with Heart Failure Questionnaire (MLHFQ)], left ventricular end-diastolic volume (LVEDV), and EMB B19V load at 6 months after randomization. LVEF significantly improved in both IVIg and placebo groups (absolute mean increase 5 ± 9%, P = 0.011 and 6 ± 10%, P = 0.008, respectively), without a significant difference between groups (P = 0.609). Additionally, change in 6MWT [median (interquartile range) IVIg 36 (13;82) vs. placebo 32 (5;80) m; P = 0.573], MLHFQ [IVIg 0 (-7;5) vs. placebo -2 (-6;6), P = 0.904] and LVEDV (IVIg -16 ± 49 mL/m2 vs. placebo -29 ± 40 mL/m2 ; P = 0.334) did not significantly differ between groups. Moreover, despite increased circulating B19V antibodies upon IVIg administration, reduction in cardiac B19V did not significantly differ between groups. CONCLUSION Intravenous immunoglobulin therapy does not significantly improve cardiac systolic function or functional capacity beyond standard medical therapy in patients with idiopathic chronic DCM and cardiac B19V persistence. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov ID NCT00892112.
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Affiliation(s)
- Mark R Hazebroek
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Anne G Raafs
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Job A J Verdonschot
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jort J Merken
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert M Dennert
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Casper Eurlings
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Myrurgia A Abdul Hamid
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Petra F G Wolffs
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stephane R B Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiovascular Research, University of Leuven, Leuven, Belgium.,Netherlands Heart Institute (Nl-HI), Utrecht, The Netherlands
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17
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Masada K, Watanabe Y, Hakoda Y, Mogami A, Tsuchiya A, Matsui S, Oda N, Urabe Y, Yamazato R, Mitsuba N, Miura F, Ueda H. Six recurrences of myocarditis in 3 years: A case report. J Cardiol Cases 2020; 23:127-130. [PMID: 33717378 DOI: 10.1016/j.jccase.2020.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/29/2020] [Accepted: 10/03/2020] [Indexed: 11/30/2022] Open
Abstract
A recent study revealed that recurrence of myocarditis occurs in a significant proportion of patients, but multiple recurrences of myocarditis have rarely been reported. The pathophysiology and best treatments for multiple recurrences of myocarditis remain unclear. A 60-year-old man presented to our emergency department with fever and chest pain. Physical examination, imaging, and laboratory findings were consistent with fulminant myocarditis. Paired titers confirmed adenovirus infection. The patient was treated with intra-aortic balloon pump and percutaneous cardiopulmonary support for 7 days and was discharged with near-normal electrocardiographic and echocardiographic findings on day 26. Over the subsequent 3 years, the patient experienced six episodes of recurrence of myocarditis with a progressive decrease in his ability to perform activities of daily living. At the time of his sixth recurrence, he died of ventricular fibrillation. Autopsy revealed mild enlargement of the left ventricle, extensive inflammatory cell infiltration, and mild interstitial fibrosis, suggesting left ventricle remodeling because of repetitive myocarditis. We have presented a case of multiple recurrences of myocarditis. This is the largest number of recurrences in a single patient reported to date. Further studies are needed to elucidate the underlying pathogenesis and best treatment of this condition. <Learning objective: Although few cases of multiple recurrent myocarditis have been reported, we recently experienced a case of multiple recurrences of myocarditis over a 3-year period. However, we did not definitively diagnose the etiology of myocarditis or perform etiologically based medical therapy, so we could not rescue our patient. In cases of multiple recurrent myocarditis, more aggressive and accurate investigation are required to elucidate the etiology and pathophysiology of this condition.>.
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Affiliation(s)
- Kenji Masada
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yoshikazu Watanabe
- Department of Cardiovascular Medicine, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Yoshimitsu Hakoda
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Atsuo Mogami
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Akane Tsuchiya
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Shogo Matsui
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Nozomu Oda
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Yoji Urabe
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Ryo Yamazato
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Naoya Mitsuba
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Fumiharu Miura
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Hironori Ueda
- Department of Cardiovascular Medicine, Hiroshima Prefectural Hospital, Hiroshima, Japan
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18
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Awadalla M, Mahmood SS, Groarke JD, Hassan MZO, Nohria A, Rokicki A, Murphy SP, Mercaldo ND, Zhang L, Zlotoff DA, Reynolds KL, Alvi RM, Banerji D, Liu S, Heinzerling LM, Jones-O'Connor M, Bakar RB, Cohen JV, Kirchberger MC, Sullivan RJ, Gupta D, Mulligan CP, Shah SP, Ganatra S, Rizvi MA, Sahni G, Tocchetti CG, Lawrence DP, Mahmoudi M, Devereux RB, Forrestal BJ, Mandawat A, Lyon AR, Chen CL, Barac A, Hung J, Thavendiranathan P, Picard MH, Thuny F, Ederhy S, Fradley MG, Neilan TG. Global Longitudinal Strain and Cardiac Events in Patients With Immune Checkpoint Inhibitor-Related Myocarditis. J Am Coll Cardiol 2020; 75:467-478. [PMID: 32029128 DOI: 10.1016/j.jacc.2019.11.049] [Citation(s) in RCA: 160] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/03/2019] [Accepted: 11/22/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND There is a need for improved methods for detection and risk stratification of myocarditis associated with immune checkpoint inhibitors (ICIs). Global longitudinal strain (GLS) is a sensitive marker of cardiac toxicity among patients receiving standard chemotherapy. There are no data on the use of GLS in ICI myocarditis. OBJECTIVES This study sought to evaluate the role of GLS and assess its association with cardiac events among patients with ICI myocarditis. METHODS This study retrospectively compared echocardiographic GLS by speckle tracking at presentation with ICI myocarditis (cases, n = 101) to that from patients receiving an ICI who did not develop myocarditis (control subjects, n = 92). Where available, GLS was also measured pre-ICI in both groups. Major adverse cardiac events (MACE) were defined as a composite of cardiogenic shock, arrest, complete heart block, and cardiac death. RESULTS Cases and control subjects were similar in age, sex, and cancer type. At presentation with myocarditis, 61 cases (60%) had a normal ejection fraction (EF). Pre-ICI, GLS was similar between cases and control subjects (20.3 ± 2.6% vs. 20.6 ± 2.0%; p = 0.60). There was no change in GLS among control subjects on an ICI without myocarditis (pre-ICI vs. on ICI, 20.6 ± 2.0% vs. 20.5 ± 1.9%; p = 0.41); in contrast, among cases, GLS decreased to 14.1 ± 2.8% (p < 0.001). The GLS at presentation with myocarditis was lower among cases presenting with either a reduced (12.3 ± 2.7%) or preserved EF (15.3 ± 2.0%; p < 0.001). Over a median follow-up of 162 days, 51 (51%) experienced MACE. The risk of MACE was higher with a lower GLS among patients with either a reduced or preserved EF. After adjustment for EF, each percent reduction in GLS was associated with a 1.5-fold increase in MACE among patients with a reduced EF (hazard ratio: 1.5; 95% confidence interval: 1.2 to 1.8) and a 4.4-fold increase with a preserved EF (hazard ratio: 4.4; 95% confidence interval: 2.4 to 7.8). CONCLUSIONS GLS decreases with ICI myocarditis and, compared with control subjects, was lower among cases presenting with either a preserved or reduced EF. Lower GLS was strongly associated with MACE in ICI myocarditis presenting with either a preserved or reduced EF.
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Affiliation(s)
- Magid Awadalla
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Syed S Mahmood
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - John D Groarke
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Malek Z O Hassan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Anju Nohria
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Adam Rokicki
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sean P Murphy
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nathaniel D Mercaldo
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lili Zhang
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kerry L Reynolds
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Raza M Alvi
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Dahlia Banerji
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shiying Liu
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lucie M Heinzerling
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen and Nurnberg, Germany
| | - Maeve Jones-O'Connor
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Rula B Bakar
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Justine V Cohen
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael C Kirchberger
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nurnberg (FAU), Erlangen and Nurnberg, Germany
| | - Ryan J Sullivan
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Dipti Gupta
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Connor P Mulligan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sachin P Shah
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Sarju Ganatra
- Cardiology Division, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Muhammad A Rizvi
- Division of Oncology and Hematology, Department of Medicine, Lehigh Valley Hospital, Allentown, Pennsylvania
| | - Gagan Sahni
- Cardiovascular Institute, School of Medicine, The Mount Sinai Hospital, New York, New York
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Sciences (CIRCET), Federico II University, Naples, Italy
| | - Donald P Lawrence
- Division of Oncology and Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Mahmoudi
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Richard B Devereux
- Cardiology Division, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York
| | - Brian J Forrestal
- Cardio-Oncology Program, Department of Cardiology, Medstar Washington Hospital Center, Medstar Heart and Vascular institute, Washington, DC
| | - Anant Mandawat
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander R Lyon
- Cardio-Oncology Program, Royal Brompton Hospital and Imperial College, London, United Kingdom
| | - Carol L Chen
- Cardiology Division, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Ana Barac
- Cardio-Oncology Program, Department of Cardiology, Medstar Washington Hospital Center, Medstar Heart and Vascular institute, Washington, DC
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paaladinesh Thavendiranathan
- Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Franck Thuny
- Cardiology Division, Cardiovascular Division, Department of Medicine, Aix-Marseille Universite, Marseille, France
| | - Stephane Ederhy
- UNICO-GRECO, Cardio-Oncology Program, Department of Cardiology, Assistance Publique-Hopitaux de Paris, Saint-Antoine Hospital, Paris, France
| | - Michael G Fradley
- Cardio-Oncology Program, H. Lee Moffitt Cancer Center & Research Institute and University of South Florida Division of Cardiovascular Medicine, Tampa, Florida
| | - Tomas G Neilan
- Cardiovascular Imaging Research Center (CIRC), Department of Radiology, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
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19
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Abstract
BACKGROUND Cardiac strain represents an imaging biomarker of contractile dysfunction. PURPOSE The purpose of this study was to investigate the diagnostic value of cardiac strain obtained by feature-tracking cardiac magnetic resonance (MR) in acute myocarditis. MATERIALS AND METHODS Cardiac MR examinations of 46 patients with myocarditis and preserved ejection fraction at acute phase and follow-up were analyzed along with cardiac MR of 46 healthy age- and sex-matched controls. Global circumferential strain and global radial strain were calculated for each examination, along with myocardial edema and late gadolinium enhancement, and left ventricle functional parameters, through manual contouring of the myocardium. Correlations were assessed using Spearman ρ. Wilcoxon and Mann-Whitney U test were used to assess differences between data. Receiver operating characteristics curves and reproducibility were obtained to assess the diagnostic role of strain parameters. RESULTS Global circumferential strain was significantly lower in controls (median, -20.4%; interquartile range [IQR], -23.4% to -18.7%) than patients in acute phase (-18.4%; IQR, -21.0% to -16.1%; P = 0.001) or at follow-up (-19.2%; IQR, -21.5% to -16.1%; P = 0.020). Global radial strain was significantly higher in controls (82.4%; IQR, 62.8%-104.9%) than in patients during the acute phase (65.8%; IQR, 52.9%-79.5%; P = 0.001). Correlations were found between global circumferential strain and global radial strain in all groups (acute, ρ = -0.580, P < 0.001; follow-up, ρ = -0.399, P = 0.006; controls, ρ = -0.609, P < 0.001), and between global circumferential strain and late gadolinium enhancement only in myocarditis patients (acute, ρ = 0.035, P = 0.024; follow-up, ρ = 0.307, P = 0.038). CONCLUSIONS Cardiac strain could potentially have a role in detecting acute myocarditis in low-risk acute myocarditis patients where cardiac MR is the main diagnosing technique.
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20
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Finocchiaro G, Merlo M, Sheikh N, De Angelis G, Papadakis M, Olivotto I, Rapezzi C, Carr‐White G, Sharma S, Mestroni L, Sinagra G. The electrocardiogram in the diagnosis and management of patients with dilated cardiomyopathy. Eur J Heart Fail 2020; 22:1097-1107. [DOI: 10.1002/ejhf.1815] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/12/2020] [Accepted: 03/14/2020] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Marco Merlo
- Cardiovascular Department A.O.U. Ospedali Riuniti Trieste Italy
| | - Nabeel Sheikh
- Cardiothoracic Centre, Guy's and St Thomas' Hospital London UK
| | | | - Michael Papadakis
- Cardiology Clinical and Academic Group St George's University of London, London and St George's University Hospital NHS Foundation Trust London UK
| | - Iacopo Olivotto
- Cardiomyopathy Unit Careggi University Hospital Florence Italy
| | - Claudio Rapezzi
- Cardiology University of Ferrara and Maria Cecilia Hospital Cotignola Italy
- GVM Care & Research Cotignola Italy
| | | | - Sanjay Sharma
- Cardiology Clinical and Academic Group St George's University of London, London and St George's University Hospital NHS Foundation Trust London UK
| | - Luisa Mestroni
- Cardiovascular Institute and Adult Medical Genetics Program University of Colorado Anschutz Medical Campus Aurora CO USA
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21
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Haploinsufficient Rock1+/- and Rock2+/- Mice Are Not Protected from Cardiac Inflammation and Postinflammatory Fibrosis in Experimental Autoimmune Myocarditis. Cells 2020; 9:cells9030700. [PMID: 32178482 PMCID: PMC7140701 DOI: 10.3390/cells9030700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/02/2020] [Accepted: 03/11/2020] [Indexed: 12/18/2022] Open
Abstract
Progressive cardiac fibrosis is a common cause of heart failure. Rho-associated, coiled-coil-containing protein kinases (ROCKs) have been shown to enhance fibrotic processes in the heart and in other organs. In this study, using wild-type, Rock1+/− and Rock2+/− haploinsufficient mice and mouse model of experimental autoimmune myocarditis (EAM) we addressed the role of ROCK1 and ROCK2 in development of myocarditis and postinflammatory fibrosis. We found that myocarditis severity was comparable in wild-type, Rock1+/− and Rock2+/− mice at day 21 of EAM. During the acute stage of the disease, hearts of Rock1+/− mice showed unaffected numbers of CD11b+CD36+ macrophages, CD11b+CD36–Ly6GhiLy6chi neutrophils, CD11b+CD36–Ly6G–Ly6chi inflammatory monocytes, CD11b+CD36–Ly6G–Ly6c– monocytes, CD11b+SiglecF+ eosinophils, CD11b+CD11c+ inflammatory dendritic cells and type I collagen-producing fibroblasts. Isolated Rock1+/− cardiac fibroblasts treated with transforming growth factor-beta (TGF-β) showed attenuated Smad2 and extracellular signal-regulated kinase (Erk) phosphorylations that were associated with impaired upregulation of smooth muscle actin alpha (αSMA) protein. In contrast to cardiac fibroblasts, expanded Rock1+/− heart inflammatory myeloid cells showed unaffected Smad2 activation but enhanced Erk phosphorylation following TGF-β treatment. Rock1+/− inflammatory cells responded to TGF-β by a reduced transcriptional profibrotic response and failed to upregulate αSMA and fibronectin at the protein levels. Unexpectedly, in the EAM model wild-type, Rock1+/− and Rock2+/− mice developed a similar extent of cardiac fibrosis at day 40. In addition, hearts of the wild-type and Rock1+/− mice showed comparable levels of cardiac vimentin, periostin and αSMA. In conclusion, despite the fact that ROCK1 regulates TGF-β-dependent profibrotic response, neither ROCK1 nor ROCK2 is critically involved in the development of postinflammatory fibrosis in the EAM model.
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22
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Degener F, Salameh A, Manuylova T, Pickardt T, Kostelka M, Daehnert I, Berger F, Messroghli D, Schubert S, Klingel K. First paediatric cohort for the evaluation of inflammation in endomyocardial biopsies derived from congenital heart surgery. Int J Cardiol 2020; 303:36-40. [DOI: 10.1016/j.ijcard.2019.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/08/2019] [Accepted: 10/02/2019] [Indexed: 12/11/2022]
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23
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Watanabe M, Panetta GL, Piccirillo F, Spoto S, Myers J, Serino FM, Costantino S, Di Sciascio G. Acute Epstein-Barr related myocarditis: An unusual but life-threatening disease in an immunocompetent patient. J Cardiol Cases 2019; 21:137-140. [PMID: 32256861 PMCID: PMC7102541 DOI: 10.1016/j.jccase.2019.12.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/11/2019] [Accepted: 11/16/2019] [Indexed: 11/21/2022] Open
Abstract
Myocarditis is an uncommon but potentially life-threatening disease. Clinical manifestations could range from subclinical disease to sudden death, due to fulminant heart failure and/or malignant ventricular arrhythmias. The most common cause of myocarditis is viral infection, including Epstein-Barr virus (EBV). Nevertheless, EBV rarely presents with cardiac involvement in immunocompetent hosts. We report a case of acute EBV-related myocarditis in a young female, complicated with malignant ventricular arrhythmias and cardiac arrest. After 20 days of hospitalization and treatment, the patient was fit for discharge on pharmacological therapy (tapering steroids, beta-blockers, amiodarone, angiotensin-converting enzyme inhibitors, and diuretics). Clinical course is described, cardiac magnetic resonance images are shown. This case underlines how myocarditis is a disease that should not be underestimated: it could present with life-threatening complications such as malignant arrhythmias and/or severe systolic dysfunction. <Learning objective: Although Epstein-Barr virus rarely presents with cardiac involvement in immunocompetent hosts, the risk should not be underestimated, as it could present with life-threatening complications.>
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Affiliation(s)
- Mikiko Watanabe
- «Doctors in Italy» Association, Rome, Italy.,Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, Rome, Italy
| | - Gaetano Luca Panetta
- «Doctors in Italy» Association, Rome, Italy.,San Giovanni Calibita - Fatebenefratelli Hospital, Rome, Italy
| | - Francesco Piccirillo
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Silvia Spoto
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | | | | | | | - Germano Di Sciascio
- Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
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24
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Lv H, Zhang S, Hao X. Swainsonine protects H9c2 cells against lipopolysaccharide-induced apoptosis and inflammatory injury via down-regulating miR-429. Cell Cycle 2019; 19:207-217. [PMID: 31876239 DOI: 10.1080/15384101.2019.1706902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pediatric myocarditis (PM) is usually related to myocardial dysfunction. Generally, 30% of PM patients will die or undergo heart transplantation. Swainsonine (SW) is a natural alkaloid and an anti-cancer substance. Our goal was to determine the roles of SW in PM in current study. H9c2 cells were pre-treated by lipopolysaccharide (LPS). Viability and apoptosis were evaluated utilizing CCK-8 assay and flow cytometry. Inflammatory cytokines' mRNA expression and production were assessed by western blot and ELISA. Western blot was utilized to distinguish apoptosis and immune-related factors expression. Sequentially, the abovementioned parameters were reassessed when miR-429 was overexpressed. LPS declined viability as well as raised apoptosis and inflammatory injury in H9c2 cells. SW alleviated apoptosis and inflammatory injury induced by LPS. MiR-429 expression was elevated by LPS and suppressed by SW. SW-induced the increasing of viability and the reduction of inflammatory injury were reversed by overexpression of miR-429. Eventually, SW inhibited p38MAPK/NF-κB pathway which activated by LPS via overexpressing miR-429. SW exerted its anti-apoptosis and anti-inflammatory function in LPS-treated H9c2 cells through p38MAPK/NF-κB pathway and down-regulation of miR-429.
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Affiliation(s)
- Hongyan Lv
- Department of Pediatrics, Jining No.1 People's Hospital, Jining, China
| | - Su Zhang
- Department of Nursing, Jining No.1 People's Hospital, Jining, China
| | - Xiaohong Hao
- Department of Pediatrics, Jining No.1 People's Hospital, Jining, China
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25
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Schubert S, Opgen-Rhein B, Boehne M, Weigelt A, Wagner R, Müller G, Rentzsch A, Zu Knyphausen E, Fischer M, Papakostas K, Wiegand G, Ruf B, Hannes T, Reineker K, Kiski D, Khalil M, Steinmetz M, Fischer G, Pickardt T, Klingel K, Messroghli DR, Degener F. Severe heart failure and the need for mechanical circulatory support and heart transplantation in pediatric patients with myocarditis: Results from the prospective multicenter registry "MYKKE". Pediatr Transplant 2019; 23:e13548. [PMID: 31297930 DOI: 10.1111/petr.13548] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/16/2019] [Accepted: 06/22/2019] [Indexed: 01/01/2023]
Abstract
Myocarditis represents an important cause for acute heart failure. MYKKE, a prospective multicenter registry of pediatric patients with myocarditis, aims to gain knowledge on courses, diagnostics, and therapy of pediatric myocarditis. The role of mechanical circulatory support (MCS) in children with severe heart failure and myocarditis is unclear. The aim of this study was to determine characteristics and outcome of patients with severe heart failure requiring MCS and/or heart transplantation. The MYKKE cohort between September 2013 and 2016 was analyzed. A total of 195 patients were prospectively enrolled by 17 German hospitals. Twenty-eight patients (14%) received MCS (median 1.5 years), more frequently in the youngest age group (0-2 years) than in the older groups (P < 0.001; 2-12 and 13-18 years). In the MCS group, 50% received a VAD, 36% ECMO, and 14% both, with a survival rate of 79%. The weaning rate was 43% (12/28). Nine (32%) patients were transplanted, one had ongoing support, and six (21%) died. Histology was positive for myocarditis in 63% of the MCS group. Patients within the whole cohort with age <2 years and/or ejection fraction <30% had a significantly worse survival with high risk for MCS, transplantation, and death (P < 0.001). Myocarditis represents a life-threatening disease with an overall mortality of 4.6% in this cohort. The fulminant form more often affected the youngest, leading to significantly higher rate of MCS, transplantation, and mortality. MCS represents an important and life-saving therapeutic option in children with myocarditis with a weaning rate of 43%.
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Affiliation(s)
- Stephan Schubert
- Department of Congenital Heart Disease - Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Bernd Opgen-Rhein
- Department for Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Boehne
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Annika Weigelt
- Department for Pediatric Cardiology, University Hospital Erlangen, Erlangen, Germany
| | - Robert Wagner
- Department for Pediatric Cardiology, Herzzentrum Leipzig, Leipzig, Germany
| | - Götz Müller
- Department for Pediatric Cardiology, Universitäres Herzzentrum Hamburg, Hamburg, Germany
| | - Axel Rentzsch
- Department for Pediatric Cardiology, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Edzard Zu Knyphausen
- Department for Pediatric Cardiology, Herz- und Diabetes-zentrum NRW, Bad Oeynhausen, Germany
| | - Marcus Fischer
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig Maximilians University of Munich, Munich, Germany
| | | | - Gesa Wiegand
- Department for Pediatric Cardiology, University Hospital Tübingen, Tübingen, Germany
| | - Bettina Ruf
- Department for Pediatric Cardiology, Deutsches Herzzentrum München, München, Germany
| | - Tobias Hannes
- Department for Pediatric Cardiology, University Hospital Köln, Köln, Germany
| | - Katja Reineker
- Department for Pediatric Cardiology, Universitäts-Herzzentrum Freiburg Bad Krozingen, Freiburg, Germany
| | - Daniela Kiski
- Department for Pediatric Cardiology, University Hospital Münster, Münster, Germany
| | - Markus Khalil
- Department for Pediatric Cardiology, University Hospital Gießen, Giessen, Germany
| | - Michael Steinmetz
- Department for Pediatric Cardiology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Gunther Fischer
- Department for Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Daniel R Messroghli
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany.,Department for Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany.,Department for Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Franziska Degener
- Department of Congenital Heart Disease - Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany.,Institute for Cardiovascular Computer-assisted Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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26
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Mirna M, Paar V, Rezar R, Topf A, Eber M, Hoppe UC, Lichtenauer M, Jung C. MicroRNAs in Inflammatory Heart Diseases and Sepsis-Induced Cardiac Dysfunction: A Potential Scope for the Future? Cells 2019; 8:cells8111352. [PMID: 31671621 PMCID: PMC6912436 DOI: 10.3390/cells8111352] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 10/18/2019] [Accepted: 10/26/2019] [Indexed: 02/06/2023] Open
Abstract
Background: MicroRNAs (miRNAs) are small, single-stranded RNA sequences that regulate gene expression on a post-transcriptional level. In the last few decades, various trials have investigated the diagnostic and therapeutic potential of miRNAs in several disease entities. Here, we provide a review of the available evidence on miRNAs in inflammatory heart diseases (myocarditis, endocarditis, and pericarditis) and sepsis-induced cardiac dysfunction. Methods: Systematic database research using the PubMed and Medline databases was conducted between July and September 2019 using predefined search terms. The whole review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results: In total, 131 studies were screened, 96 abstracts were read, and 69 studies were included in the review. Discussion: In the future, circulating miRNAs could serve as biomarkers for diagnosis and disease monitoring in the context of inflammatory heart diseases and sepsis-induced cardiac dysfunction. Considering the promising results of different animal models, certain miRNAs could also emerge as novel therapeutic approaches in this setting.
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Affiliation(s)
- Moritz Mirna
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria.
| | - Vera Paar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria.
| | - Richard Rezar
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria.
| | - Albert Topf
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria.
| | - Miriam Eber
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria.
| | - Uta C Hoppe
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria.
| | - Michael Lichtenauer
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria.
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, 40225 Duesseldorf, Germany.
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Razzano D, Fallon JT. Myocarditis: somethings old and something new. Cardiovasc Pathol 2019; 44:107155. [PMID: 31760237 DOI: 10.1016/j.carpath.2019.107155] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 11/29/2022] Open
Abstract
"Since the pathological conditions take place at the cellular level, viral myocarditis and postinfectious autoimmunity can be suggested but not diagnosed clinically. All clinical methods including imaging techniques are misleading if infectious agents are involved. Accurate diagnosis demands simultaneous histologic, immunohistochemical, and molecular biological workup of the tissue. If the primary infectious or immune-mediated causes of the disease are carefully defined by clinical and biopsy-based tools, specific antiviral treatment options in addition to basic symptomatic therapy are available under certain conditions. These may allow a tailored cause-specific treatment that improves symptoms and prognosis of patients with acute and chronic disease." Uwe Kühl; Heinz-Peter SchultheissViral myocarditis.Swiss Medical Weekly. 144():w14010, JAN 2014 DOI:10.4414/smw.2014.14010.
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Affiliation(s)
- Dana Razzano
- New York Medical College at Westchester Medical Center, Valhalla, NY, 10595, USA.
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28
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Katzmann JL, Schlattmann P, Rigopoulos AG, Noutsias E, Bigalke B, Pauschinger M, Tschope C, Sedding D, Schulze PC, Noutsias M. Meta-analysis on the immunohistological detection of inflammatory cardiomyopathy in endomyocardial biopsies. Heart Fail Rev 2019; 25:277-294. [DOI: 10.1007/s10741-019-09835-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Mirna M, Paar V, Kraus T, Sotlar K, Wernly B, Pistulli R, Hoppe UC, Lichtenauer M. Autoimmune myocarditis is not associated with left ventricular systolic dysfunction. Eur J Clin Invest 2019; 49:e13132. [PMID: 31125424 PMCID: PMC6771695 DOI: 10.1111/eci.13132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/26/2019] [Accepted: 05/21/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Experimental autoimmune myocarditis (EAM) is a common animal model for the investigation of the pathophysiology of myocarditis. Because of diverging findings from previous studies, we performed serial echocardiographic examinations throughout the course of the disease and investigated the dimensions of the murine heart and left ventricular (LV) systolic function. MATERIALS AND METHODS Experimental autoimmune myocarditis was induced in male Balb/c mice by subcutaneous injection of a fragment of the α-myosin heavy chain (MyHC-α 614-629: Ac-SLKLMATLFSTYASAD). Transthoracic echocardiography was performed on days 0, 7 and 21 in healthy animals and mice with EAM. RESULTS Experimental autoimmune myocarditis was associated with a reduction in LV systolic function and an increase in LV internal diameter in diastole (LVIDd) and systole (LVIDs) 7 days postimmunization. After 21 days, EAM led to a significant increase in LV-thickness (1.3-fold increase in LV anterior wall diameter in diastole [LVAWDd]), but there was no difference in LV systolic function between immunized animals and healthy controls. LV-thickness correlated well with the severity of myocarditis in the histopathological examination (LVAWDd: rs = 0.603, P = 0.003, LV anterior wall diameter in systole (LVAWDs): rs = 0.718, P < 0.0001). CONCLUSION Our results indicate that EAM leads to an initial dilatation of the LV that is followed by ventricular "hypertrophy." On day 21, there was no significant difference in LV systolic function between immunized animals and controls. Furthermore, the ageing of the animals had a major impact on the echocardiographic parameters; therefore, the use of healthy age-matched controls seems warranted when echocardiography is performed in rodents.
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Affiliation(s)
- Moritz Mirna
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Vera Paar
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Theo Kraus
- Institute of Pathology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Karl Sotlar
- Institute of Pathology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Bernhard Wernly
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Rudin Pistulli
- Department of Cardiology I, Coronary and Peripheral Vascular Diseases, Heart Failure, University Hospital Münster, Münster, Germany
| | - Uta C Hoppe
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Michael Lichtenauer
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
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Tschöpe C, Van Linthout S, Spillmann F, Posch MG, Reinke P, Volk HD, Elsanhoury A, Kühl U. Targeting CD20+ B-lymphocytes in inflammatory dilated cardiomyopathy with rituximab improves clinical course: a case series. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 3:5542049. [PMID: 31365055 PMCID: PMC6764574 DOI: 10.1093/ehjcr/ytz131] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/16/2019] [Accepted: 07/05/2019] [Indexed: 01/11/2023]
Abstract
Background The aetiology of dilated cardiomyopathy (DCM) is highly heterogeneous including genetic and/or acquired (infective, toxic, immune, endocrine, and nutritional) factors. The major part of acquired DCM in developed countries is caused by either viral or autoimmune myocarditis. It is believed that the activation of the T-lymphocyte cell system is the major pathomechanism underlying autoimmune myocarditis and inflammatory DCM (DCMi). However, in the hearts of a subset of patients, a significant number of CD20+ B-lymphocytes can be detected too. Limited information exists on the role of B-cell-dependent mechanisms in the progression of DCMi. Particularly CD20+ B-lymphocytes, which can be targeted by anti-CD20+ B-lymphocytes antibodies or inhibitors, might contribute to the pathogenesis of myocardial damage beyond antibody production. Case summary Here, we present a case series of six patients with subacute and chronic endomyocardial biopsy-proven CD20+ B-lymphocyte-associated DCMi, where symptomatic heart failure therapy, with or without combined immunosuppressive therapy with steroid-based treatment regime, was insufficient to improve cardiac function. Five patients improved clinically several weeks after a standard infusion protocol with rituximab, a chimeric monoclonal antibody against the pan-B-cell surface molecule CD20. Discussion Our case series shows that CD20+ B-lymphocyte persistence can play a pathophysiologic role in a subset of DCMi patients and highlights the potential of targeting CD20+ B cells in patients with prominent CD20+ B-lymphocyte persistence.
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Affiliation(s)
- Carsten Tschöpe
- Department of Cardiology, Charité, University Medicine Berlin, Humboldt-Universität zu Berlin, Campus Virchow, Berlin, Germany.,Experimental Immunocardiology, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Augustenburger Platz 1, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Oudenarder Str. 16, Berlin, Germany
| | - Sophie Van Linthout
- Department of Cardiology, Charité, University Medicine Berlin, Humboldt-Universität zu Berlin, Campus Virchow, Berlin, Germany.,Experimental Immunocardiology, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Augustenburger Platz 1, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Oudenarder Str. 16, Berlin, Germany
| | - Frank Spillmann
- Department of Cardiology, Charité, University Medicine Berlin, Humboldt-Universität zu Berlin, Campus Virchow, Berlin, Germany
| | - Maximilian G Posch
- Charité Research Organisation, Charité, University Medicine Berlin, Campus Mitte, Berlin, Germany
| | - Petra Reinke
- Experimental Immunocardiology, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Augustenburger Platz 1, Berlin, Germany.,Charité, University Medicine Berlin, Berlin Center for Advanced Therapies (BECAT), Campus Virchow, Berlin, Germany
| | - Hans-Dieter Volk
- Experimental Immunocardiology, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Augustenburger Platz 1, Berlin, Germany.,Department of Immunology, Charité, University Medicine Berlin, Institute of Medical Immunology, Campus Virchow, Berlin, Germany
| | - Ahmed Elsanhoury
- Department of Cardiology, Charité, University Medicine Berlin, Humboldt-Universität zu Berlin, Campus Virchow, Berlin, Germany.,Experimental Immunocardiology, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Augustenburger Platz 1, Berlin, Germany
| | - Uwe Kühl
- Department of Cardiology, Charité, University Medicine Berlin, Humboldt-Universität zu Berlin, Campus Virchow, Berlin, Germany.,Experimental Immunocardiology, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Augustenburger Platz 1, Berlin, Germany
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31
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Cannie DE, Akhtar MM, Elliott P. Hidden in Heart Failure. Eur Cardiol 2019; 14:89-96. [PMID: 31360229 PMCID: PMC6659034 DOI: 10.15420/ecr.2019.19.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/06/2019] [Indexed: 02/06/2023] Open
Abstract
Current diagnostic strategies fail to illuminate the presence of rare disease in the heart failure population. One-third of heart failure patients are categorised as suffering an idiopathic dilated cardiomyopathy, while others are labelled only as heart failure with preserved ejection fraction. Those affected frequently suffer from delays in diagnosis, which can have a significant impact on quality of life and prognosis. Traditional rhetoric argues that delineation of this patient population is superfluous to treatment, as elucidation of aetiology will not lead to a deviation from standard management protocols. This article emphasises the importance of identifying genetic, inflammatory and infiltrative causes of heart failure to enable patients to access tailored management strategies.
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Affiliation(s)
- Douglas Ewan Cannie
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
| | - Mohammed Majid Akhtar
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
| | - Perry Elliott
- University College London Institute for Cardiovascular Science London, UK.,Barts Heart Centre, Barts Health NHS Trust London, UK
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32
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García-Becerril GE, Cruz-Montalvo AE, De La Cruz MA, Ares MA, Moreno-Ruiz LA, García-Chequer AJ, Maldonado-Bernal C, Gómez-Jiménez LM, Flores-García CA, Garrido-Garduño MH, Cárdenas-Mondragón MG. Differential expression of coxsackievirus and adenovirus receptor in endomyocardial tissue of patients with myocarditis. Mol Med Rep 2019; 20:2189-2198. [PMID: 31257515 PMCID: PMC6691199 DOI: 10.3892/mmr.2019.10444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 06/05/2019] [Indexed: 12/15/2022] Open
Abstract
Recent studies demonstrated that the expression of coxsackievirus and adenovirus receptor (CAR) is implicated in the pathophysiology of myocarditis. The aim of the present study was to assess the association between active and borderline myocarditis and CAR expression in endomyocardial tissues, and analyze the association between CAR expression and treatment response. An analytic, cross-sectional, retrospective study was performed in 26 patients with myocarditis and 10 control subjects without heart disease. Myocardial biopsies were obtained and CAR transcription was measured by reverse transcription-quantitative polymerase chain reaction analysis. The association between CAR mRNA levels and the response to immunosuppressive or conventional therapy (treatment responders, n=17; non-responders, n=9) or with the type of histological myocarditis (active myocarditis, n=16; borderline myocarditis, n=10) was analyzed. CAR transcription levels were significantly lower (P=0.012) in patients with myocarditis compared with controls, and a significant decrease was observed (P=0.023) in CAR mRNA levels among patients with borderline myocarditis compared with the no myocarditis group. Patients responding to therapy exhibited higher CAR mRNA levels (P=0.036) compared with patients not responding to treatment, as evaluated based on clinical and echocardiographic criteria (immunosuppressive therapy, n=8; conventional therapy, n=1). Myocarditis in non-responders was associated with fewer clinical manifestations and lower CAR mRNA levels. A significant difference was only found regarding the use of oral steroids in patients with active myocarditis who responded to treatment (P=0.02), with no difference in borderline myocarditis. In conclusion, the transcriptional level of CAR is low in the endomyocardial tissue of patients with myocarditis, and it is lower in borderline myocarditis and in non-responder patients. These findings may enable early identification of patients who may benefit from treatment and timely determination of prognosis.
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Affiliation(s)
- Gustavo E García-Becerril
- Clínica de Insuficiencia Cardiaca, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo‑XXI, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
| | - Aníbal E Cruz-Montalvo
- Unidad de Cuidados Intensivos Cardiovasculares, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo‑XXI, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
| | - Miguel A De La Cruz
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría 'Dr. Silvestre Frenk Freund', Centro Médico Nacional Siglo‑XXI, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
| | - Miguel A Ares
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría 'Dr. Silvestre Frenk Freund', Centro Médico Nacional Siglo‑XXI, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
| | - Luis A Moreno-Ruiz
- Servicio de Hospitalización Adultos, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo‑XXI, IMSS, Mexico City 06720, Mexico
| | - Adda J García-Chequer
- Laboratorio en Biología del Desarrollo, Unidad de Hemato‑Oncología e Investigación del Hospital Infantil de México, 'Federico Gómez', Secretaria de Salud, Mexico City 06720, Mexico
| | - Carmen Maldonado-Bernal
- Laboratorio de Investigación en Inmunología y Proteómica, Hospital Infantil de México, 'Federico Gómez', Secretaria de Salud, Mexico City 06720, Mexico
| | - Luz M Gómez-Jiménez
- Servicio de Patología UMAE Hospital de Especialidades del Centro Médico Nacional Siglo‑XXI, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
| | - Cesar A Flores-García
- Servicio de Patología, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo‑XXI, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
| | - Martín H Garrido-Garduño
- Clínica de Insuficiencia Cardiaca, UMAE Hospital de Cardiología del Centro Médico Nacional Siglo‑XXI, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
| | - María G Cárdenas-Mondragón
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría 'Dr. Silvestre Frenk Freund', Centro Médico Nacional Siglo‑XXI, Instituto Mexicano del Seguro Social, Mexico City 06720, Mexico
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Systematic Review of PCR Proof of Parvovirus B19 Genomes in Endomyocardial Biopsies of Patients Presenting with Myocarditis or Dilated Cardiomyopathy. Viruses 2019; 11:v11060566. [PMID: 31216741 PMCID: PMC6631559 DOI: 10.3390/v11060566] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Diverse viral infections have been associated with myocarditis (MC) and dilated cardiomyopathy (DCM). In this meta-analysis, we summarize the published results on the association of parvovirus B19 (B19V) genomes with human MC/DCM versus controls. Methods: n = 197 publications referring to B19V and MC or DCM were retrieved using multiple PubMed search modes. Out of these, n = 29 publications met the inclusion criteria with data from prospective analyses on >10 unselected patients presenting with MC or DCM (dataset: MA01). Data retrieved simultaneously from both controls and MC/DCM patients were available from n = 8 from these publications (dataset: MA02). Results: In the dataset MA01 B19V genomes were detected in 42.6% of the endomyocardial biopsies (EMB) in this cohort by PCR. In the dataset MA02 comprising n = 638 subjects, there was no statistically significant different rate of B19V positivity in myocardial tissues comparing controls (mean: 38.8 + 24.1%) versus the MC/DCM-patients (45.5 + 24.3%; p = 0.58). There was also no statistical difference between the positivity rate of B19V genomes in myocardial tissues of MA01 (46.0 + 19.5%) and the two patient groups of MA02 (p > 0.05). Conclusions: This systematic review reveals that the mean rate of PCR detected B19V genomes in patients presenting with MC/DCM does not differ significantly from the findings in control myocardial tissues. These data imply pathogenetically insignificant latency of B19V genomes in a proportion of myocardial tissues, both in MC-/DCM-patients and in controls. More information (i.e., replicative status, viral protein expression) is pertinent to achieve a comprehensive workup of myocardial B19V infection.
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35
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Błyszczuk P. Myocarditis in Humans and in Experimental Animal Models. Front Cardiovasc Med 2019; 6:64. [PMID: 31157241 PMCID: PMC6532015 DOI: 10.3389/fcvm.2019.00064] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/30/2019] [Indexed: 12/21/2022] Open
Abstract
Myocarditis is defined as an inflammation of the cardiac muscle. In humans, various infectious and non-infectious triggers induce myocarditis with a broad spectrum of histological presentations and clinical symptoms of the disease. Myocarditis often resolves spontaneously, but some patients develop heart failure and require organ transplantation. The need to understand cellular and molecular mechanisms of inflammatory heart diseases led to the development of mouse models for experimental myocarditis. It has been shown that pathogenic agents inducing myocarditis in humans can often trigger the disease in mice. Due to multiple etiologies of inflammatory heart diseases in humans, a number of different experimental approaches have been developed to induce myocarditis in mice. Accordingly, experimental myocarditis in mice can be induced by infection with cardiotropic agents, such as coxsackievirus B3 and protozoan parasite Trypanosoma cruzi or by activating autoimmune responses against heart-specific antigens. In certain models, myocarditis is followed by the phenotype of dilated cardiomyopathy and the end stage of heart failure. This review describes the most commonly used mouse models of experimental myocarditis with a focus on the role of the innate and adaptive immune systems in induction and progression of the disease. The review discusses also advantages and limitations of individual mouse models in the context of the clinical manifestation and the course of the disease in humans. Finally, animal-free alternatives in myocarditis research are outlined.
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Affiliation(s)
- Przemysław Błyszczuk
- Department of Clinical Immunology, Jagiellonian University Medical College, Cracow, Poland.,Department of Rheumatology, Center of Experimental Rheumatology, University Hospital Zurich, Zurich, Switzerland
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Abstract
Myocarditis is commonly a diagnosis of exclusion. We report a case of fulminant myocarditis in a patient with cardiogenic shock in whom the initial diagnosis was unclear. Early supportive care including extracorporeal membrane oxygenation and intraaortic balloon pump were instituted. Complete recovery of cardiac function was achieved. This case highlights the difficulty in diagnosing myocarditis and the benefits of early intensive support.
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Affiliation(s)
- W Ahmar
- Departments of Cardiology, The Melbourne Heart Centre, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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37
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Lundberg G, Walsh MN, Mehta LS. Sex-Specific Differences in Risk Factors for Development of Heart Failure in Women. Heart Fail Clin 2019; 15:1-8. [DOI: 10.1016/j.hfc.2018.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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38
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Li Y, Yu Y, Chen S, Liao Y, Du J. Corticosteroids and Intravenous Immunoglobulin in Pediatric Myocarditis: A Meta-Analysis. Front Pediatr 2019; 7:342. [PMID: 31475124 PMCID: PMC6706783 DOI: 10.3389/fped.2019.00342] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 07/31/2019] [Indexed: 01/04/2023] Open
Abstract
Background: The efficacy of corticosteroids and intravenous immunoglobulin (IVIG) in pediatric myocarditis remains controversial. Objectives: The authors performed a meta-analysis to assess the therapeutic efficacy of corticosteroids and IVIG in children with myocarditis. Methods: We retrieved the trials on corticosteroids and IVIG therapy, respectively, in pediatric myocarditis from nine databases up to December 2018. Statistical analysis was performed using Review Manager 5.3. Results: Our analysis included 8 studies and 334 pediatric patients. The data demonstrated that children receiving corticosteroids showed no significant improvement on left ventricular ejection fraction (LVEF) from 1 to 8 month-follow-up (MD = 5.17%, 95% CI = -0.26% to 10.60%, P = 0.06), and no significant improvement in death or heart transplantation incidence at the end of follow-up (OR = 1.33, 95% CI = 0.27-6.70, P = 0.73). However, children receiving IVIG revealed a statistically remarkable increase in LVEF at a follow-up over the course of 6 months to 1 year (MD = 18.91%, 95% CI = 11.74-26.08%, P < 0.00001), and a decrease in death or heart transplantation at the end of follow-up (OR = 0.31, 95% CI = 0.12-0.75, P = 0.01). Further comparisons showed that the mortality and heart transplantation rate of children with myocarditis treated with IVIG were significantly lower than those with corticosteroid therapy (t' = 11.336, P < 0.001). Conclusions: IVIG might be beneficial to improve LVEF and survival for myocarditis in children. However, the present evidence does not support corticosteroids as superior to conventional therapy in children with myocarditis. Further randomized controlled trials with a larger sample size are required.
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Affiliation(s)
- Yining Li
- Department of Pediatrics, Peking University First Hospital, Beijing, China.,Department of Basic Medical Sciences, Peking University School of Basic Medical Sciences, Beijing, China
| | - Yuqing Yu
- Department of Pediatrics, Peking University First Hospital, Beijing, China.,Department of Basic Medical Sciences, Peking University School of Basic Medical Sciences, Beijing, China
| | - Selena Chen
- Division of Biological Sciences, University of California, San Diego, La Jolla, CA, United States
| | - Ying Liao
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Junbao Du
- Department of Pediatrics, Peking University First Hospital, Beijing, China
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Lv J, Han B, Wang C, Wang J, Jiang D, Zhao L, Yi Y, Zhang J. The Clinical Features of Children With Acute Fulminant Myocarditis and the Diagnostic and Follow-Up Value of Cardiovascular Magnetic Resonance. Front Pediatr 2019; 7:388. [PMID: 31632937 PMCID: PMC6779687 DOI: 10.3389/fped.2019.00388] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/09/2019] [Indexed: 12/03/2022] Open
Abstract
Objective: To investigate the clinical features and the diagnostic and follow-up value of acute fulminant myocarditis (AFM) in children. Methods: A total of 20 children diagnosed with AFM admitted to our department were reviewed, and the clinical manifestations; pathogenic examination results; myocardial injury biomarkers; and electrocardiography, echocardiogram, and cardiovascular magnetic resonance (CMR) results were analyzed. Results: Twenty children with AFM, including 12 males and 8 females, aged 3-16 years, were analyzed. The initial symptoms were abdominal pain, vomiting, fatigue, syncope, and convulsions. All children had significantly increased hs-cTnT and NT-pro BNP. In addition to nonspecific ST-T changes, there were 10 cases of complete atrioventricular block, 2 cases of advanced atrioventricular block, and 1 case of ventricular tachycardia. Echocardiography showed an increase in the cardiac chamber sizes in 15 patients and a decrease in left ventricular ejection fraction (LVEF) in 17 patients. There were 16 patients with abnormal CMR findings, including 13 cases of high T2-weighted image (T2WI) signal and 14 cases of late gadolinium enhancement (LGE). In the patients who underwent CMR within 14 days of onset, the sensitivity of T2WI and LGE and the positive diagnosis rate were higher than in those who underwent CMR after 14 days, but the difference was not statistically significant. CMR was followed up in 10 patients: 7 patients returned to normal, 2 patients still had mild LGE, and 1 patient developed inflammatory dilated cardiomyopathy. All patients were treated with high-dose immunoglobulin, 11 of whom received high-dose immunoglobulin combined with glucocorticoids. Eight patients received temporary pacemakers, and 1 patient received ECMO. None of the patients died. The peak of hs-cTnT was significantly higher in the glucocorticoid group than in the unused glucocorticoid group (2853.4 ± 2217.2 and 1124.7 ± 527.3 pg/ml, respectively). Conclusion: Children with AFM have unique clinical features. Early identification and effective treatment can reduce the mortality rate and improve the prognosis. CMR is highly sensitive in the diagnosis of ARM, especially within 14 days of onset, and is a useful noninvasive imaging technique for the early identification of AFM in children. The dynamic observation and follow-up of children with AFM through CMR can guide clinical decision-making and prognosis assessment.
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Affiliation(s)
- Jianli Lv
- Department of Pediatric Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Bo Han
- Department of Pediatric Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Cuiyan Wang
- Shandong Medical Imaging Research Institute, Jinan, China
| | - Jing Wang
- Department of Pediatric Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Diandong Jiang
- Department of Pediatric Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Lijian Zhao
- Department of Pediatric Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Yingchun Yi
- Department of Pediatric Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Jianjun Zhang
- Department of Pediatric Cardiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
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Arterial Structure and Function Following Viral Myocarditis. Pediatr Cardiol 2019; 40:133-137. [PMID: 30178188 DOI: 10.1007/s00246-018-1969-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
Acute viral myocarditis is an uncommon inflammatory disease of the myocardium. Little is known about the long-term cardiovascular risk for individuals who have recovered from the acute illness. We compared intermediate vascular phenotypes relating to arterial structure (aortic and carotid intima-media thickness) and function (pulse wave velocity, carotid arterial distensibility and compliance) in 15 participants, a median of 9.1 years after an episode of acute viral myocarditis, and 45 control participants. Following adjustment for age, sex and triglycerides, there were no differences in mean and maximum carotid and aortic intima-media thickness, pulse wave velocity, carotid artery distensibility and compliance between viral myocarditis participants and controls. In conclusion, we found no evidence of changes in intermediate vascular phenotypes indicative of increased cardiovascular risk in individuals who had fully recovered from viral myocarditis.
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41
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Tanabe K, Sakamoto T. Heart failure with recovered ejection fraction. J Echocardiogr 2018; 17:5-9. [PMID: 30218436 DOI: 10.1007/s12574-018-0396-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 01/06/2023]
Abstract
Substantial or complete myocardial recovery occurs in many patients with heart failure (HF). HF patients with myocardial recovery or recovered left ventricular (LV) ejection fraction (EF; HFrecEF) are a distinct population of HF patients with different underlying etiologies, comorbidities, response to therapies, and outcomes compared with HF patients with persistent reduced or preserved EF. Improvement in LVEF has been systematically linked to improved quality of life, and lower rehospitalization rates and mortality. However, the mortality and morbidity in HFrecEF patients remain higher than those in the normal population. Currently, data to guide the management of HFrecEF patients are lacking. This review discusses specific characteristics, pathophysiology, and clinical implications for HFrecEF.
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Affiliation(s)
- Kazuaki Tanabe
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, 693-8501, Japan.
| | - Takahiro Sakamoto
- Division of Cardiology, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo, 693-8501, Japan
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A Very Rare Complication of Hepatitis A Infection: Acute Myocarditis-A Case Report with Literature Review. Case Rep Med 2018; 2018:3625139. [PMID: 30302093 PMCID: PMC6158949 DOI: 10.1155/2018/3625139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/13/2018] [Indexed: 01/25/2023] Open
Abstract
Hepatitis A is a common viral infection with a benign course but in rare cases can progress to acute liver failure. It usually presents with abdominal pain, nausea, vomiting, diarrhea, jaundice, anorexia, or asymptomatically, but it can also present atypically with relapsing hepatitis and prolonged cholestasis. In addition, extrahepatic manifestations have been reported, including urticarial and maculopapular rash, acute kidney injury, autoimmune hemolytic anemia, aplastic anemia, acute pancreatitis, mononeuritis, reactive arthritis, glomerulonephritis, cryoglobulinemia, Guillain–Barre syndrome, and pleural or pericardial effusion. A rare manifestation of hepatitis A is acute myocarditis. We report a case of a young woman who presented with “flu-like symptoms” and was found to have severe elevation of liver enzymes due to acute hepatitis A infection. On her 3rd day of admission, the patient developed chest pain and nonspecific electrocardiographic changes. Her troponins rose to 16.4 ng/mL, and a transthoracic echocardiogram revealed global hypokinesis and a depressed ejection fraction at 30%. A CT angiography showed no evidence of significant coronary artery disease. The patient was managed supportively, and symptoms and laboratory findings slowly improved over the next 7 days. Her chest pain resolved and a follow-up echocardiogram showed improved ejection fraction to 45%.
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43
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Cikiriz N, Zdravkovic M, Simovic S, Zivkovic V, Jakovljevic B, Hinic S, Maksimovic R, Srejovic I, Jakovljevic V. Focal Myocarditis in Professonal Female Athlete: A Case Report. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2018. [DOI: 10.1515/sjecr-2017-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
A 35-year-old female athlete appealed to her sports physician on new onset of frequent palpitations, just before an important competition. Initial electrocardiography revealed unifocal premature ventricular complexes in the form of bigeminy. Echocardiography revealed fine-granulated hyperdensic changes in septum. Global strain rate was within a range normal, as well as pulsed tissue Doppler ultrasound. Patient was referred for cardiac MRI, which revealed interventricular septum with rougher compounds, but with preserved continuity, with thickness of 10 mm, which is in the middle of the LV, in length of 5 mm, thinned to a thickness of 4 mm. ELISA laboratory test demonstrated an increased titer of IgM antibodies for adenovirus. Six months later, the patient was referred for control MRI of the heart, which showed pronounced trabeculation of infero-lateral wall of the left ventricle, but without certain criteria for non-compaction cardiomyopathy. There was T1 oedema component in apical septal segment and apical segment of the left ventricle. There was increase of the signal in late gadolinium enhancement in the medial parts of the same segments but also in the segment of the basomedial septum, with previous focal myocarditis. These findings suggest myocardial fibrosis in the segments that were stricken by myocarditis, now without active ongoing myocarditis, but without consequent myocardial fibrosis.
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Affiliation(s)
- Nikola Cikiriz
- Department of Exercise Physiology, Institute of Hygiene, Military Medical Academy , Belgrade , Serbia
| | - Marija Zdravkovic
- University Hospital Medical Center “Bezanijska Kosa”, Faculty of Medicine , University of Belgrade , Belgrade , Serbia
| | - Stefan Simovic
- Clinic for Cardiology, Clinical Center Kragujevac , Kragujevac , Serbia
| | - Vladimir Zivkovic
- University of Kragujevac , Faculty of Medical Sciences, Department of Physiology , Kragujevac , Serbia
| | - Biljana Jakovljevic
- Medical College of applied sciences in Zemun , University of Belgrade , Belgrade , Serbia
| | - Sasa Hinic
- University Hospital Medical Center “Bezanijska Kosa”, Faculty of Medicine , University of Belgrade , Belgrade , Serbia
| | - Ruzica Maksimovic
- Institute of Radiology, Clinical Center Serbia, Faculty of Medicine , University of Belgrade , Belgrade , Serbia
| | - Ivan Srejovic
- University of Kragujevac , Faculty of Medical Sciences, Department of Physiology , Kragujevac , Serbia
| | - Vladimir Jakovljevic
- University of Kragujevac , Faculty of Medical Sciences, Department of Physiology , Kragujevac , Serbia
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44
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Zhao J, Lv T, Quan J, Zhao W, Song J, Li Z, Lei H, Huang W, Ran L. Identification of target genes in cardiomyopathy with fibrosis and cardiac remodeling. J Biomed Sci 2018; 25:63. [PMID: 30115125 PMCID: PMC6094872 DOI: 10.1186/s12929-018-0459-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/06/2018] [Indexed: 02/07/2023] Open
Abstract
Background Identify genes probably associated with chronic heart failure and predict potential target genes for dilated cardiomyopathy using bioinformatics analyses. Methods Gene expression profiles (series number GSE3585 and GSE42955) of cardiomyopathy patients and healthy controls were downloaded from the Expression Omnibus Gene (GEO) database. Differential expression of genes (DEGS) between the two groups of total 14 cardiomyopathy patients and 10 healthy controls were subsequently identified by limma package of R. Database for Annotation, Visualization, and Integrated Discovery (DAVID Tool), which is an analysis of enriched biological processes. Search Tool for the Retrieval Interacting Genes (STRING) was used as well for the analysis of protein-protein interaction network (PPI). Prediction of the potential drugs was suggested based on the preliminarily identified genes using Connectivity Map (CMap). Results Eighty-nine DEGs were identified (57 up-regulated and 32 down-regulated). The most enrichment Gene Ontology (GO) terms (P < 0.05) contain genes involved in extracellular matrix (ECM) and biological adhesion signal pathways (P < 0.05, ES > 1.5) such as ECM-receptors, focal adhesion and transforming growth factor beta (TGF-β), etc. Fifty-one differentially expressed genes were found to encode interacting proteins. Eleven key genes along with related transcription factors were identified including CTGF, POSTN, CORIN, FIGF, etc. Conclusion Bioinformatics-based analyses reveal the targeted genes probably associated with cardiomyopathy, which provide clues for pharmacological therapies aiming at the targets.
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Affiliation(s)
- Jianquan Zhao
- Department of Cardiology, Bayannaoer City Hospital, 35 Xinhua District, Bayannaoer, 015000, Inner Mongolia, China.
| | - Tiewei Lv
- Department of Cardiology, Children's hospital, Chongqing Medical University, Chongqing, China
| | - Junjun Quan
- Department of Cardiology, Children's hospital, Chongqing Medical University, Chongqing, China
| | - Weian Zhao
- Department of Cardiology, Children's hospital, Chongqing Medical University, Chongqing, China
| | - Jing Song
- Department of Bioinformatics, Chongqing Medical University, 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China
| | - Zhuolin Li
- Department of Vascular Cardiology, the First Affiliated Hospital of Chongqing, Medical University, Chongqing, China
| | - Han Lei
- Department of Vascular Cardiology, the First Affiliated Hospital of Chongqing, Medical University, Chongqing, China
| | - Wei Huang
- Department of Vascular Cardiology, the First Affiliated Hospital of Chongqing, Medical University, Chongqing, China
| | - Longke Ran
- Department of Bioinformatics, Chongqing Medical University, 1 Yixueyuan Road, Yuzhong District, Chongqing, 400016, China.
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45
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Cho Y, Kim SH, Kim YR, Kim YN, Kim JY, Kim TH, Nam GB, Roh SY, Park KM, Park HS, Pak HN, Bae EJ, Oh S, Yoon N, Lee MY, Cho Y, Jin ES, Cha TJ, Choi JI, Kim J. 2018 KHRS Guidelines for Catheter Ablation of Ventricular Arrhythmias – Part3. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2018. [DOI: 10.18501/arrhythmia.2018.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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47
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Wang Y, Jia L, Shen J, Wang Y, Fu Z, Su SA, Cai Z, Wang JA, Xiang M. Cathepsin B aggravates coxsackievirus B3-induced myocarditis through activating the inflammasome and promoting pyroptosis. PLoS Pathog 2018; 14:e1006872. [PMID: 29360865 PMCID: PMC5809100 DOI: 10.1371/journal.ppat.1006872] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 02/12/2018] [Accepted: 01/09/2018] [Indexed: 12/22/2022] Open
Abstract
Cathepsin B (CatB) is a cysteine proteolytic enzyme widely expressed in various cells and mainly located in the lysosomes. It contributes to the pathogenesis and development of many diseases. However, the role of CatB in viral myocarditis (VMC) has never been elucidated. Here we generated the VMC model by intraperitoneal injection of coxsackievirus B3 (CVB3) into mice. At day 7 and day 28, we found CatB was significantly activated in hearts from VMC mice. Compared with the wild-type mice receiving equal amount of CVB3, genetic ablation of CatB (Ctsb-/-) significantly improved survival, reduced inflammatory cell infiltration, decreased serum level of cardiac troponin I, and ameliorated cardiac dysfunction, without altering virus titers in hearts. Conversely, genetic deletion of cystatin C (Cstc-/-), which markedly enhanced CatB levels in hearts, distinctly increased the severity of VMC. Furthermore, compared with the control, we found the inflammasome was activated in the hearts of wild-type mice with VMC, which was attenuated in the hearts of Ctsb-/- mice but was further enhanced in Cstc-/- mice. Consistently, the inflammasome-initiated pyroptosis was reduced in Ctsb-/- mice hearts and further increased in Cstc-/- mice. These results suggest that CatB aggravates CVB3-induced VMC probably through activating the inflammasome and promoting pyroptosis. This finding might provide a novel strategy for VMC treatment. Severe VMC could lead to sudden cardiac death especially in youths, and is also the most common cause of secondary dilated cardiomyopathy. However, we still lack effective and specific clinical treatments currently. Therefore, further exploration of the pathogenesis and new therapeutic targets are urgently needed. Our results implied that CatB, a cysteine protease mainly located in the lysosome, is activated in the hearts of mice with VMC induced by intraperitoneal injection of CVB3. Genetic deletion of CatB significantly improves survival, attenuates cardiac inflammation, decreases serum cardiac troponin I levels and alleviates cardiac dysfunction, without altering virus titers in hearts. However, ablation of its main endogenous inhibitor, cystatin C, distinctly exaggerates the disease severity. Mechanistically, we found that CatB influences VMC probably by activating the NLRP3 inflammasome and promoting caspase-1-induced pyroptosis. This may provide a potential new therapeutic strategy for VMC.
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Affiliation(s)
- Yaping Wang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Liangliang Jia
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Jian Shen
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Yidong Wang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Zurong Fu
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Sheng-an Su
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Zhejun Cai
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
- * E-mail: (MX); (ZC)
| | - Jian-an Wang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
| | - Meixiang Xiang
- Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Cardiovascular Key Lab of Zhejiang Province, Hangzhou, Zhejiang, China
- * E-mail: (MX); (ZC)
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48
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Haouzi A, Ahmed A. 'Clinically suspected myocarditis with pseudoinfarct presentation' complicated with left ventricular aneurysm. BMJ Case Rep 2018; 2018:bcr-2017-222114. [PMID: 29348279 PMCID: PMC5778224 DOI: 10.1136/bcr-2017-222114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2017] [Indexed: 11/04/2022] Open
Abstract
A 51-year-old man presented with chest pain, high troponin level, inflammatory syndrome and ST-segment elevation in the anterior leads. While the transthoracic echocardiogram (TTE) showed anteroseptal hypokinesis and apical akinesis, the coronary angiogram was normal. Cardiac MR demonstrated a typical aspect of myocarditis (multiple areas of mid-myocardial late gadolinium enhancement, sparing the subendocardial layer, along with oedema). The initial diagnosis was clinically suspected myocarditis with pseudoinfarct presentation. However, the short-term evolution was not typical of this syndrome, since an apical transmural scar with aneurysm developed within 2 weeks. Seven years later, the patient remained asymptomatic, while Q waves persisted in anterior leads along with an apical aneurysm on TTE. A transmural myocardial necrosis with aneurysm is an unusual complication of acute myocarditis. The potential mechanisms accounting for the development of these lesions are reviewed, and the clinical implications for the diagnosis and monitoring of acute myocarditis are discussed.
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Affiliation(s)
- Annick Haouzi
- Heart and Vascular Institute, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Ahmed Ahmed
- Department of Cardiology, St Bernards Heart and Vascular, Jonesboro, Arkansas, USA
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49
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Spieker M, Katsianos E, Gastl M, Behm P, Horn P, Jacoby C, Schnackenburg B, Reinecke P, Kelm M, Westenfeld R, Bönner F. T2 mapping cardiovascular magnetic resonance identifies the presence of myocardial inflammation in patients with dilated cardiomyopathy as compared to endomyocardial biopsy. Eur Heart J Cardiovasc Imaging 2017; 19:574-582. [DOI: 10.1093/ehjci/jex230] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 09/07/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Spieker
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
| | - E Katsianos
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
| | - M Gastl
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
| | - P Behm
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
| | - P Horn
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
| | - C Jacoby
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
| | - B Schnackenburg
- Philips Healthcare, Röntgenstraße 24, Hamburg 22335, Germany
| | - P Reinecke
- Insitute of Pathology, Heinrich-Heine University, Moorenstraße 5, Duesseldorf 40221, Germany
| | - M Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
- CARID (Cardiovascular Research Institute Düsseldorf), Moorenstraße 5, Duesseldorf 40221, Germany
| | - R Westenfeld
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
| | - F Bönner
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Moorenstraße 5, Duesseldorf 40221, Germany
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50
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Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 435] [Impact Index Per Article: 62.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
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Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
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