Speckle tracking echocardiography in plasma cell disorders: The role of advanced imaging in the early diagnosis of AL systemic cardiac amyloidosis

INTRODUCTION

Amyloid light-chain amyloidosis is a rare condition characterized by the abnormal production of immunoglobulin light chain that misshape and form amyloid fibrils. Over time, these amyloid deposits can accumulate slowly, causing dysfunction in organs and tissues. Early identification is crucial to ensure optimal treatment. We aim to identify a better marker of cardiac amyloidosis, using advanced echocardiography, to improve diagnosis and the timing of available treatments.

MATERIALS AND METHODS

108 consecutive hematological patients (32, 30% female and 76, 70% male) with a plasma cell disorder referred to our Cardiological center underwent ECG, first and second-level echocardiography (Speckle Tracking) and complete biochemical profile. The best predictors of ALCA (AUC ≥ 0.8) were included in a further analysis stratified by AL score.

RESULTS

At ROC analysis, the best bio-humoral predictors for the diagnosis of ALCA were Nt-pro-BNP (AUC: 0.97; p < 0.01) and Hs-Tn (AUC: 0.87; p < 0.01). Regarding echocardiography, the best diagnostic predictors were left atrial stiffness (LAS) (AUC: 0.83; p < 0.01) for the left atrium; free wall thickness for the right ventricle (AUC: 0.82; <0.01); left ventricular global longitudinal strain (LVGLS) (AUC: 0.92; p < 0.01) and LVMi (AUC 0.80; p < 0.001) for the left ventricle; and AL-score (AUC 0.83 p < 0.01). In patients with AL-SCORE < 1, LAS (AUC 0.86 vs AUC 0.79), LVGLS (AUC 0.92 vs AUC 0.86) and LV mass (AUC 0.91 vs AUC 0.72) had better diagnostic accuracy than patients with higher AL-score (AL SCORE ≥ 1).

CONCLUSION

Multi-parametric imaging approach with LVGLS and LAS may be helpful for detecting early cardiac involvement in AL amyloidosis.

Serial Changes in Cardiopulmonary Exercise Testing Parameters in Untreated Patients With Transthyretin Cardiac Amyloidosis

BACKGROUND

Transthyretin amyloid cardiomyopathy (ATTR-CM) is associated with a progressive reduction of functional capacity. The progression of cardiopulmonary exercise testing (CPET) parameters over time is still unknown.

METHODS

In this study, 55 patients with ATTR-CM underwent 2 serial cardiologic evaluations and CPETs in a national referral center for cardiac amyloidosis (Careggi University Hospital, Florence).

RESULTS

Forty-three patients (78%) had wild-type ATTR. Median age was 80 years (interquartile range [IQR] 76-83 years), and 50 of the patients (91%) were men. At baseline, median peak oxygen consumption (pVO2) was 15 mL/kg/min (IQR 12-18 mL/kg/min), percentage of predicted pVO2 (%ppVO2) was 71% (IQR 60%-83%) and VE/VCO2 slope was 31 (IQR 26-34). After a median follow-up of 14 months (IQR 13-16 months), pVO2, %ppVO2 and VE/VCO2 slope were significantly worsened (-1.29 mL/kg/min [95% confidence interval (CI): -1.85 to -0.74; P < 0.01], -4.5% [95% CI: -6.9 to -2.02; P < 0.01], and 8.6 [95% CI 6-11; P < 0.01], respectively). Furthermore, exercise time (-39 s, 95% CI: -59 to -19; P < 0.01), exercise tolerance (-0.47 metabolic equivalents, 95% CI: -0.69 to -0.2; P < 0.01), and peak systolic pressure (-10.8 mm Hg, 95% CI: -16.2 to -5.4; P < 0.01) were significantly reduced. The worsening in CPET variables did not correspond with a significant change in echocardiographic parameters.

CONCLUSIONS

Cardiorespiratory response to exercise significantly worsened over a short period of time in patients with ATTR-CM. Serial CPET may be useful to identify early disease progression.

Real-world candidacy to mavacamten in a contemporary hypertrophic obstructive cardiomyopathy population

AIMS

In the EXPLORER-HCM trial, mavacamten reduced left ventricular outflow tract obstruction (LVOTO) and improved functional capacity of symptomatic hypertrophic obstructive cardiomyopathy (HOCM) patients. We sought to define the potential use of mavacamten by comparing real-world HOCM patients with those enrolled in EXPLORER-HCM and assessing their eligibility to treatment.

METHODS AND RESULTS

We collected information on HOCM patients followed up at 25 Italian HCM outpatient clinics and with significant LVOTO (i.e. gradient ≥30 mmHg at rest or ≥50 mmHg after Valsalva manoeuvre or exercise) despite pharmacological or non-pharmacological therapy. Pharmacological or non-pharmacological therapy resolved LVOTO in 1044 (61.2%) of the 1706 HOCM patients under active follow-up, whereas 662 patients (38.8%) had persistent LVOTO. Compared to the EXPLORER-HCM trial population, these real-world HOCM patients were older (62.1 ± 14.3 vs. 58.5 ± 12.2 years, p = 0.02), had a lower body mass index (26.8 ± 5.3 vs. 29.7 ± 4.9 kg/m2 , p < 0.0001) and a more frequent history of atrial fibrillation (21.5% vs. 9.8%, p = 0.027). At echocardiography, they had lower left ventricular ejection fraction (LVEF, 66 ± 7% vs. 74 ± 6%, p < 0.0001), higher left ventricular outflow tract gradients at rest (60 ± 27 vs. 52 ± 29 mmHg, p = 0.003), and larger left atrial volume index (49 ± 16 vs. 40 ± 12 ml/m2 , p < 0.0001). Overall, 324 (48.9%) would have been eligible for enrolment in the EXPLORER-HCM trial and 339 (51.2%) for treatment with mavacamten according to European guidelines.

CONCLUSIONS

Real-world HOCM patients differ from the EXPLORER-HCM population for their older age, lower LVEF and larger atrial volume, potentially reflecting a more advanced stage of the disease. About half of real-world HOCM patients were found eligible to mavacamten.

[Therapeutic approaches in hypertrophic cardiomyopathy: from symptom relief to precision therapy]

Hypertrophic cardiomyopathy is the most common genetic cardiomyopathy. Main complications include the development of arrhythmias and heart failure, and the latter may be triggered by left ventricular outflow tract obstruction. The treatment of left ventricular outflow tract obstruction includes pharmacological therapies (beta-blockers, calcium channel blockers, disopyramide) and septal reduction therapies (alcohol septal ablation, surgical myectomy). Myosin inhibitors represent a new therapeutic opportunity and in recent clinical trials proved effective in symptom relief, improvement of functional capacity and quality of life in patients with obstructive hypertrophic cardiomyopathy. In this narrative review we will summarize the available and under development therapeutic approaches for hypertrophic cardiomyopathy.

The evolving paradigm and current perception of hypertrophic cardiomyopathy: Implications for management

Recent evidence from imaging and genetic screening studies has clearly shown that hypertrophic cardiomyopathy (HCM) is more common than initially perceived, emphasizing the need to reassess its associated clinical and social burden. While clinical and academic efforts have long been focused on stratification of arrhythmic risk and management of intraventricular obstruction, progression of cardiac dysfunction and heart failure-related complications have emerged as most relevant from the epidemiological standpoint, delineating a major unmet need. Furthermore, a broader perspective of our patients' needs has become central in the care of individuals with HCM, addressing issues that are not strictly clinical but equally important to their wellbeing, such as quality of life, athletic participation, lifestyle and reproductive choices and psychological adaptation to a chronic condition often detected at a young age. The appropriate evaluation and objective assessment of disease burden associated with HCM are increasingly relevant not only to management but also to trial design and evaluation of the efficacy of emerging, targeted treatments. In this review, we discuss the evolving perception of HCM prevalence and natural history, as well as recent acquisitions regarding its true, often under-appreciated socio-economic and clinical burden.

Real-World Use and Predictors of Response to Disopyramide in Patients with Obstructive Hypertrophic Cardiomyopathy

Background: Although disopyramide has been widely used to reduce left ventricular outflow obstruction (LVOTO) and to improve symptoms in patients with obstructive hypertrophic cardiomyopathy (oHCM), its use in real world as well as patient characteristics associated with a positive treatment response are still unclear. Methods: From 1980 to 2021, 1527 patients with HCM were evaluated and 372 (23%) had a LVOTO with active follow-up. The efficacy and safety of disopyramide were assessed systematically during 12 months (2-, 6-, and 12-month visits). Responders were patients with a final NYHA = I and a LVOTO < 30 mmHg; incomplete responders were those patients with NYHA > I and a LVOTO < 30 mmHg; and non-responders were symptomatic patients with no change in functional class NYHA and a LVOT gradient > 30 mmHg. Results: Two-hundred-fifty-four (66%) patients were in functional class NYHA I/II and 118 (34%) in NYHA III/IV. A total of 118/372 (32%, 55 ± 16 years) underwent disopyramide therapy. Twenty-eight (24%) patients responded to therapy, 39 (33%) were incomplete responders, and 51 (43%) did not respond. Responder were mainly patients in functional NYHA class I/II (24/28, 86%), whereas incomplete responders and non-responders were more often in functional NYHA class III/IV (50/54 (93%)). An independent predictor of response to disopyramide treatment was the presence of NYHA I/II at the initiation of therapy (HR 1.5 (95% CI 1.1–4.5), p = 0.03). No major life-threatening arrhythmic events or syncope occurred, despite 19 (16%) patients showing reduced QTc from baseline, 19 (16%) having no difference, while 80 (69%) patients had prolonged QTc interval. Thirty-one (26%) patients experienced side effects, in particular, 29 of the anticholinergic type. Conclusions: Disopyramide was underused in oHCM but effective in reducing LVOTO gradients and symptoms in slightly symptomatic patients with less severe disease phenotype with a safe pro-arrhythmic profile.

Speckle tracking echocardiography in plasma cell disorders: the role of advanced imaging in the early diagnosis of AL (Light Chain) cardiac amyloidosis

Introduction

Cardiac involvement is described as the most important prognostic factor in light chain amyloidosis. An early diagnosis is mandatory to customize the follow-up timing and the best treatment. The aim of the study was to identify the role of advanced echocardiography in the diagnosis of amyloid light chain cardiac amyloidosis (ALCA).

Material and methods

Seventy-seven patients were prospectively included in the study: 22 patients with biopsy proven ALCA, 28 patients with multiple mieloma, and 27 with monoclonal gammopathy of undetermined significance. All patients underwent first and second level imaging including Speckle Tracking and complete biochemical profile. Univariate and Multivariate analysis was applied to the best multi-chamber predictor assessed with Receiver Operating Curve analysis. Continuous variables were discretized and compared with different subgroups based on multiparametric imaging assessment using available AL score.

Results

Biochemical indices have been confirmed as the best predictors of ALCA. More specifically, high sensitivity troponin (hsTn) and N-terminal pro brain natriuretic peptide (NT-pro-BNP) showed an AUC of 0.88 and 0.91 respectively. Among left ventricular systolic function parameters, left ventricular longitudinal strain (AUC: 0.92); apical sparing pattern (AUC: 0.75) and relative wall thickness (RWT) (AUC: 0.88) showed the best diagnostic accuracy. Atrial parameters such as left atrial volume index (LAVI) (AUC: 0.74), left atrial stiffness (LAS) (AUC: 0.82) and inter-atrial septum diameter (AUC: 0.75) showed a good diagnostic accuracy in ALCA (Figure 1). LAS and AL score maintained their diagnostic value in the multivariate model analysis (B=2,16; p=0,01 and B= 0,72; p&lt;0.01 respectively). However, only LAS, with a cut off value of 0.65, was able to discriminate ALCA when AL score was not detrimental (P&lt;0.001).

Conclusion

ALCA diagnosis often relies only on the biochemical profile. A comprehensive cardiac evaluation by a multiparametric imaging approach with LAS estimation is mandatory to ensure early diagnosis and a prompt treatment through a multidisciplinary team assessment.

Funding Acknowledgement

Type of funding sources: None.

C74 ESCALATION AND DE–ESCALATION OF MECHANICAL CIRCULATORY SUPPORT IN PATIENT WITH CARDIOGENIC SHOCK DUE TO ELECTRICAL STORM

 

We describe a case of a 63 year–old man with familiar dilated cardiomyopathy, with severe left ventricle dysfunction (EF 20%) and severe mitral regurgitation.A progressive worsening of functional status was detected (peak VO2 11 ml/kg/min, NYHA III) with some episodes of VT interrupted by bicameral ICD,for which the patient was referred to our center and included in the heart transplant (HT) list. In the following months sustained VT with hemodynamic impact were recorded, with consequent worsening in class INTERMACS 2. The patient underwent to endocardial and epicardial VT ablation, complicated with electrical storm with deterioration towards cardiogenic shock (INTERMACS 1), requiring vaso–inotropic drugs,mechanical ventilation and femoro–femoral VA–ECMO.The patient was centralized in our ICCU, where he maintained a adequate MAP, SvcO2 50% and active diuresis but at echocardiography left ventricle appeared dilated with high filling pressure, X–ray and pulmonary ultrasonography showed congestion, lactate value rapidly increased (5 mmol/mol), renal and hepatic function worsened (creat 2 mg/dl, bil 2.8 mg/dl). After multidisciplinary discussion an escalation of mechanical circulatory support (MCS) was performed, changing ECMO configuration: an arterial cannula was positioned in the right axillary artery and venting cannula positioned in the apex of the left ventricle. The hemodynamic and respiratory parameters quickly improved,the right pulmonary catheterization showed good pulmonary resistence,organ perfusion improved and neurological status was intact, therefore the patient was inserted in emergency list for HT. After few days a de–escalation of MCS was performed,removing venous cannula and oxygenator, changing the circuit in para–corporeal left ventricle mid–term support as bridge to transplantation. The patient maintained conscious, in spontaneous breathing,able to perform physiotherapy and spontaneous nutrition. The de–escalation of MCS allowed to reduce potential complications of MCS and achieve the HT intervention in a better general and functional condition. After 36 days the patient underwent HT with positive outcome.

Conclusion

MCS are device that require a continuous re–assessment a re–modulation to ensure in the early stages the optimization of haemodynamic support, perfusion of vital organs and unloading of the Vsx and in the following stages an adjustment to long–term strategies (bridge to recovery, bridge to VAD, bridge to heart transplantation).

Biomarkers Predict In-Hospital Major Adverse Cardiac Events in COVID-19 Patients: A Multicenter International Study

BACKGROUND

The COVID-19 pandemic carries a high burden of morbidity and mortality worldwide. We aimed to identify possible predictors of in-hospital major cardiovascular (CV) events in COVID-19.

METHODS

We retrospectively included patients hospitalized for COVID-19 from 10 centers. Clinical, biochemical, electrocardiographic, and imaging data at admission and medications were collected. Primary endpoint was a composite of in-hospital CV death, acute heart failure (AHF), acute myocarditis, arrhythmias, acute coronary syndromes (ACS), cardiocirculatory arrest, and pulmonary embolism (PE).

RESULTS

Of the 748 patients included, 141(19%) reached the set endpoint: 49 (7%) CV death, 15 (2%) acute myocarditis, 32 (4%) sustained-supraventricular or ventricular arrhythmias, 14 (2%) cardiocirculatory arrest, 8 (1%) ACS, 41 (5%) AHF, and 39 (5%) PE. Patients with CV events had higher age, body temperature, creatinine, high-sensitivity troponin, white blood cells, and platelet counts at admission and were more likely to have systemic hypertension, renal failure (creatinine ≥ 1.25 mg/dL), chronic obstructive pulmonary disease, atrial fibrillation, and cardiomyopathy. On univariate and multivariate analysis, troponin and renal failure were associated with the composite endpoint. Kaplan-Meier analysis showed a clear divergence of in-hospital composite event-free survival stratified according to median troponin value and the presence of renal failure (Log rank p < 0.001).

CONCLUSIONS

Our findings, derived from a multicenter data collection study, suggest the routine use of biomarkers, such as cardiac troponin and serum creatinine, for in-hospital prediction of CV events in patients with COVID-19.

Evidence of superfluidity in a dipolar supersolid from nonclassical rotational inertia

A key manifestation of superfluidity in liquids and gases is a reduction of the moment of inertia under slow rotations. Nonclassical rotational effects have also been considered in the context of the elusive supersolid phase of matter, in which superfluidity coexists with a lattice structure. Here, we show that the recently discovered supersolid phase in dipolar quantum gases features a reduced moment of inertia. Using a dipolar gas of dysprosium atoms, we studied a peculiar rotational oscillation mode in a harmonic potential, the scissors mode, previously investigated in ordinary superfluids. From the measured moment of inertia, we deduced a superfluid fraction that is different from zero and of order of unity, providing direct evidence of the superfluid nature of the dipolar supersolid.

COVID-19 and Acute Coronary Syndromes: Current Data and Future Implications

Coronavirus disease-2019 (COVID-19) pandemic is a global healthcare burden, characterized by high mortality and morbidity rates all over the world. During the outbreak period, the topic of acute coronary syndromes (ACS) has raised several clinical issues, due to the risks of COVID-19 induced myocardial injury and to the uncertainties about the management of these cardiologic emergency conditions, which should be organized optimizing the diagnostic and therapeutic resources and ensuring the maximum protection to healthcare personnel and hospital environment. COVID-19 status should be assessed as soon as possible. Moreover, considerably lower rates of hospitalization for ACS have been reported all over the world, due to patients' hesitations to refer to hospital and to missed diagnosis. As a result, short- and long-term complications of myocardial infarction are expected in the near future; therefore, great efforts of healthcare providers will be required to limit the effects of this issue. In the present review we discuss the impact of COVID-19 pandemic on ACS diagnosis and management, with possible incoming consequences, providing an overview of the available evidence and suggesting future changes in social and clinical approach to ACS.

Influence of cueing on the preparation and execution of untrained and trained complex motor responses

This study investigated the influence of cueing on the performance of untrained and trained complex motor responses. Healthy adults responded to a visual target by performing four sequential movements (complex response) or a single movement (simple response) of their middle finger. A visual cue preceded the target by an interval of 300, 1000, or 2000 ms. In Experiment 1, the complex and simple responses were not previously trained. During the testing session, the complex response pattern varied on a trial-by-trial basis following the indication provided by the visual cue. In Experiment 2, the complex response and the simple response were extensively trained beforehand. During the testing session, the trained complex response pattern was performed in all trials. The latency of the untrained and trained complex responses decreased from the short to the medium and long cue-target intervals. The latency of the complex response was longer than that of the simple response, except in the case of the trained responses and the long cue-target interval. These results suggest that the preparation of untrained complex responses cannot be completed in advance, this being possible, however, for trained complex responses when enough time is available. The duration of the 1st submovement, 1st pause and 2nd submovement of the untrained and the trained complex responses increased from the short to the long cue-target interval, suggesting that there is an increase of online programming of the response possibly related to the degree of certainty about the moment of target appearance.

Molecular analysis of hepatitis B virus (HBV) in an HIV co-infected patient with reactivation of occult HBV infection following discontinuation of lamivudine-including antiretroviral therapy

Background

Occult hepatitis B virus (HBV) infection (OBI) is characterized by HBV DNA persistence even though the pattern of serological markers indicates an otherwise resolved HBV infection. Although OBI is usually clinically silent, immunocompromised patients may experience reactivation of the liver disease.

Case presentation

We report the case of an individual with human immunodeficiency virus (HIV) infection and anti-HBV core antibody positivity, who experienced severe HBV reactivation after discontinuation of lamivudine-including antiretroviral therapy (ART). HBV sequencing analysis showed a hepatitis B surface antigen escape mutant whose presence in an earlier sample excluded reinfection. Molecular sequencing showed some differences between two isolates collected at a 9-year interval, indicating HBV evolution. Resumption of ART containing an emtricitabine/tenofovir combination allowed control of plasma HBV DNA, which fell to undetectable levels.

Conclusion

This case stresses the ability of HBV to evolve continuously, even during occult infection, and the effectiveness of ART in controlling OBI reactivation in HIV-infected individuals.