The effects of lockdown-induced air quality changes on the results of cardiac functional stress testing in coronary artery disease and heart failure patients

In vulnerable subjects, the increase in air pollution worsens the signs of myocardial ischemia. Lockdown during COVID-19 pandemics substantially cleaned the air. The objective of this is to assess the effects of air cleaning due to lockdown on stress echocardiography (SE) results. We enrolled 19 patients with chronic coronary artery disease and/or heart failure referred to SE (semi-supine bicycle exercise, n = 8, or dipyridamole, n = 11). Before and soon after lockdown, we assessed regional wall motion abnormalities (abnormal value: worsening of ≥ 2 segments), B-lines (a sign of pulmonary congestion, 4-site simplified scan, abnormal value ≥ 2), and coronary flow velocity reserve in left anterior descending artery (CFVR, abnormal value < 2.0). Local air quality indicators (same day of SE) of fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂) were obtained from publicly available data sets of the regional authority of environmental protection. After lockdown, NO₂ concentration decreased from 19 ± 10 to 10 ± 4 μg/m³ (p = 0.006). After lockdown, abnormal responses remained unchanged for ischemia (21% vs 16%, p = ns) and decreased for B-lines (42% vs 5%, p = 0.008) and CFVR (84 vs 42%, p = 0.007). Changes in coronary flow velocity reserve (CFVR) were correlated to same-day variations in NO₂ (r = -0.578, p = 0.010) and preceding 30-day changes in PM_2.5 (r = -0.518, p = 0.023). After lockdown, air cleaning was associated with a beneficial effect on coronary small vessel dysfunction and alveolar-capillary barrier distress mirrored by improvement of CFVR and B-lines during SE in vulnerable patients. ClinicalTrials.gov Identifier: NCT 030.49995.

Multimodality imaging in COVID-19 patients: A key role from diagnosis to prognosis

The integrated clinical, laboratory and ultrasound approach is essential for the diagnosis, evaluation and monitoring of the patient's therapy in coronavirus disease 2019 pneumonia. The ideal imaging approach in this context is not yet well defined. Chest X-ray is characterized by low sensitivity in identifying earlier lung changes. The "bedside" pulmonary ultrasound has an undeniable series of advantages in the patient at high infectious risk and can provide incremental data in the respiratory intensive care for the serial control of the individual patient as well as for the home delivery of the stabilized subjects. Pulmonary computed tomography shows high sensitivity but should not be routinely performed in all patients, because in the first 48 h it can be absolutely negative and in the late phase the imaging findings may not change the therapeutic approach. Echocardiography should be limited to patients with hemodynamic instability to assess ventricular function and pulmonary pressures.

Inverse response of global longitudinal strain after dipyridamole stress echocardiography in patients with microvascular coronary dysfunction

Background

Coronary microvascular dysfunction (CMD) is a potential cause of myocardial ischemia and may affect myocardial function at rest and during stress. CMD can be identified, in patients with non-obstructive coronary artery disease (CAD), by a reduced transthoracic Doppler-derived coronary flow reserve (CFR), which is an index of coronary arterial reactivity, and can be impaired in both obstructive CAD and CMD.

The aim of this study was to investigate the dipyridamole-induced changes of global longitudinal strain (GLS) in patients with CMD.

Methods

43 patients (29M, 14F; mean age 68±7 years) without obstructive CAD, assessed by invasive coronary angiogram, underwent dipyridamole stress echocardiography. Coronary flow was assessed in the left anterior descending coronary artery (LAD) and was identified as the colour signal directed from the base to the apex of the left ventricle, containing the characteristic biphasic pulsed-Doppler flow signals. CFR were determined as the ratio of hyperaemic to baseline diastolic coronary flow velocity. CMD was defined as CFR &lt;2.

GLS was measured using automated function imaging, through the positioning of three endocardial markers (two markers at the mitral annulus and one at the apex) in each apical view. Subsequently, the obtained segmental values of GLS were visualized as a bull's-eye map in a quick and feasible manner. We had optimal left ventricular endocardial tracking in the overall population.

In each patient, we used a frame rate of 70 frames/sec for adequate 2D strain analysis. We analyzed GLS at each step of stress test and compared peak-dose values with baseline.

Results

Thirteen patients (30%) among the overall population showed CMD. There were no significant differences in baseline characteristics between patients with or without CMD. GLS, at baseline, was significantly lower in patients with CMD (−16.9±3.78 vs. −17.8±3.77 – p&lt;0.01). We observed a different response to dipyridamole stress echocardiography, between the two groups: GLS significantly increased up to peak dose in patients without CMD (from −17.8±3.77 to −19.3±4.09 – p&lt;0.01), whereas on the other hand, a significant decrease from rest to peak dose was observed in patients with CMD (from −16.9±3.78 to −15.5±4.18 – p&lt;0.01). There was a significant inverse correlation between CFR and delta GLS measured at rest and after dipyridamole peak dose (r=−0.82 – p&lt;0.01).

Conclusions

GLS analysis, particularly performed by comparing dipyridamole peak-dose with baseline values, shows that in patients with CMD there is a different response of left ventricular myocardiim to stress test.

It could be assumed that the inverse correlation between CFR and delta GLS reflects a progressive subclinical worsening of left ventricular myocardial function in these patients. Larger studies could confirm our data.

Funding Acknowledgement

Type of funding source: None

Abstract 298: Downregulation of Delta and Kappa Opioid Receptors in Post-heart Transplantation in Human and Rats

Over the past decade, multiple data regarding local opioid regulation of heart function have been demonstrated. However, opioid receptors (ORs) have not yet characterized in post-heart transplantation. Since a transplanted heart is devoid of innervations and autonomic innervations modulate ORs, we assessed the hypothesis that a possible down-regulation of k-OR and δ-OR in heart transplants.

Endomyocardial biopsies were collected in 15 male patients at 30 days of orthotopic heart transplantation and in 15 control male patients during aortic valve surgery in human. Another study performed in 20 heterotopic heart transplants (HHT) and 20 naïve hearts of Sprague-Dawley male rats. The mRNA transcript encoding the Oprd1 and Oprk1, KOR and DOR proteins, distribution, and cellular localization were identified using RT-qPCR, Western blot, IHC, and IF, respectively.

Transcripts of mRNA encoding the Oprd1 and Oprk1 were detected in hearts of human and rats. Expression of Oprd1 (p=0.036) and Oprk1 (p = 0.004) was significantly reduced in transplanted hearts. In Western blot analysis, KOR and DOR levels of expression were significantly lowered (p=0.03, KOR; p=0.01, DOR) in HHT compared to naïve hearts in rats. Immunohistochemistry analysis demonstrated a lighter labeling on the distribution of DOR and KOR in heart transplants` tissue in both rats and human. In both species, dual labeling myocardial isoforms (KOR and DOR) co-localized in cardiomyocytes of transplant and control hearts.

These findings suggest that the down-regulation of DOR and KOR receptors in hearts transplant of both human and rats might have a possible increased susceptibility to ischemia-reperfusion injury.

The K219T-Lamin mutation induces conduction defects through epigenetic inhibition of SCN5A in human cardiac laminopathy

Mutations in LMNA, which encodes the nuclear proteins Lamin A/C, can cause cardiomyopathy and conduction disorders. Here, we employ induced pluripotent stem cells (iPSCs) generated from human cells carrying heterozygous K219T mutation on LMNA to develop a disease model. Cardiomyocytes differentiated from these iPSCs, and which thus carry K219T-LMNA, have altered action potential, reduced peak sodium current and diminished conduction velocity. Moreover, they have significantly downregulated Nav1.5 channel expression and increased binding of Lamin A/C to the promoter of SCN5A, the channel's gene. Coherently, binding of the Polycomb Repressive Complex 2 (PRC2) protein SUZ12 and deposition of the repressive histone mark H3K27me3 are increased at SCN5A. CRISPR/Cas9-mediated correction of the mutation re-establishes sodium current density and SCN5A expression. Thus, K219T-LMNA cooperates with PRC2 in downregulating SCN5A, leading to decreased sodium current density and slower conduction velocity. This mechanism may underlie the conduction abnormalities associated with LMNA-cardiomyopathy.

Echocardiography in Athletes in Primary Prevention of Sudden Death

Echocardiography is a noninvasive imaging technique useful to provide clinical data regarding physiological adaptations of athlete's heart. Echocardiographic characteristics may be helpful for the clinicians to identify structural cardiac disease, responsible of sudden death during sport activities. The application of echocardiography in preparticipation screening might be essential: it shows high sensitivity and specificity for identification of structural cardiac disease and it is the first-line imagining technique for primary prevention of SCD in athletes. Moreover, new echocardiographic techniques distinguish extreme sport cardiac remodeling from beginning state of cardiomyopathy, as hypertrophic or dilated cardiomyopathy and arrhythmogenic right ventricle dysplasia. The aim of this paper is to review the scientific literature and the clinical knowledge about athlete's heart and main structural heart disease and to describe the rule of echocardiography in primary prevention of SCD in athletes.

Significance of Ascitic Fluid and Peritoneal Washing Cytology in Ovarian Tumor Diagnosis

The results of the cytological test on 179 ascitic fluids and 88 peritoneal washes of patients suspected to have ovarian tumors are critically reviewed to illustrate the difficulties, limitations and future possibilites of this technique. Tissue correlation was available in all cases. The data was evaluated in order to obtain information as to the accuracy, sensitivity and specificity of cytological examination, both in ascitic fluids and in peritoneal washings. A correct diagnosis as to the ovarian tumor histotype was obtained in more than 80 per cent of the cases.

Blastic Transformation Induced on the Lymphocytes «in vitro» by an Exudate of Reticulum Cell Sarcoma

The blood lymphocyte culture «in vitro» has been employed in order to investigate (a) the presence of neoplastic antigens in reticulum cell sarcoma exudates, and (b) the ability of patients with reticulum cell proliferative diseases (reticulum cell sarcoma, reticulum cell reticulosis) to give immune reactions to such antigens. Lymphocytes from a patient with reticulum cell reticulosis showed a 7.3% transformation to blast cells in the presence of the pleural exudate from a reticulum cell sarcoma patient. However, this same exudate did not induce transformation of lymphocytes from two other patients with reticulum cell sarcoma nor of normal lymphocytes. Lymphocytes from the exudate donor patient did show a small percentage transformation in the presence as well as in the absence of the exudate (2.3, and 2.1%, respectively). With the purpose of identification of the transformating factor, fractionation studies were performed yielding a carbohydrate-rich, partially dialyzable mucoprotein. The conclusion is drawn that lymphocytes from the patient with reticulum cell reticulosis were immunologically reactive to a neoplastic antigen contained in the reticulum cell sarcoma exudate, and possibly produced by the proliferating reticulum cells.

Effectiveness and Safety of Transcatheter Aortic Valve Implantation in Patients With Pure Aortic Regurgitation and Advanced Heart Failure

Results of transcatheter aortic valve implantation (TAVI) for treatment of severe noncalcific isolated aortic regurgitation (AR) complicated by advanced heart failure or cardiogenic shock has been previously reported only in isolated case reports. Current self-expanding transcatheter aortic valves are designed to treat aortic valve stenosis, and have also been implanted in cases of severe AR due to degenerated bioprosthesis and in very few cases of native aortic valves. We report 13 consecutive inoperable patients with noncalcific, pure AR, and advanced heart failure treated with emergency percutaneous transfemoral implantation with self-expandable CoreValves at our institution between July 2012 and September 2017. The immediate and long-term clinical outcome was prospectively assessed according to the Valve Academic Research Consortium-2 criteria for device success and safety. All but 3 patients had previous surgery of the aortic root, including 2 implants of Heart Mate-II left ventricle assist device; none had surgical aortic bioprosthesis at the time of the TAVI. Valve implantation was successful in 12 of 13 patients (92%) and 1 patient required a second unplanned valve procedure within 18 hours. Oversizing the prosthesis by approximately 15% yielded better results with 1 valve. Two patients with left ventricle assist device died within 30 days of TAVI. All patients who survived to hospital discharge had none or just mild residual AR, improved their cardiac function, and survived at long-term without recurrence of clinical events. In conclusion, implanting self-expandable transcatheter valves in patients pure AR in this small study was safe and effective, and represented an important option for inoperable patients with noncalcific severe AR.

4D-π-1A type β-substituted ZnII-porphyrins: ideal green sensitizers for building-integrated photovoltaics

Two novel green β-substituted Zn^II-porphyrins, G1 and G2, based on a 4D-π-1A type substitution pattern have been synthesized. Their enhanced push-pull character, by reduction of H-L energy gaps, promotes broadening and red-shifting of absorption bands. The effective synthetic pathway and the remarkable spectroscopic properties make G2 ideal for BIPV application.

Abstract 11: Lamin A/C Mutations Epigenetically Dysregulate Scn5a Gene Expression, Perturbing Action Potential Properties in IPSC-derived Cardiomyocytes

Mutations of the LMNA gene, encoding the nuclear lamina proteins Lamin A/C, are a common cause of dilated cardiomyopathy, typically manifesting in association with cardiac conduction defects. LaminA/C regulate various nuclear activities, including maintenance of the nuclear structure, gene transcription and chromatin organization. Most studies on the consequences of Lamin A/C defects were conducted on fibroblasts, while studies on human cardiomyocytes (CMs) are scarce. We therefore generated a cardiac model of laminopathy obtained by differentiation of CMs from induced pluripotent stem cells (iPSCs) of patients carrying the K219T Lamin A/C mutation. In vitro, these cells recapitulate the morphological features of dilated cardiomyopathy, specifically sarcomeric disorganization and increased size. Using this model, we performed a comprehensive analysis of the electrophysiological properties of LMNA-CMs both at single cell level and in a multi-cellular setting. Using patch-clamp technique, results revealed significant changes in maximal upstroke velocity (dV/dt max ), action potential amplitude (APA) and overshoot (OV) in LMNA-CMs compared to those obtained from family-matched healthy controls (CNTR); these defects were associated with a reduction of the peak sodium currents and a diminished conduction velocity, measured in strands of electrically-coupled CMs. Biochemical studies showed a significant reduction of both the sodium channel Nav1.5 protein and its transcript in LMNA-CMs, accompanied by an increased binding of LaminA/C to the promoter of its coding gene, SCN5A. Binding of the Polycomb group protein SUZ12 and of the H3K27me3 histone repressive mark was also increased. Consistently, 3D-FISH experiments also indicated a preferential localization of SCN5A genomic loci at the nuclear periphery in LMNA-CMs. As a whole, our findings support a model in which mutated Lamin A/C perturb SCN5A gene expression by favouring PRC2 (Polycomb Repressive Complex 2) binding to its promoter, leading to decreased sodium current peak and slower conduction velocity. This mechanism may eventually sustain the conduction abnormalities inevitably occurring in patients with LMNA-cardiomyopathy.

Cyclometalated Pt(ii) complexes with a bidentate Schiff-base ligand displaying unexpected cis/trans isomerism: synthesis, structures and electronic properties

Unexpected cis/trans isomerism in a bis-cyclometalated Pt(ii) complex is investigated by NMR, X-ray diffraction, optical, electrochemical and computational methods and rationalized.

Stimuli-responsive NLO properties of tetrathiafulvalene-fused donor–acceptor chromophores

Tetrathiafulvalene-fused electron donor–acceptor dyads display second order nonlinear optical properties that can be triggered by a pH or a redox stimulus.

Long-living optical gain induced by solvent viscosity in a push–pull molecule

The combination of continuum and ultrafast pump–probe spectroscopy, in viscous and non-viscous environments, with DFT and TDDFT calculations, is effective in unraveling important features of the twisted intramolecular charge transfer mechanism in a new push–pull molecule that possesses aggregation induced emission properties.

Disseminated Mycobacterium avium complex disease in a patient with left ventricular assist device (Heart Mate II)

Although disseminated Mycobacterium avium complex disease occurs mainly in immunocompromised hosts, especially HIV-infected patients in the last stage of the disease (AIDS), this condition is still rare in immunocompetent subjects. We report the case of a Caucasian man who received a left ventricular assist device two years before as a bridge to heart transplantation, that began to present signs and symptoms of mycobacterial infection. The diagnostic work-up we performed showed the presence of Mycobacterium intracellulare in lungs and both peripherical and bone marrow blood. Although evaluated, we found no abnormalities in the patient's immune system that can be related to mycobacterial infection. The beginning of a specific therapy made the patient slowly improve and further nuclear medicine assay (PET-TC) showed a good reduction in radio-labelled drug captation.

[Thalamo-mesencephalic aspergillus abscess in a heart transplant subject: a case report and literature review]

Cerebral aspergillosis is a rare and highly fatal infection that mainly affects immunocompromised patients. We report on a case of a heart transplanted Caucasian man, who arrived at our hospital because of the onset of diplopy. We performed a broad diagnostic work-up: the brain MRI showed a single ring-enhancing thalamo-mesencephalic area suggestive of abscess lesion; cerebrospinal fluid (CSF) analysis disclosed galactomannan and beta-D-glucan antigens. Thus the antifungal therapy was immediately started. We decided to discontinue the therapy 16 months later because of severe hepatic toxicity, given that the patient was persistently asymptomatic, brain imaging showed a progressive resolution of the abscess area and CSF antigen analysis was persistently negative. The follow-up at three months was unchanged.

Doubly heterozygous LMNA and TTN mutations revealed by exome sequencing in a severe form of dilated cardiomyopathy

Familial dilated cardiomyopathy (DCM) is a heterogeneous disease; although 30 disease genes have been discovered, they explain only no more than half of all cases; in addition, the causes of intra-familial variability in DCM have remained largely unknown. In this study, we exploited the use of whole-exome sequencing (WES) to investigate the causes of clinical variability in an extended family with 14 affected subjects, four of whom showed particular severe manifestations of cardiomyopathy requiring heart transplantation in early adulthood. This analysis, followed by confirmative conventional sequencing, identified the mutation p.K219T in the lamin A/C gene in all 14 affected patients. An additional variant in the gene for titin, p.L4855F, was identified in the severely affected patients. The age for heart transplantation was substantially less for LMNA:p.K219T/TTN:p.L4855F double heterozygotes than that for LMNA:p.K219T single heterozygotes. Myocardial specimens of doubly heterozygote individuals showed increased nuclear length, sarcomeric disorganization, and myonuclear clustering compared with samples from single heterozygotes. In conclusion, our results show that WES can be used for the identification of causal and modifier variants in families with variable manifestations of DCM. In addition, they not only indicate that LMNA and TTN mutational status may be useful in this family for risk stratification in individuals at risk for DCM but also suggest titin as a modifier for DCM.

Analysis of the 3'UTR of the prostaglandin synthetase-2 (PTGS-2/COX-2) gene in non-melanoma skin cancer after organ transplantation

To define the potential involvement of polymorphisms in the 3'untranslated region (3'UTR) of the prostaglandin synthetase-2 (PTGS-2) gene to non-melanoma skin cancer (NMSC) predisposition after transplantation, we screened for genetic variant, relevant parts of this region. It contains binding sites for trans-acting factors, an alternative polyadenylation site and putative target sequences for miRNAs. Variant +8473T>C did not appear to play a functional role in the regulation of gene expression in human keratinocyte-transfected cells. In addition to the well-known +8473T>C, we identified four polymorphisms: +8293G>C, +10259T>G, +10267G>A and +10335G>A. No allele frequency differences were observed between cases and controls neither for +8473T>C nor for any of the identified polymorphisms, suggesting that polymorphisms in the 3'UTR of the PTGS2 gene are rare and unlikely to represent risk factor for NMSC after transplantation.

Results with expanded donor acceptance criteria in heart transplantation

OBJECTIVE

Over the past years both donor and recipient profiles have changed in heart transplantation. Satisfactory clinical outcomes of marginal donors in candidates >60 years of age have led us to allocate suboptimal donors to younger recipients as well. Therefore, we retrospectively reviewed our experience.

METHODS

Among 199 patients undergoing heart transplantation from January 2000 to February 2010, there were 83 (41%) aged 61-72 years. The other 116 (59%) ranged in age between 18 and 60 years. According to their clinical conditions as heart transplantation candidates, They were classified into 4 groups: younger recipients (n=116) of either optimal donors (n=72; group 1 [G1]) or marginal donors (n=44; group 2 [G2]) and older recipients (n=83) of either marginal grafts (n=70, group 3 [G3]) or optimal grafts (n=13; group 4 [G4]). The gender distribution, cause of end-stage heart failure, preoperative pulmonary hypertension incidence, pretransplantation clinical status, and mean follow-up were not significantly different among the 4 groups.

RESULTS

Overall 30-day survival was 90 ± 1% and 10-year rate was 78 ± 9%. Among the groups, 30-day and 10-year actuarial survival rates were, respectively: 94 ± 4% and 87 ± 1% for G1; 86 ± 5% and 84 ± 7% for G2; 88 ± 4% and 71 ± 7% for G3 and were 100% and 82 ± 7% for G4 (P=.7). In comparison among the 4 groups, there was no significant difference regarding freedom from graft failure (P=.3), right ventricular failure (P=.3), acute rejection episodes (P = .2), chronic rejection (P=.2), neoplasia (P=.5), or chronic renal failure (P=.1). Older recipients of marginal donors [G3] had a 4% (n=3) prevalence of permanent pacemaker implant, versus G2: 3% (n=2) among (P=.1).

CONCLUSION

Our results suggest that extended donor and recipient criteria do not compromise clinical outcomes after transplantation.

Impact of donor quality on outcome of heart transplantation

OBJECTIVE

Over the last few years, there have been changes in both donor and recipient profiles in heart transplantation. Encouraging clinical outcome of marginal donors in candidates older than 60 years of age led us to allocate suboptimal donors for younger recipients as well. We reviewed our experience retrospectively so as to assess the impact of donor quality on heart transplantation.

METHODS

Among 181 patients who underwent heart transplantation between January 2000 and February 2009, there were 75 patients (41%) aged 61-70 years and 106 patients (59%) ranging in age between 18 and 60 years. According to the recipient's age, they were classified into four groups. The younger recipients (106 patients) had either optimal donors (70 patients, group 1) or marginal donors (36 patients, group 2). The older recipients (75 patients) had either marginal grafts (64 patients, group 3) or optimal grafts (11 patients, group 4). Sex distribution, cause of end-stage heart failure, preoperative pulmonary hypertension, pre-heart-transplantation clinical status or mean follow-up duration did not show any statistically significant difference among the four groups.

RESULTS

Overall, the 9-year actuarial survival rate was 78%±1%. The 30 days and 9-year actuarial survival rates were 94%±2% and 80%±1% in group 1; 86%±5% and 55%±12% in group 2; 90%±4% and 73%±7% in group 3; 99%±1% and 82%±7% in group 4 (P=0.07). Comparison among the four groups did not show any statistical difference in terms of freedom from graft failure (P=0.3), right ventricular failure (P=0.3), acute rejection (P=0.2), chronic rejection (P=0.2), neoplasia (P=0.5) and chronic renal failure (P=0.2). Older recipients of marginal donors (group 3) had slightly higher prevalence of permanent pacemaker implants: eight permanent pacemakers versus two in group 2, and none in group 1 and group 4 (P=0.4).

CONCLUSIONS

Our results suggest that extended donor acceptance criteria may not compromise clinical outcome after heart transplantation. Further follow-up is warranted.

Incidence and clinical predictors of a subsequent nonmelanoma skin cancer in solid organ transplant recipients with a first nonmelanoma skin cancer: a multicenter cohort study

OBJECTIVE

To compare the long-term risk of primary nonmelanoma skin cancer (NMSC) and the risk of subsequent NMSC in kidney and heart transplant recipients.

DESIGN

Partially retrospective cohort study.

SETTING

Two Italian transplantation centers.

PATIENTS

The study included 1934 patients: 1476 renal transplant recipients and 458 heart transplant recipients.

MAIN OUTCOME MEASURES

Cumulative incidences and risk factors of the first and subsequent NMSCs.

RESULTS

Two hundred patients developed a first NMSC after a median follow-up of 6.8 years after transplantation. The 3-year risk of the primary NMSC was 2.1%. Of the 200 patients with a primary NMSC, 91 (45.5%) had a second NMSC after a median follow-up after the first NMSC of 1.4 years (range, 3 months to 10 years). The 3-year risk of a second NMSC was 32.2%, and it was 49 times higher than that in patients with no previous NMSC. In a Cox proportional hazards regression model, age older than 50 years at the time of transplantation and male sex were significantly related to the first NMSC. Occurrence of the subsequent NMSC was not related to any risk factor considered, including sex, age at transplantation, type of transplanted organ, type of immunosuppressive therapy, histologic type of the first NMSC, and time since diagnosis of the first NMSC. Histologic type of the first NMSC strongly predicted the type of the subsequent NMSC.

CONCLUSIONS

Development of a first NMSC confers a high risk of a subsequent NMSC in transplant recipients. Intensive long-term dermatologic follow-up of these patients is advisable.

[Early interventricular septum rupture after systemic thrombolysis in a patient with STEMI]

Intraventricular septal rupture (ISR) is one of the most dreadful complications during AMI, requiring early diagnosis and urgent surgery. However, medical (90%) and surgical (50%) mortality remain elevated. We report a case of a 59 years old patient with infero-posterior AMI complicated by ISR after thrombolysis. Despite early recognition of this complication by trans-thoracic echocardiography at bedside and prompt surgical intervention the patient died on the second post-surgical day.

Incidence and clinical predictors of primary opportunistic deep cutaneous mycoses in solid organ transplant recipients: a multicenter cohort study

BACKGROUND

Primary opportunistic deep cutaneous fungal infections may cause significant morbidity and mortality in solid organ transplant recipients (OTR), but no data exist about their incidence, timing, and clinical predictors in a long-term follow-up.

PATIENTS AND METHODS

A series of 3293 consecutive OTR including 1991 kidney, 929 heart, and 373 liver transplant recipients were enrolled. Patients were regularly followed up since time at transplantation (mean 5.5 yr +/-5.9 SD) and primary opportunistic fungal infections registered. Persons-year at risk (PYs), incidence rates (IR), incidence rate ratios (IRR), and 95% confidence intervals were computed.

RESULTS

Twenty-two cases of deep cutaneous mycoses were detected, (IR 1.2 cases per 1000 PYs) after a mean follow-up time since transplantation of 2.5 yr +/- 2.0 SD (median 1.8 yr). Six patients had subsequent systemic involvement and three patients died of systemic dissemination. A higher risk for mycoses was observed in the first two yr after transplantation, (IRR 35.9, p < 0.0001), in renal transplant recipients (IRR 5.1 p = 0.030), and in patients transplanted after the age of 50 (IRR 11.5 p = 0.020).

CONCLUSIONS

Primary deep cutaneous opportunistic mycoses in OTR occur mainly in the first two yr after transplantation, in renal transplant recipients, and in older patients.

Heart Transplantation in Older Candidates

Over the last few years significant changes have occurred in both donor and recipient profiles for heart transplantation (HTX). New therapeutic approaches to chronic heart failure have created a novel class of patients aged between 61 and 70 years. Although they are older than the conventional upper limit, they may undergo HTX using marginal donors. We retrospectively reviewed the outcomes of suboptimal donor implants in older recipients to examine negative prognostic factor.

METHODS

Among 272 patients who underwent HTX at our institution from May 1994 to December 2005, 75 (26.5%) were 61 to 72 years (group 1). The remaining 197 (73.5%) denoted as group 2 ranged in age from 18 to 60 years. The Sex distribution, cause of end-stage heart failure, preoperative pulmonary hypertension, pre-HTX clinical status and mean follow-up did not show any significant difference between the two groups. However, group 1 patients had their organs retrieved from marginal donors (89%) vs group 2 (29%; P < .005). They were deceased mainly due to cerebrovascular events, (namely, 82% vs 27%, respectively, P < .005).

RESULTS

All analyzed variables-actuarial survival, perioperative mortality, 12-month acute rejection freedom, 100-month chronic rejection freedom, infection freedom, neoplasia freedom, chronic renal failure freedom-did not show any significant difference.

CONCLUSION

Advances in chronic heart failure medical therapy have generated a new class of HTX candidates aged between 61 and 70 years who benefitted from transplantation of organs retrieved from suboptimal donors.

Association of functional gene variants in the regulatory regions of COX-2 gene (PTGS2) with nonmelanoma skin cancer after organ transplantation

BACKGROUND

Overexpression of cyclooxygenase-2 (COX-2), resulting in excessive prostaglandin production, has been observed in human epidermal keratinocytes after ultraviolet B injury, in squamous cell skin carcinoma (SCC), in actinic keratoses, and in the early stages of carcinogenesis in a wide variety of tissues. The dysregulation of COX-2 expression can in part be due to functional changes affecting regulatory elements in the promoter or 3' untranslated region (UTR) of the gene. Two common polymorphisms (-765G-->C, and -1195A-->G) in the promoter region of the COX-2 gene (now PTGS2), and one common polymorphism in the 3' UTR (8473T-->C) have been described, and reported as associated with various malignancies.

OBJECTIVES

To determine if common known polymorphisms in the regulatory region of the COX-2 gene (PTGS2) can be associated with nonmelanoma skin cancer (NMSC) predisposition after organ transplantation, to evaluate if cancer risks are associated with specific COX-2 gene (PTGS2) haplotypes containing these polymorphisms, and to identify possible new genetic polymorphisms in the proximal 5' or 3' regulatory regions of the gene associated with disease.

METHODS

The frequency of the three polymorphisms was determined in 240 Northern Italian transplant recipient patients (107 cases and 133 controls) with polymerase chain reaction-restriction fragment length polymorphism analysis. The proximal 5' and 3' regulatory regions of the gene were screened by heteroduplex analysis.

RESULTS

Stratification by age at transplant and type of tumours [SCC or basal cell carcinoma (BCC)] demonstrated that allele -765C represented a protective factor in BCC cases undergoing transplantation before 50 years of age (CC + CG vs. GG, Fisher exact test P = 0.003). One rare polymorphism, -62C-->G, was detected in the 5' flanking region. The allele frequency of -62G was 0.019, and no difference in genotype between cases and controls was observed. No other variants were found, suggesting that sequence variations in these regions are not likely to contribute to NMSC risk in this population. Haplotype analysis showed that the haplotype containing all major alleles represents a protective factor in patients with SCC undergoing transplantation after 50 years of age [P = 0.009; OR = 0.37 (0.18-0.79)] and that variant -1195A-->G may represent a risk factor in this subgroup of patients [P = 0.01; OR = 4.77 (1.47-16.41)]. Haplotype analysis in patients with BCC revealed that variant -765C might be a protective factor in patients undergoing transplantation before 50 years of age. Variant 8473T-->C, located in the 3' UTR region of the gene, showed no association with NMSC risk after transplantation.

CONCLUSIONS

COX-2 common variants -765G-->C and -1195A-->G appear to be associated with risk of NMSC, although in different ways in the SCC and BCC subgroups, indicating that environmental and genetic risk factors may play different roles in the outcome leading to these two phenotypes.

Glutathione S-transferase and CYP1A1 gene polymorphisms and non-melanoma skin cancer risk in Italian transplanted patients

Solid organ transplant recipients are at higher risk of non-melanoma skin cancer (NMSC), especially basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Genetic alterations in the production of detoxifying enzymes such as glutathione S-transferase (GST) and CYP1A1 may enhance this risk. We investigated the frequency of GST genotypes (GSTM1, GSTM3, GSTT1 and GSTP1) and CYP1A1 in 239 transplant recipients: 107 cases with NMSC and 132 controls free from NMSC matched for type of transplanted organ, duration of transplantation, sex and age. Allele GSTP1*A was associated with a higher risk of NMSC [odds ratio (OR) 1.7 (1.1-2.5); P = 0.017]. Homozygosity for allele GSTP1 Val(105) was lower in cases [OR 0.3 (0.1-0.8); P = 0.012], especially in patients with SCC [OR 0.1 (0.0-0.7); P = 0.012]. A higher risk of BCC was found in patients with GSTM1 null/null [null/null versus A + B, OR 3.1 (1.4-6.8); P = 0.003]. Analysis of allelism and interaction between allelic variants showed significant association between combined GSTM1 and CYP1A1 Val(462) genotypes, where individuals homozygous for the risk allele GSTM1 null and carrying also the allele CYP1A1 Val(462), show a higher risk of developing NMSC [OR 4.5 (1.1-21.4); P = 0.03], especially SCC [OR 6.5 (1.4-34.4); P = 0.01]. GSTP1 polymorphisms are associated with both BCC and SCC risk. GSTM1 polymorphisms seem to be involved in BCC risk, while GSTM1 null/null genotype combined with CYP1A1 allele Val(462) are associated with a higher risk for SCC, indicating that allelism and/or interactions between allelic variants at other loci may also influence the risk of NMSC, particularly SCC.

WITHDRAWN: Prognostic Value of Pharmacologic Stress Echocardiography in Diabetic Patients

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 202-208, . The duplicate article has therefore been withdrawn.

Aβ peptides as one of the crucial volume transmission signals in the trophic units and their interactions with homocysteine. Physiological implications and relevance for Alzheimer’s disease

Amyloid peptides (Abeta) can operate as volume transmission (VT) signals since they are continuously released from cells of the central nervous system and diffuse in the extra-cellular space of the brain. They have both regulatory and trophic functions on cellular networks. In agreement with Abeta regulatory actions on glial-neuronal networks, the present paper reports new findings demonstrating that intrastriatal injections of Abeta peptides reduce striatal tyrosine hydroxylase, increase striatal GFAP immunoreactivities and lower pain threshold in experimental rats. Furthermore, it has been demonstrated that exogenous homocysteine (Hcy) binds Abeta(1-40) favouring its beta-sheet conformation both in vitro and in vivo and hence the formation of beta-fibrils and development of neurotoxicity. Thus, the hypothesis is discussed that Abeta peptides represent crucial VT-signals in the brain and their action is altered by dysmetabolic signals such as high Hcy extra-cellular levels, known to be an important risk factor for Alzheimer's disease.

Prognostic value of supine bicycle exercise stress echocardiography in patients with known or suspected coronary artery disease

AIMS

To assess the prognostic significance of supine bicycle exercise stress echocardiography (ESE) for cardiac events, and the ESE additional role compared to other traditional clinical and echo variables, in patients with proven or suspected coronary artery disease (CAD).

METHODS AND RESULTS

Clinical status and long-term outcome were assessed in 607 patients, for a mean period of 49.9 +/- 12.5 months. ESE was performed for the diagnosis of suspected CAD in 267 patients, and for the risk stratification in 340 patients. At baseline, the mean value of WMSI was 1.22 +/- 0.36, and the mean left ventricular ejection fraction was 58.2 +/- 10.9%. The ESE was positive for ischemia in 210 patients (34.9%), while the ECG was suggestive for ischemia in 157 patients. At peak effort, the mean WMSI was 1.38 +/- 0.46. Low work load was achieved by 158 patients (26.1%). During the follow-up period there were 222 events, including 48 cardiac deaths and 34 acute non-fatal myocardial infarction. By multivariable model, cigarette smoking, peak WMSI, positive ESE for ischemia and low work load were the only independent predictors of cardiac death. The cumulative 5-year mean survival rate according to ESE response was 95.9% in patients with negative ESE, and 81.7% in positive ESE (p < 0.00001).

CONCLUSIONS

In patients with known or suspected CAD able to perform a physical stress, bicycle ESE is able to stratify patients at higher risk of cardiac events. The final report of an ESE performed for prognostic purpose should include both the assessment of induced dyssinergy and the evaluation of indexes of the extent and the severity of myocardial ischemia.

Risk stratification and prognosis of patients with known or suspected coronary artery disease by use of supine bicycle exercise stress echocardiography

BACKGROUND

The aim of this study was to assess the long-term predictive values of supine bicycle exercise stress echocardiography (ESE), and the ESE additional role compared to other traditional clinical and rest echocardiographic variables, in 607 patients with low, intermediate and high pretest risk of cardiac events.

METHODS

Clinical status and long-term outcome were assessed for a mean period of 46 months (range 12-60 months). ESE was performed for the diagnosis of suspected coronary artery disease (CAD) in 267 patients (43.9%), and for risk stratification of known CAD in 340 patients (56.1%). At baseline, the mean value of wall motion score index (WMSI) was 1.22 +/- 0.36, and the mean left ventricular ejection fraction was 58.5 +/- 10.9%.

RESULTS

ESE was positive for ischemia in 210 patients (34.9%), while ECG was suggestive for ischemia in 157 patients (25.8%). During the test only 97 patients (15.9%) experienced angina. At peak effort, the mean WMSI was 1.38 +/- 0.46. A low workload was achieved by 158 patients (26.1%). During the follow-up period there were 222 events, including 82 hard events (36.9%), 48 deaths (21.6%) and 34 acute non-fatal myocardial infarction (15.3%). At stepwise multivariate model, cigarette smoking (p < 0.01), peak WMSI (p < 0.001), ESE positive for ischemia (p < 0.001) and low workload (p < 0.01) were the only independent predictors of cardiac death, while positive ESE, peak WMSI, angina during the test and hypercholesterolemia were the only independent determinants of hard cardiac events. The cumulative 5-year mean survival rate according to ESE response was 95.9% in patients with negative ESE, and 83.7% in patients with positive ESE (log rank 13.6; p < 0.00001).

CONCLUSIONS

ESE yields prognostic information in known or suspected CAD, especially in patients with intermediate pretest risk level. The combined evaluation of clinical variables and other ESE variables, such as peak WMSI and exercise capacity, may further select patients at greatest risk of cardiac death in the overall population.

Malignant melanoma in a candidate for heart transplantation

A superficial spreading melanoma (Breslow thickness 0.4 mm) was diagnosed in a 65-year-old candidate for heart transplantation due to refractory end stage heart failure. After extensive review of the literature (USA and Europe), no clear guidelines about the management of candidates for transplantation with a previous diagnosis of melanoma were found. As this patient had a 5-year probability of survival higher than 95% and heart transplantation was necessary for saving his life, the final decision was to perform the transplantation. Unfortunately, the patient died of heart failure before a suitable heart became available. This case stresses the need for early and continuous dermatological evaluation of all candidates for solid organ transplantation. Clear guidelines for screening of skin cancer before transplantation are needed.

Donor organ preservation in high-risk cardiac transplantation

AIM

To evaluate safety and efficacy of blood cardioplegia in a retrospective selected (but not randomized) donor/recipient population as standard organ preservation technique in high-risk heart transplants (HTX).

MATERIALS AND METHODS

The rationale of different strategies was based on both donor and recipient evaluations. Unstable donors with a long history of well-known risk factors and/or long-distance retrieval were given blood cardioplegia, particularly for HTX candidates in poor preoperative clinical condition. Organ protection was performed by administration of St Thomas II crystalloid cardioplegia in 74 patients (group 1) while 58 others (group 2) received blood cardioplegia.

RESULTS

Groups I versus II shows comparable results for immediate postoperative mortality rates (4% vs 7%, P =.4), high doses of inotropic drug support (48% vs 20%, P =.08), and the need for postoperative mechanical assistance devices (9% vs 4.5%, P =.4). In contrast statistically significant differences were observed for occurrence of acute right ventricular failure (50% vs 5%; P =.004), atrioventricular conduction disturbances (63% vs 10%, P =.003), spontaneous sinus rhythm recovery (18% vs 64% P =.0038) and reperfusion interval (RI) (time between removal of aortic cross-clamp and discontinuation of extracorporeal circulation (ECC)) exceeding 30 minutes (70% vs 21%, P =.0004). Higher peak creatine kinase MB mean value (176 +/- 23 vs 90 +/- 19, P =.06) indicated more severe ischemic damage among G1 patients.

CONCLUSION

This study suggests that high-risk heart transplant candidates benefit from blood cardioplegia, due to the reduced incidence of both right ventricular failure and severe cardiac arrhythmia. Potential limitations to this novel technique may be linked to the higher expenses due to the need for a perfusion technician. Improved myocardial protection can be seen even in a longitudinal study on chronic rejection: this form of allograft protection may preserve the matrix and the endothelium.

Prognostic value of pharmacological stress echocardiography in diabetic patients

Our study was undertaken to assess the prognostic significance of pharmacological stress echocardiography in 325 diabetic patients. Pharmacological stress echocardiography was performed for diagnosis of coronary artery disease in 128 patients, and for risk stratification in 197 patients. Follow-up was 34 months. Cardiac-related death and non-fatal myocardial infarction were considered hard events. During the follow-up period, there were 38 deaths and 23 acute non-fatal myocardial infarctions. By univariate analysis, a pharmacological stress echocardiography positive response for ischaemia indicated an increased risk of cardiovascular death. However, by multivariate analysis, advanced age and peak ejection fraction <40% were the only independent predictors of cardiac death. The same peak ejection fraction (EF) <40%, rest wall motion score index and previous myocardial infarction were independent predictors of hard events. After dividing the population into two subgroups on the basis of EF at rest, only a peak EF <40% and a pharmacological stress echocardiography positive test were powerful independent predictors of cardiovascular mortality.