Magnetic resonance imaging of cardiovascular fibrosis and inflammation: from clinical practice to animal studies and back

Patient-specific multi-physics simulations of fibrotic changes in left atrial tissue mechanics impact on hemodynamics

Stroke is a leading cause of death and disability worldwide. Atrial myopathy, including fibrosis, is associated with an increased risk of ischemic stroke, but the mechanisms underlying this association are poorly understood. Fibrosis modifies myocardial structure, impairing electrical propagation and tissue biomechanics, and creating stagnant flow regions where clots could form. Fibrosis can be mapped non-invasively using late gadolinium enhancement magnetic resonance imaging (LGE-MRI). However, fibrosis maps are not currently incorporated into stroke risk calculations or computational electro-mechano-fluidic models. We present multi-physics simulations of left atrial (LA) myocardial motion and hemodynamics using patient-specific anatomies and fibrotic maps from LGE-MRI. We modify tissue stiffness and active tension generation in fibrotic regions and investigate how these changes affect LA flow for different fibrotic burdens. We find that fibrotic regions and, to a lesser extent, non-fibrotic regions experience reduced myocardial strain, resulting in decreased LA emptying fraction consistent with clinical observations. Both fibrotic tissue stiffening and hypocontractility independently reduce LA function, but together, these two alterations cause more pronounced effects than either one alone. Fibrosis significantly alters flow patterns throughout the atrial chamber, and particularly, the filling and emptying jets of the left atrial appendage (LAA). The effects of fibrosis in LA flow are largely captured by the concomitant changes in LA emptying fraction except inside the LAA, where a multi-factorial behavior is observed. This work illustrates how high-fidelity, multi-physics models can be used to study thrombogenesis mechanisms in a patient-specific manner, shedding light onto the link between atrial fibrosis and ischemic stroke.

Key points

Left atrial (LA) fibrosis is associated with arrhythmogenesis and increased risk of ischemic stroke; its extent and pattern can be quantified on a patient-specific basis using late gadolinium enhancement magnetic resonance imaging.Current stroke risk prediction tools have limited personalization, and their accuracy could be improvedfib by incorporating patient-specific information like fibrotic maps and hemodynamic patterns.We present the first electro-mechano-fluidic multi-physics computational simulations of LA flow, including fibrosis and anatomies from medical imaging.Mechanical changes in fibrotic tissue impair global LA motion, decreasing LA and left atrial appendage (LAA) emptying fractions, especially in subjects with higher fibrosis burdens.Fibrotic-mediated LA motion impairment alters LA and LAA flow near the endocardium and the whole cavity, ultimately leading to more stagnant blood regions in the LAA.

Dynamic changes in cardiac morphology, function, and diffuse myocardial fibrosis duration of diabetes in type 1 and type 2 diabetic mice models using 7.0 T CMR and echocardiography

Background

Diabetes mellitus (DM) is associated with an increased risk of cardiovascular disease (CVD). Hence, early detection of cardiac changes by imaging is crucial to reducing cardiovascular complications.

Purpose

Early detection of cardiac changes is crucial to reducing cardiovascular complications. The study aimed to detect the dynamic change in cardiac morphology, function, and diffuse myocardial fibrosis(DMF) associated with T1DM and T2DM mice models.

Materials and methods

4-week-old C57Bl/6J male mice were randomly divided into control (n=30), T1DM (n=30), and T2DM (n=30) groups. A longitudinal study was conducted every 4 weeks using serial 7.0T CMR and echocardiography imaging. Left ventricular ejection fraction (LV EF), tissue tracking parameters, and DMF were measured by cine CMR and extracellular volume fraction (ECV). Global peak circumferential strain (GCPS), peak systolic strain rate (GCPSSR) values were acquired by CMR feature tracking. LV diastolic function parameter (E/E') was acquired by echocardiography. The correlations between the ECV and cardiac function parameters were assessed by Pearson's test.

Results

A total of 6 mice were included every 4 weeks in control, T1DM, and T2DM groups for analysis. Compared to control group, an increase was detected in the LV mass and E/E' ratio, while the values of GCPS, GCPSSR decreased mildly in DM. Compared to T2DM group, GCPS and GCPSSR decreased earlier in T1DM(GCPS 12W,P=0.004; GCPSSR 12W,P=0.04). ECV values showed a significant correlation with GCPS and GCPSSR in DM groups. Moreover, ECV values showed a strong positive correlation with E/E'(T1DM,r=0.757,P<0.001;T2DM, r=0.811,P<0.001).

Conclusion

The combination of ECV and cardiac mechanical parameters provide imaging biomakers for pathophysiology, early diagnosis of cardiac morphology, function and early intervention in diabetic cardiomyopathy in the future.

Sodium-glucose Cotransporter 2 Inhibitors and Pathological Myocardial Hypertrophy

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are a new type of oral hypoglycemic drugs that exert a hypoglycemic effect by blocking the reabsorption of glucose in the proximal renal tubules, thus promoting the excretion of glucose from urine. Their hypoglycemic effect is not dependent on insulin. Increasing data shows that SGLT2 inhibitors improve cardiovascular outcomes in patients with type 2 diabetes. Previous studies have demonstrated that SGLT2 inhibitors can reduce pathological myocardial hypertrophy with or without diabetes, but the exact mechanism remains to be elucidated. To clarify the relationship between SGLT2 inhibitors and pathological myocardial hypertrophy, with a view to providing a reference for the future treatment thereof, this study reviewed the possible mechanisms of SGLT2 inhibitors in attenuating pathological myocardial hypertrophy. We focused specifically on the mechanisms in terms of inflammation, oxidative stress, myocardial fibrosis, mitochondrial function, epicardial lipids, endothelial function, insulin resistance, cardiac hydrogen and sodium exchange, and autophagy.

Quantification of Early Diffuse Myocardial Fibrosis Through 7.0 T Cardiac Magnetic Resonance T1 Mapping in a Type 1 Diabetic Mellitus Mouse Model

BACKGROUND

Diffuse myocardial interstitial fibrosis (DMIF) is a key factor for heart failure (HF) in diabetic cardiomyopathy. MRI T1-mapping technique can quantitatively evaluate DMIF.

PURPOSE

To evaluate of early DMIF in a type 1 diabetes mellitus (T1DM) mouse model through 7.0 T MRI T1 mapping.

STUDY TYPE

Prospective.

ANIMAL MODEL

A total of 50 8-week-old C57Bl/6J male mice were divided into control (n = 20) and T1DM (n = 30) groups.

FIELD STRENGTH/SEQUENCE

A 7.0 T small animal MRI; gradient echo Look-Locker inversion recovery T1-mapping sequence; cine MRI. Scans were acquired in control and T1DM mice every 4 weeks until 24 weeks.

ASSESSMENT

End-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), left ventricle (LV) mass, fractional shortening (FS), and E/A ratio. They were evaluated through echocardiography and cine MRI. The extracellular volume fraction (ECV) was calculated. Sirius Red staining was performed and calculated collagen volume fraction (CVF).

STATISTICAL TESTS

Differences in ECV and CVF between two groups were analyzed using one-way analysis of variance. The correlation between ECV and CVF was assessed using Pearson's correlations.

RESULTS

Compared with the control group, a progressive decrease in FS, EF, and E/A ratio was observed in the T1DM group. Both ECV and CVF values gradually increased during diabetes progression. A significant increase in ECV and CVF values was observed at 12 weeks (ECV: 32.5% ± 1.6% vs. 28.1% ± 1.8%; CVF: 6.9% ± 1.8% vs. 3.3% ± 1.1%). ECV showed a strong correlation with CVF (r = 0.856).

DATA CONCLUSION

ECV is an accurate and feasible imaging marker that can be used to quantitatively assess DMIF changes over time in T1DM mice. ECV has potential to accurately detect DMIF in the early stage and may be a useful imaging tool to assess the need for early intervention in T1DM mice.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 3.

An end-to-end framework for intima media measurement and atherosclerotic plaque detection in the carotid artery

BACKGROUND AND OBJECTIVES

The detection and delineation of atherosclerotic plaque are usually manually performed by medical experts on the carotid artery. Evidence suggests that this manual process is subject to errors and has a large variability between experts, equipment, and datasets. This paper proposes a robust end-to-end framework for automatic atherosclerotic plaque detection.

METHODS

The proposed framework is composed of: (1) a semantic segmentation model based on U-Net, with EfficientNet as the backbone, that obtains a segmentation mask with the carotid intima-media region; and (2) a convolutional neural network designed using Bayesian optimization that simultaneously performs a regression to get the average and maximum carotid intima media thickness, and a classification to determine the presence of plaque.

RESULTS

Our approach improves the state-of-the-art in both co and bulb territories in the REGICOR database, with more than 8000 images, while providing predictions in real-time. The correlation coefficient was 0.89 in the common carotid artery and 0.74 for bulb region, and the F1 score for atherosclerotic plaque detecting was 0.60 and 0.59, respectively. The experimentation carried out includes a comparison with other fully automatic methods for carotid intima media thickness estimation found in the literature. Additionally, we present an extensive experimental study to evaluate the robustness of our proposal, as well as its suitability and efficiency compared to different versions of the framework.

CONCLUSIONS

The proposed end-to-end framework significantly improves the automatic characterization of atherosclerotic plaque. The generation of the segmented mask can be helpful for practitioners since it allows them to evaluate and interpret the model's results by visual inspection. Furthermore, the proposed framework overcomes the limitations of previous research based on ad-hoc post-processing, which could lead to overestimations in the case of oblique forms of the carotid artery.

Time-dependent dual effect of NLRP3 inflammasome in brain ischemia

BACKGROUND

Post-ischemic inflammation contributes to worsening of ischemic brain injury and in this process, the inflammasomes play a key role. Inflammasomes are cytosolic multiprotein complexes which upon assembly activate the maturation and secretion of the inflammatory cytokines IL-1β and IL-18. However, participation of the NLRP3 inflammasome in ischemic stroke remains controversial. Our aims were to determine the role of NLRP3 in ischemia and to explore the mechanism involved in the potential protective effect of the neurovascular unit.

METHODS

WT and NLRP3 knock-out mice were subjected to ischemia by middle cerebral artery occlusion (60 minutes) with or without treatment with MCC950 at different time points post-stroke. Brain injury was measured histologically with 2,3,5-triphenyltetrazolium chloride (TTC) staining.

RESULTS

We identified a time-dependent dual effect of NLRP3. While neither the pre-treatment with MCC950 nor the genetic approach (NLRP3 KO) proved to be neuroprotective, post-reperfusion treatment with MCC950 significantly reduced the infarct volume in a dose-dependent manner. Importantly, MCC950 improved the neuro-motor function and reduced the expression of different pro-inflammatory cytokines (IL-1β, TNF-α), NLRP3 inflammasome components (NLRP3, pro-caspase-1), protease expression (MMP9) and endothelial adhesion molecules (ICAM, VCAM). We observed a marked protection of the blood-brain barrier (BBB), which was also reflected in the recovery of the tight junctions proteins (ZO-1, Claudin-5). Additionally, MCC950 produced a reduction of the CCL2 chemokine in blood serum and in brain tissue, which lead to a reduction in the immune cell infiltration.

CONCLUSIONS

These findings suggest that post-reperfusion NLRP3 inhibition may be an effective acute therapy for protecting the blood-brain barrier in cerebral ischemia with potential clinical translation.

Biomedical Applications of Biomolecules Isolated from Methanotrophic Bacteria in Wastewater Treatment Systems

Wastewater treatment plants and other remediation facilities serve important roles, both in public health, but also as dynamic research platforms for acquiring useful resources and biomolecules for various applications. An example of this is methanotrophic bacteria within anaerobic digestion processes in wastewater treatment plants. These bacteria are an important microbial source of many products including ectoine, polyhydroxyalkanoates, and methanobactins, which are invaluable to the fields of biotechnology and biomedicine. Here we provide an overview of the methanotrophs' unique metabolism and the biochemical pathways involved in biomolecule formation. We also discuss the potential biomedical applications of these biomolecules through creation of beneficial biocompatible products including vaccines, prosthetics, electronic devices, drug carriers, and heart stents. We highlight the links between molecular biology, public health, and environmental science in the advancement of biomedical research and industrial applications using methanotrophic bacteria in wastewater treatment systems.

Does Transient Receptor Potential Vanilloid Type 1 Alleviate or Aggravate Pathological Myocardial Hypertrophy?

Transient receptor potential vanilloid type 1 (TRPV1) is a non-selective cation channel, which is involved in the endogenous stress adaptation mechanism for protection of the heart as well as the occurrence and development of some heart diseases. Although the effect of activation of the TRPV1 channel on different types of non-neural cells in the heart remains unclear, most data show that stimulation of sensory nerves expressing TRPV1 or stimulation/overexpression of the TRPV1 channel has a beneficial role in heart disease. Some studies have proven that TRPV1 has an important relationship with pathological myocardial hypertrophy, but the specific mechanism and effect are not clear. In order to help researchers better understand the relationship between TRPV1 and pathological myocardial hypertrophy, this paper aims to summarize the effect of TRPV1 and the related mechanism in the occurrence and development of pathological myocardial hypertrophy from the following three points of view: 1) role of TRPV1 in alleviation of pathological myocardial hypertrophy; 2) role of TRPV1 in aggravation of pathological myocardial hypertrophy; and 3) the point of view of our team of researchers. It is expected that new therapies can provide potential targets for pathological myocardial hypertrophy.

Study of the phenolic compound profile and antioxidant activity of human milk from Spanish women at different stages of lactation: A comparison with infant formulas

Human milk (HM) has been proven to have important and essential antioxidant properties to counteract infant susceptibility to oxidative stress. Phenolic compounds are secondary metabolites which come from plants and are potent natural antioxidants. The ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method used in the present study allowed the quantification of 26 phenolic compounds (ten hydroxybenzoic acids, seven hydroxycinnamic acids, four flavonoids, three hydroxybenzaldehydes and two other polyphenols) in HM samples at different stages of lactation (colostrum, transitional milk and mature milk) and infant formulas (IF). Many of the phenolic compounds identified have been reported to be present in HM for the first time. The total phenolic compound content (TPC) was quantified using the Folin assay and the antioxidant activity (AC) was evaluated with the DPPH, ABTS and FRAP assays. Significant differences were evidenced between HM and IF. HM from mothers with an adherence to a Mediterranean diet contained twice as many individual phenolic compounds as infant formulas, with a higher proportion of hydroxybenzoic acids. Conversely, IF showed a higher proportion of hydroxycinnamic acids. Overall, the antioxidant activity of HM showed small variations during lactation.

The Tumor Microenvironment Impairs Th1 IFNγ Secretion through Alternative Splicing Modifications of Irf1 Pre-mRNA

It is clearly established that the immune system can affect cancer response to therapy. However, the influence of the tumor microenvironment (TME) on immune cells is not completely understood. In this respect, alternative splicing is increasingly described to affect the immune system. Here, we showed that the TME, via a TGFβ-dependent mechanism, increased alternative splicing events and induced the expression of an alternative isoform of the IRF1 transcription factor (IRF1Δ7) in Th1 cells. We found that the SFPQ splicing factor (splicing factor, proline- and glutamine-rich) was responsible for the IRF1Δ7 production. We also showed, in both mice and humans, that the IRF1 alternative isoform altered the full-length IRF1 transcriptional activity on the Il12rb1 promoter, resulting in decreased IFNγ secretion in Th1 cells. Thus, the IRF1Δ7 isoform was increased in the TME, and inhibiting IRF1Δ7 expression could potentiate Th1 antitumor responses.

Methodological Considerations for Neuroimaging in Deep Brain Stimulation of the Subthalamic Nucleus in Parkinson's Disease Patients

Deep brain stimulation (DBS) of the subthalamic nucleus is a neurosurgical intervention for Parkinson's disease patients who no longer appropriately respond to drug treatments. A small fraction of patients will fail to respond to DBS, develop psychiatric and cognitive side-effects, or incur surgery-related complications such as infections and hemorrhagic events. In these cases, DBS may require recalibration, reimplantation, or removal. These negative responses to treatment can partly be attributed to suboptimal pre-operative planning procedures via direct targeting through low-field and low-resolution magnetic resonance imaging (MRI). One solution for increasing the success and efficacy of DBS is to optimize preoperative planning procedures via sophisticated neuroimaging techniques such as high-resolution MRI and higher field strengths to improve visualization of DBS targets and vasculature. We discuss targeting approaches, MRI acquisition, parameters, and post-acquisition analyses. Additionally, we highlight a number of approaches including the use of ultra-high field (UHF) MRI to overcome limitations of standard settings. There is a trade-off between spatial resolution, motion artifacts, and acquisition time, which could potentially be dissolved through the use of UHF-MRI. Image registration, correction, and post-processing techniques may require combined expertise of traditional radiologists, clinicians, and fundamental researchers. The optimization of pre-operative planning with MRI can therefore be best achieved through direct collaboration between researchers and clinicians.

Diagnostic work-up and therapeutic implications in MINOCA: need for a personalized approach

Myocardial infarction with non-obstructive coronary artery (MINOCA) disease represents a heterogeneous clinical conundrum accounting for about 6% of all acute myocardial infarction (MI) cases. Initially believed to be a benign condition, is now becoming clear that MINOCA is associated with a non-negligible risk of mortality, rehospitalization, disability and angina burden at follow-up, with high socioeconomic costs. To date, there are no prospective clinical trials in this population and cannot be assumed that benefits observed in patients suffering from MI with obstructive coronary artery disease may successfully translate to this syndrome. Herein, we comment on the importance of the multimodality assessment to properly identify and treat the specific causes of MINOCA, in order to improve prognosis and the quality of life in these patients.

Potential Antioxidant Activity of Calcium and Selected Oxidative Stress Markers in Lead- and Cadmium-Exposed Workers

Occupational lead (Pb) and cadmium (Cd) exposure occurs during processing and casting of nonferrous metals such as zinc. In contrast to Pb and Cd, Ca is essential for living organisms due to its important role in a multitude of functions, from cell signaling to bone growth. Pb and Cd exposure affects calcium metabolism in various ways. The aim of this study was to investigate the blood levels of Pb, Cd, and Ca and the levels of selected oxidative stress biomarkers in workers exposed to Pb and Cd. Population groups included 264 male employees in a lead-zinc smelter. The study population was divided into two subgroups based on the median of Ca serum level (2.42 mmol/l): the low-Ca-level group (L-Ca group) and the high-Ca-level group (H-Ca group). Ca level was significantly higher in the H-Ca group than in the L-Ca group due to the study design (by 26%). The level of zinc protoporphyrin (ZPP) was significantly higher in the L-Ca group than in the H-Ca group by 13%, while the blood lead levels (PbB) were similar in the examined groups. The level of cadmium (CdB) was significantly higher in the L-Ca group than in the H-Ca group by 33%. From oxidative stress markers in serum, only the levels of malondialdehyde (MDA) and ceruloplasmin (CER) were significantly higher in the L-Ca group than in the H-Ca group, by 12% and 4%, respectively. The correlation analysis showed negative correlations between Ca level and the levels of PbB, ZPP, CdB, and MDA. The presented results indicate that Ca level modulates the serum concentration of Cd and has an impact on Pb-induced impairment of heme synthesis. The higher Ca levels may lead to a decrease in the concentration of lipid peroxidation products. Moreover, serum calcium level seems to be able to modify the level of acute-phase proteins. Obtained results suggest that higher Ca level may be useful in reducing Cd level in occupationally exposed workers.

Current understanding of fibrosis in genetic cardiomyopathies

Myocardial fibrosis is the excessive deposition of extracellular matrix proteins, including collagens, in the heart. In cardiomyopathies, the formation of interstitial fibrosis and/or replacement fibrosis is almost always part of the pathological cardiac remodeling process. Different forms of cardiomyopathies show particular patterns of myocardial fibrosis that can be considered as distinctive hallmarks. Although formation of fibrosis is initially aimed to be a reparative mechanism, in the long term, on-going and excessive myocardial fibrosis may lead to arrhythmias and stiffening of the heart wall and subsequently to diastolic dysfunction. Ultimately, adverse remodeling with progressive myocardial fibrosis can lead to heart failure. Not surprisingly, the presence of fibrosis in cardiomyopathies, even when subtle, has consistently been associated with complications and adverse outcomes. In the last decade, non-invasive in vivo techniques for visualization of myocardial fibrosis have emerged, and have been increasingly used in research and in the clinic. In this review, we will describe the epidemiology, distribution, and role of myocardial fibrosis in genetic cardiomyopathies, including hypertrophic, dilated, arrhythmogenic, and non-compaction cardiomyopathy, and a few specific forms of genetic cardiomyopathies.

The value of cardiac MRI versus echocardiography in the pre-operative assessment of patients with Duchenne muscular dystrophy

BACKGROUND/PURPOSE

Duchenne Mmuscular Ddystrophy (DMD) related cardiomyopathy is associated with significant perioperative mortality. Cardiac MRI (CMR) has not previously been systematically evaluated as pre-operative assessment tool for heart function in DMD. Our aim was to establish whether CMR versus echocardiography contributes to pre-operative DMD assessment.

METHODS

Case records were retrospectively reviewed of 35 consecutive DMD boys who underwent evaluation for surgical procedures between 2010 and 2013.

RESULTS

Echocardiography revealed a median left ventricular (LV) shortening fraction (SF) of 29/% (range: 7-44). 37% of boys (13/35) had abnormal SF <25%, 66% (23/35) showed hypokinesia and 26% (9/35) had LV dilatation. CMR revealed a median left ventricular ejection fraction (LVEF) of 52% (range: 27-67%). 57% of boys (20/35) had abnormal LVEF <55%, 71% (25/35) had hypokinesia, and 82% late gadolinium enhancement. Extensive versus minimal late gadolinium enhancement was associated with reduced left ventricular ejection fraction (48% vs 58%; p = 0.003) suggesting more severe cardiomyopathy. Although echocardiography shortening fraction correlated with CMR ejection fraction (rs = 0.67; p < 0.001), three-quarter of echocardiography studies had suboptimal scanning windows and in 26% measurements significantly over- or underestimated left-ventricular function compared to CMR.

CONCLUSION

Our findings clearly demonstrate the added value of CMR versus echocardiography in assessing DMD-cardiomyopathy. Particularly when echocardiographic scanning windows are suboptimal, CMR should be considered to allow accurate pre-operative cardiac assessment.

Role of cardiac magnetic resonance in the evaluation of dilated cardiomyopathy: diagnostic contribution and prognostic significance

Dilated cardiomyopathy (DCM) represents the final common morphofunctional pathway of various pathological conditions in which a combination of myocyte injury and necrosis associated with tissue fibrosis results in impaired mechanical function. Recognition of the underlying aetiology of disease and accurate disease monitoring may be crucial to individually optimize therapeutic strategies and stratify patient's prognosis. In this regard, CMR has emerged as a new reference gold standard providing important information for differential diagnosis and new insight about individual risk stratification. The present review article will focus on the role of CMR in the evaluation of present condition, analysing respective strengths and limitations in the light of current literature and technological developments.