Myocardial sodium-glucose cotransporter 2 expression and cardiac remodelling in patients with severe aortic stenosis: The BIO-AS study

AIM

Cardiac remodelling plays a major role in the prognosis of patients with aortic stenosis (AS) and could impact the benefits of aortic valve replacement. Our study aimed to evaluate the expression of sodium-glucose cotransporter 2 (SGLT2) gene and protein in patients with severe AS stratified in high gradient (HG) and low flow-low gradient (LF-LG) AS and its association with cardiac functional impairments.

METHODS AND RESULTS

Gene expression and protein levels of main biomarkers of cardiac fibrosis (galectin-3, sST2, serpin-4, procollagen type I amino-terminal peptide, procollagen type I carboxy-terminal propeptide, collagen, transforming growth factor [TGF]-β), inflammation (growth differentiation factor-15, interleukin-6, nuclear factor-κB [NF-κB]), oxidative stress (superoxide dismutase 1 [SOD1] and 2 [SOD2]), and cardiac metabolism (sodium-hydrogen exchanger, peroxisome proliferator-activated receptor [PPAR]-α, PPAR-γ, glucose transporter 1 [GLUT1] and 4 [GLUT4]) were evaluated in blood samples and heart biopsies of 45 patients with AS. Our study showed SGLT2 gene and protein hyper-expression in patients with LF-LG AS, compared to controls and HG AS (p < 0.05). These differences remained significant even after adjusting for age, gender, body mass index, history of diabetes mellitus, arterial hypertension, and coronary artery disease. SGLT2 gene expression was positively correlated with: (i) TGF-β (r = 0.72, p < 0.001) and collagen (r = 0.73, p < 0.001) as markers of fibrosis; (ii) NF-κB (r = 0.36, p < 0.01) and myocardial interleukin-6 (r = 0.68, p < 0.001) as markers of inflammation: (iii) SOD2 (r = -0.38, p < 0.006) as a marker of oxidative stress; (iv) GLUT4 (r = 0.33, p < 0.02) and PPAR-α (r = 0.36, p < 0.01) as markers of cardiac metabolism.

CONCLUSION

In patients with LF-LG AS, SGLT2 gene and protein were hyper-expressed in cardiomyocytes and associated with myocardial fibrosis, inflammation, and oxidative stress.

Fetal aortic isthmus Doppler assessment to predict the adverse perinatal outcomes associated with fetal growth restriction: systematic review and meta-analysis

PURPOSE

Fetal growth restriction (FGR) management and delivery planning is based on a multimodal approach. This meta-analysis aimed to evaluate the prognostic accuracies of the aortic isthmus Doppler to predict adverse perinatal outcomes in singleton pregnancies with FGR.

METHODS

PubMed, EMBASE, the Cochrane Library, ClinicalTrials.gov and Google scholar were searched from inception to May 2021, for studies on the prognostic accuracy of anterograde aortic isthmus flow compared with retrograde aortic isthmus flow in singleton pregnancy with FGR. The meta-analysis was registered on PROSPERO and was assessed according to PRISMA and Newcastle-Ottawa Scale. DerSimonian and Laird's random-effect model was used for relative risks, Freeman-Tukey Double Arcsine for pooled estimates and exact method to stabilize variances and CIs. Heterogeneity was quantified using I2 statistics.

RESULTS

A total of 2933 articles were identified through the electronic search, of which 6 studies (involving 240 women) were included. The quality evaluation of studies revealed an overall acceptable score for study group selection and comparability and substantial heterogeneity. The risk of perinatal death was significantly greater in fetuses with retrograde Aortic Isthmus blood flow, with a RR of 5.17 (p value 0.00001). Similarly, the stillbirth rate was found to have a RR of 5.39 (p value 0.00001). Respiratory distress syndrome had a RR of 2.64 (p value = 0.03) in the group of fetuses with retrograde Aortic Isthmus blood flow.

CONCLUSION

Aortic Isthmus Doppler study may add information for FGR management. However, additional clinical trial are required to assess its applicability in clinical practice.

Mechanical heart valves and oral anticoagulation: a survey of the Italian Society of Cardiac Surgery

In the latest European guidelines for the management of valvular heart disease, mechanical valve prostheses maintain a strategic role, particularly for certain patient subsets and age groups. Despite the high number of devices implanted in clinical practice, particularly in non-European and North American regions, current scientific literature and debate seem to suggest a limited use of mechanical heart valves. The cardiac surgery community seems to be highly interested in biological and transcatheter valve prostheses but less interested in mechanical heart valves, including possible strategies for self-management of anticoagulation therapy. In this respect, the Italian Society of Cardiac Surgery (SICCH), in particular the Italian Group of Research for Outcome in Cardiac Surgery (GIROC), has promoted a survey among its members to stimulate the interest in this topic and express their opinion on this issue that, due to the prevalence of the affected population and the new treatment options for improving patients' quality of life, should be more appraised and debated in the cardiac surgery community. The recorded results, obtained on the answers to 111 questionnaires, seem to divide the specialists into 'pros' and 'contras' on a useful tool for the entire cardiac surgery community. For this reason, SICCH proposes in conclusion to declare its unified and institutional opinion on this topic.

[Choosing a tailored prosthetic valve in cardiac surgery: what is the current role of mechanical prostheses?]

The choice of the mechanical/biological heart valve prosthesis is a topic currently debated in the light of the transcatheter prosthetic models and the results obtained/expected with the new biological valve models. Consequently, it seems that increasingly younger patients would be indicated for an implantation of a biological prosthesis. This is also in order to improve the quality of life of patients who want to avoid oral anticoagulant therapy. On the other hand, the guidelines for the treatment of heart valve disease assign a central role to the use of mechanical valve prostheses, particularly for certain patient subsets and age groups. This means that mechanical prostheses are still widely used worldwide, especially in non-European or North American regions. The cardiac surgery community therefore seems to be very interested in biological prostheses and transcatheter implants and scarcely interested in mechanical prostheses, including possible strategies for self-management of anticoagulant therapy. Recently, the Italian Society of Cardiac Surgery promoted a survey among its members to stimulate interest in the cardiac surgery community. This review article aims to summarize the most current results recorded with the use of mechanical prostheses and possible strategies, especially for the management of oral anticoagulant therapy, which can improve the patient's quality of life.

An Unusual Case of a Double Tricuspid and Mitral Valves Infective Endocarditis Complicated by Multiple Septic Embolisms Secondary to an Atrial Septal Defect: A Case Report and Review of Literature

Multivalvular endocarditis (MVE) is an uncommon infection that mostly involves mitral and aortic valves, and it is related to a higher risk of congestive heart failure and a higher mortality. We described a case of a bilateral MVE and performed a review of the literature on similar clinical cases. We reported an unusual case of a 68-year-old male patient with a tricuspid and mitral infective endocarditis due to a methicillin-resistant Staphylococcus aureus complicated by multiple right- and left-sided septic embolization (lungs, brain, spleen, L2-L3 vertebral bones) due to an unknown atrial septal defect identified and repaired during cardiac surgery. Despite the severity of the clinical case, the patient experienced a good clinical outcome also thanks to a multidisciplinary approach. We identified 21 case reports describing bilateral MVE. A multidisciplinary approach is essential in the management of valve diseases to improve the prognosis of patients, especially in bilateral MVE.

A Mouse Model of Dilated Cardiomyopathy Produced by Isoproterenol Acute Exposure Followed by 5-Fluorouracil Administration

Appropriate dilated cardiomyopathy (DCM) animal models are highly desirable considering the pathophysiological and clinical heterogeneity of DCM. Genetically modified mice are the most widely and intensively utilized research animals for DCM. However, to translate discoveries from basic science into new and personalized medical applications, research in non-genetically based DCM models remains a key issue. Here, we characterized a mouse model of non-ischemic DCM induced by a stepwise pharmacologic regime of Isoproterenol (ISO) high dose bolus followed by a low dose systemic injection of the chemotherapy agent, 5-Fluorouracil (5-FU). C57BL/6J mice were injected with ISO and, 3 days after, were randomly assigned to saline or 5-FU. Echocardiography and a strain analysis show that ISO + 5FU in mice induces progressive left ventricular (LV) dilation and reduced systolic function, along with diastolic dysfunction and a persistent global cardiac contractility depression through 56 days. While mice treated with ISO alone recover anatomically and functionally, ISO + 5-FU causes persistent cardiomyocyte death, ensuing in cardiomyocyte hypertrophy through 56 days. ISO + 5-FU-dependent damage was accompanied by significant myocardial disarray and fibrosis along with exaggerated oxidative stress, tissue inflammation and premature cell senescence accumulation. In conclusions, a combination of ISO + 5FU produces anatomical, histological and functional cardiac alterations typical of DCM, representing a widely available, affordable, and reproducible mouse model of this cardiomyopathy.

Cellular and Molecular Mechanisms Underlying Tricuspid Valve Development and Disease

Tricuspid valve (TV) disease is highly prevalent in the general population. For ages considered "the forgotten valve" because of the predominant interest in left-side valve disease, the TV has now received significant attention in recent years, with significant improvement both in diagnosis and in management of tricuspid disease. TV is characterized by complex anatomy, physiology, and pathophysiology, in which the right ventricle plays a fundamental role. Comprehensive knowledge of molecular and cellular mechanisms underlying TV development, TV disease, and tricuspid regurgitation-related right-ventricle cardiomyopathy is necessary to enhance TV disease understanding to improve the ability to risk stratify TR patients, while also predicting valve dysfunction and/or response to tricuspid regurgitation treatment. Scientific efforts are still needed to eventually decipher the complete picture describing the etiopathogenesis of TV and TV-associated cardiomyopathy, and future advances to this aim may be achieved by combining emerging diagnostic imaging modalities with molecular and cellular studies. Overall, basic science studies could help to streamline a new coherent hypothesis underlying both the development of TV during embryogenesis and TV-associated disease and its complications in adult life, providing the conceptual basis for the ultimate and innovative field of valve repair and regeneration using tissue-engineered heart valves.

The Novel Role of Noncoding RNAs in Modulating Platelet Function: Implications in Activation and Aggregation

It is currently believed that plaque complication, with the consequent superimposed thrombosis, is a key factor in the clinical occurrence of acute coronary syndromes (ACSs). Platelets are major players in this process. Despite the considerable progress made by the new antithrombotic strategies (P2Y12 receptor inhibitors, new oral anticoagulants, thrombin direct inhibitors, etc.) in terms of a reduction in major cardiovascular events, a significant number of patients with previous ACSs treated with these drugs continue to experience events, indicating that the mechanisms of platelet remain largely unknown. In the last decade, our knowledge of platelet pathophysiology has improved. It has been reported that, in response to physiological and pathological stimuli, platelet activation is accompanied by de novo protein synthesis, through a rapid and particularly well-regulated translation of resident mRNAs of megakaryocytic derivation. Although the platelets are anucleate, they indeed contain an important fraction of mRNAs that can be quickly used for protein synthesis following their activation. A better understanding of the pathophysiology of platelet activation and the interaction with the main cellular components of the vascular wall will open up new perspectives in the treatment of the majority of thrombotic disorders, such as ACSs, stroke, and peripheral artery diseases before and after the acute event. In the present review, we will discuss the novel role of noncoding RNAs in modulating platelet function, highlighting the possible implications in activation and aggregation.

Current Views on Infective Endocarditis: Changing Epidemiology, Improving Diagnostic Tools and Centering the Patient for Up-to-Date Management

Infective endocarditis (IE) is a rare but potentially life-threatening disease, sometimes with longstanding sequels among surviving patients. The population at high risk of IE is represented by patients with underlying structural heart disease and/or intravascular prosthetic material. Taking into account the increasing number of intravascular and intracardiac procedures associated with device implantation, the number of patients at risk is growing too. If bacteremia develops, infected vegetation on the native/prosthetic valve or any intracardiac/intravascular device may occur as the final result of invading microorganisms/host immune system interaction. In the case of IE suspicion, all efforts must be focused on the diagnosis as IE can spread to almost any organ in the body. Unfortunately, the diagnosis of IE might be difficult and require a combination of clinical examination, microbiological assessment and echocardiographic evaluation. There is a need of novel microbiological and imaging techniques, especially in cases of blood culture-negative. In the last few years, the management of IE has changed. A multidisciplinary care team, including experts in infectious diseases, cardiology and cardiac surgery, namely, the Endocarditis Team, is highly recommended by the current guidelines.

Streptozotocin-Induced Type 1 and 2 Diabetes Mellitus Mouse Models Show Different Functional, Cellular and Molecular Patterns of Diabetic Cardiomyopathy

The main cause of morbidity and mortality in diabetes mellitus (DM) is cardiovascular complications. Diabetic cardiomyopathy (DCM) remains incompletely understood. Animal models have been crucial in exploring DCM pathophysiology while identifying potential therapeutic targets. Streptozotocin (STZ) has been widely used to produce experimental models of both type 1 and type 2 DM (T1DM and T2DM). Here, we compared these two models for their effects on cardiac structure, function and transcriptome. Different doses of STZ and diet chows were used to generate T1DM and T2DM in C57BL/6J mice. Normal euglycemic and nonobese sex- and age-matched mice served as controls (CTRL). Immunohistochemistry, RT-PCR and RNA-seq were employed to compare hearts from the three animal groups. STZ-induced T1DM and T2DM affected left ventricular function and myocardial performance differently. T1DM displayed exaggerated apoptotic cardiomyocyte (CM) death and reactive hypertrophy and fibrosis, along with increased cardiac oxidative stress, CM DNA damage and senescence, when compared to T2DM in mice. T1DM and T2DM affected the whole cardiac transcriptome differently. In conclusion, the STZ-induced T1DM and T2DM mouse models showed significant differences in cardiac remodeling, function and the whole transcriptome. These differences could be of key relevance when choosing an animal model to study specific features of DCM.

P371 1 YEAR OUTCOME OF BICARBON AORTIC MECHANICAL VALVE IN LOW–INR REGIMEN: RESULTS FROM SURE–AVR REGISTRY

Background

The drawback of using mechanical valve is lifelong anticoagulation use, and close monitoring is required to prevent postoperative complications, including thromboembolism and anticoagulation–related bleeding. Moderate anticoagulation after mechanical heart valve replacement has been proposed to reduce these risks. The present study aimed to evaluate the safety and feasibility of reduced oral anticoagulation after Bicarbon aortic mechanical valve replacement.

Methods

SURE–AVR is a propsective, multinational registry of patients undergoing aortic valve replacement. Between July 2018 and October 2020, among subjects undergoing AVR with Bicarbon valve in the SURE–AVR registry, 108 were assigned at discharge to low–INr regimen (international normalized ratio 1.5–2.5). Mean INr at discharge was 1.8+/–0.5 and 2.2+/–0.4 at 1 year. in–hospital and post–discharge outcomes up to 1 years were collected. The mean age was 55.5 +/–10.6 years old (range 25–82). Concomitant procedures included coronary artery bypass grafting (14.6%), mitral valve procedure (3.7%) and myectomy (1.9%). The follow–up duration averaged 1 year (361.8 +/– 258 days).

Results

No bleeding events were reported in the late follow up. The low–INR regimen did not affect the thromboembolism rates, since no stroke or transient ischemic attack were reported post–operatively at each time point. No in–hospital or late deaths were reported among the 108 subjects analyzed. In the early period (&lt;30 days), three reinterventions occurred: two because of postoperative bleeding requiring thoracotomy and one due to pericardial effusion. In the late postoperative period two reinterventions with device explant occurred (one for non–structural valve dysfunction and one for endocarditis (1.2%).

Conclusion

The results of the SURE–AVr Registry demonstrated that the proposed Lower–INR Target is safe and feasible after Bicarbon aortic mechanical valve replacement. The low–intensity anticoagulation strategy is associated with a low risk of hemorrhagic events without any increase of thromboembolic complications.

Diabetes-Induced Cellular Senescence and Senescence-Associated Secretory Phenotype Impair Cardiac Regeneration and Function Independently of Age

Diabetes mellitus (DM) affects the biology of multipotent cardiac stem/progenitor cells (CSCs) and adult myocardial regeneration. We assessed the hypothesis that senescence and senescence-associated secretory phenotype (SASP) are main mechanisms of cardiac degenerative defect in DM. Accordingly, we tested whether ablation of senescent CSCs would rescue the cardiac regenerative/reparative defect imposed by DM. We obtained cardiac tissue from nonaged (50- to 64-year-old) patients with type 2 diabetes mellitus (T2DM) and without DM (NDM) and postinfarct cardiomyopathy undergoing cardiac surgery. A higher reactive oxygen species production in T2DM was associated with an increased number of senescent/dysfunctional T2DM-human CSCs (hCSCs) with reduced proliferation, clonogenesis/spherogenesis, and myogenic differentiation versus NDM-hCSCs in vitro. T2DM-hCSCs showed a defined pathologic SASP. A combination of two senolytics, dasatinib (D) and quercetin (Q), cleared senescent T2DM-hCSCs in vitro, restoring their expansion and myogenic differentiation capacities. In a T2DM model in young mice, diabetic status per se (independently of ischemia and age) caused CSC senescence coupled with myocardial pathologic remodeling and cardiac dysfunction. D + Q treatment efficiently eliminated senescent cells, rescuing CSC function, which resulted in functional myocardial repair/regeneration, improving cardiac function in murine DM. In conclusion, DM hampers CSC biology, inhibiting CSCs' regenerative potential through the induction of cellular senescence and SASP independently from aging. Senolytics clear senescence, abrogating the SASP and restoring a fully proliferative/differentiation-competent hCSC pool in T2DM with normalization of cardiac function.

Effects of Sodium-Glucose Transporter 2 Inhibitors (SGLT2-I) in Patients With Ischemic Heart Disease (IHD) Treated by Coronary Artery Bypass Grafting via MiECC: Inflammatory Burden, and Clinical Outcomes at 5 Years of Follow-Up

Introduction: Minimally invasive extracorporeal circulation (MiECC) reduced inflammatory burden, leading to best clinical outcomes in patients treated with coronary artery bypass grafting (CABG). Despite this, the patients with type 2 diabetes mellitus (T2DM) vs those without T2DM (non-T2DM) have a worse prognosis, caused by over-inflammation and modulated by sodium-glucose transporter 2 receptors. However, we evaluated the inflammatory burden and clinical outcomes in non-T2DM vs T2DM patients under sodium-glucose transporter 2 inhibitors (SGLT2-I users) vs non-SGLT2-I users at 5 years of follow-up post-CABG via MiECC. Materials and methods: In a multicenter study, we screened consecutive patients with indications to receive CABG. The study endpoints were the inflammatory burden (circulating serum levels of tumor necrosis factor-alpha (TNF-α), interleukin 1 and 6 (IL-1 and IL-6), C-reactive protein (CRP), and leucocytes count) and the clinical outcomes at follow-up of 5 years in non-T2DM vs SGLT2-I users, in non-T2DM vs non-SGLT2-I users, and SGLT2-I users vs non-SGLT2-I users. Results: At baseline, and at one year and 5 years of follow-up, the non-T2DM vs SGLT2-I users, non-T2DM vs non-SGLT2-I users, and SGLT2-I users vs non-SGLT2-I users had the lowest values of IL-1, IL-6, and TNF-α (p < 0.05). At one year of follow-up, SGLT2-I users vs non-T2DM and non-SGLT2-I users vs non-T2DM users had a higher rate of all deaths, cardiac deaths, re-myocardial infarction, repeat revascularization, and stroke, and of the composite endpoint (p < 0.05). In a multivariate Cox regression analysis, the composite endpoint was predicted by IL-1 [2.068 (1.367-3.129)], TNF-α [1.989 (1.081-2.998)], and SGLT2-I [0.504 (0.078-0.861)]. Conclusion: In T2DM patients, the SGLT2-I significantly reduced the inflammatory burden and ameliorated clinical outcomes at 5 years of follow-up post-CABG via MiECC.

Metformin Therapy Effects on the Expression of Sodium-Glucose Cotransporter 2, Leptin, and SIRT6 Levels in Pericoronary Fat Excised from Pre-Diabetic Patients with Acute Myocardial Infarction

BACKGROUND AND PURPOSE

pericoronary fat over-inflammation might lead to the development and destabilization of coronary plaque in patients with pre-diabetes (PDM). Notably, pericoronary fat could over-express the sodium-glucose cotransporter 2 (SGLT2) and leptin, along with decreased sirtuin 6 (SIRT6) expression in PDM vs. normoglycemic (NG) patients undergoing coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI). However, in the current study, we evaluated inflammatory markers, SGLT2, SIRT6, and leptin levels in pericoronary fat and, subsequently, 12-month prognosis comparing PDM to NG subjected to CABG for AMI. In addition, we evaluated in PDM patients the effects of metformin therapy on SIRT6 expression, leptin, and SGLT2 levels, and assessed its beneficial effect on nitrotyrosine and inflammatory cytokine levels.

METHODS

we studied AMI patients referred for CABG, divided into PDM and NG-patients. PDM patients were divided into never-metformin users and metformin users. Finally, we evaluated major adverse cardiac events (MACE) at a 12-month follow-up.

RESULTS

the MACE was 9.1% in all PDM and 3% in NG patients (p < 0.05). Metformin users presented a significantly lower MACE rate in PDM than never-metformin users (p < 0.05). PDM showed higher inflammatory cytokines, 3-nitrotyrosine levels, SGLT2, and leptin content, and decreased SIRT6 protein levels in pericoronary fat compared to NG-patients (p < 0.05). PDM never-metformin-users showed higher SGLT2 and leptin levels in pericoronary fat than current-metformin-users (p < 0.05).

CONCLUSIONS

metformin therapy might ameliorate cardiovascular outcomes by reducing inflammatory parameters, SGLT2, and leptin levels, and finally improving SIRT6 levels in AMI-PDM patients treated with CABG.

Atrial myxomas arise from multipotent cardiac stem cells

Aims

Cardiac myxomas usually develop in the atria and consist of an acid-mucopolysaccharide-rich myxoid matrix with polygonal stromal cells scattered throughout. These human benign tumours are a valuable research model because of the rarity of cardiac tumours, their clinical presentation and uncertain origin. Here, we assessed whether multipotent cardiac stem/progenitor cells (CSCs) give rise to atrial myxoma tissue.

Methods and results

Twenty-three myxomas were collected and analysed for the presence of multipotent CSCs. We detected myxoma cells positive for c-kit (c-kit^pos) but very rare Isl-1 positive cells. Most of the c-kit^pos cells were blood lineage-committed CD45^pos/CD31^pos cells. However, c-kit^pos/CD45^neg/CD31^neg cardiac myxoma cells expressed stemness and cardiac progenitor cell transcription factors. Approximately ≤10% of the c-kit^pos/CD45^neg/CD31^neg myxoma cells also expressed calretinin, a characteristic of myxoma stromal cells. In vitro, the c-kit^pos/CD45^neg/CD31^neg myxoma cells secrete chondroitin-6-sulfate and hyaluronic acid, which are the main components of gelatinous myxoma matrix in vivo. In vitro, c-kit^pos/CD45^neg/CD31^neg myxoma cells have stem cell properties being clonogenic, self-renewing, and sphere forming while exhibiting an abortive cardiac differentiation potential. Myxoma-derived CSCs possess a mRNA and microRNA transcriptome overall similar to normal myocardium-derived c-kit^pos/CD45^neg/CD31^negCSCs , yet showing a relatively small and relevant fraction of dysregulated mRNA/miRNAs (miR-126-3p and miR-335-5p, in particular). Importantly, myxoma-derived CSCs but not normal myocardium-derived CSCs, seed human myxoma tumours in xenograft’s in immunodeficient NOD/SCID mice.

Conclusion

Myxoma-derived c-kit^pos/CD45^neg/CD31^neg CSCs fulfill the criteria expected of atrial myxoma-initiating stem cells. The transcriptome of these cells indicates that they belong to or are derived from the same lineage as the atrial multipotent c-kit^pos/CD45^neg/CD31^neg CSCs. Taken together the data presented here suggest that human myxomas could be the first-described CSC-related human heart disease.

Identification of risk-factors for the development of depressive symptoms in perinatal period: A longitudinal study

Introduction

Perinatal depression is a severe and disabling condition, which affects negatively both mothers’ and children’s mental health and well-being. About 12.8% of pregnant women report depressive symptoms in the perinatal period.

Objectives

The aims of the present study are to: 1) identify factors (socio-demographic and clinical) associated with an increased risk of developing PD; 2) promote a screening program on PD.

Methods

All pregnant women were assessed at each trimester of pregnancy, three days after the childbirth and after 1, 3, 6 and 12 months, with the Edinburgh Postpartum Depression Scale (EPDS). Women scoring ≥10 on the EPDS were invited to receive a full psychiatric evaluation to confirm the diagnosis.

Results

420 women were recruited. 52.9%, 27.6% and 31.6% of participants presented an EPDS≥ 10 score at The I, II and III trimester of pregnancy, respectively. The percentage of patients with and EPS score ≥19 is 16.6%, 6.8%, 6.8%, 11.3% and 7.8% in 3 days following the childbirth and after 3, 6, 9 and 12 months, respectively. Higher EPDS scores are predicted by the presence of anxiety symptoms before pregnancy and of depressive and anxiety symptoms in previous pregnancies (p<0.05). Women with family conflicts and with anxiety symptoms in the partner are more likely to report higher EPDS scores (p<0.001).

Conclusions

Our results confirm that perinatal depression is a highly prevalent condition. An early identification of depressive symptoms during this period is crucial in order to reduce the long-term negative impact on the mothers, the newborn and other family members.

Disclosure

No significant relationships.

Microbiota thrombus colonization may influence athero-thrombosis in hyperglycemic patients with ST segment elevation myocardialinfarction (STEMI). Marianella study

OBJECTIVES

We examined the association of the coronary thrombus microbiota and relative metabolites with major adverse cardiovascular events (MACE) in hyperglycemic patients with ST segment elevation myocardial infarction (STEMI).

BACKGROUND

Hyperglycemia during STEMI may affect both development and progression of coronary thrombus via gut and thrombus microbiota modifications.

METHODS

We undertook an observational cohort study of 146 first STEMI patients treated with primary percutaneous coronary intervention (PPCI) and thrombus-aspiration (TA). Patients were clustered, based on admission blood glucose levels, in hyperglycemic (≥140 mg/dl) and normoglycemic (<140 mg/dl). We analyzed gut and thrombus microbiota in all patients. Moreover, we assessed TMAO, CD40L and von Willebrand Factor (vWF) in coronary thrombi. Cox regressions were used for the association between Prevotellaspp. and TMAO terziles and MACE. MACE endpoint at 1 year included death, re-infarction, unstable angina.

RESULTS

In fecal and thrombus samples, we observed a significantly different prevalence of both Prevotellaspp. and Alistipesspp. between patients with hyperglycemia (n = 56) and those with normal glucose levels (n = 90). The abundance of Prevotella increased in hyperglycemic vs normoglycemic patients whereas the contrary was observed for Alistipes. Interestingly, in coronary thrombus, the content of Prevotella was associated with admission blood glucose levels (p < 0.01), thrombus dimensions (p < 0.01), TMAO, CDL40 (p < 0.01) and vWF (p < 0.01) coronary thrombus contents. Multivariate Cox-analysis disclosed a reduced survival in patients with high levels of Prevotella and TMAO in coronary thrombus as compared to patients with low levels of Prevotella and TMAO, after 1-year follow up.

CONCLUSIONS

Hyperglycemia during STEMI may increase coronary thrombus burden via gut and thrombus microbiota dysbiosis characterized by an increase of Prevotella and TMAO content in thrombi.

CLINICAL TRIAL REGISTRATION

NCT03439592. September 30, 2016. Ethic Committee Vanvitelli University: 268/2016.

Cardiac surgery practice during the COVID-19 outbreak: a regionwide survey

Background

Health systems worldwide have been overburdened by the “COVID-19 surge”. Consequently, strategies to remodulate non-COVID medical and surgical care had to be developed. Knowledge of the impact of COVID surge on cardiac surgery practice is mainstem. Present study aims to evaluate the regional practice pattern during lockdown in Campania.

Methods

A multicenter regional observational 26-question survey was conducted, including all adult cardiac surgery units in Campania, Italy, to assess how surgical practice has changed during COVID-19 national lockdown.

Results

All centers adopted specific protocols for screening patients and personnel. A significant reduction in the number of dedicated intensive care unit (ICU) beds (–30.0%±38.1%, range: 0–100%) and cardiac operating rooms (–22.2%±26.4%, range: 0–50%) along with personnel relocation to other departments was disclosed (anesthesiologists –5.8%±11.1%, range: 0–33.3%; perfusionists –5.6%±16.7%, range: 0–50%; nurses –4.8%±13.2%, range: 0–40%; cardiologists –3.2%±9.5%, range: 0–28.6%). Cardiac surgeons were never reallocated to other services. Globally, we witnessed dramatically lower adult cardiac surgery case volumes (335 vs. 667 procedures, P<0.001), as institutions and surgeons followed guidelines to curtail non-urgent operations.

Conclusions

This regional survey demonstrates major changes in practice as a response to the COVID-19 pandemic. In this respect, this experience might lead to the development of permanent systems-based plans for future pandemic and may effectively help policy decision making when prioritizing healthcare resource reallocation during and after the pandemic.

Safety of low intensity oral anticoagulant therapy in patients with bileaflet mechanical aortic valve prosthesis: A propensity weighted study

BACKGROUND

Scarce data are available on the long-term outcomes of different regimens of oral anticoagulation in an all comer population of patients undergoing aortic valve replacement with a bileaflet mechanical heart valve.

METHODS

Outcomes of 88 patients discharged with a target INR of 2.0 (LOW-INR) were compared to 147 contemporary patients who have been recommended a target INR of 2.5 (CONV). Primary outcome was the composite of any thromboembolic or haemorrhagic events. Secondary outcomes were the individual components of the primary outcome, cardiovascular mortality and stroke. To reduce selection bias, a propensity weighted analysis was performed.

RESULTS

After inverse probability of treatment weighting, the primary endpoint occurred in 0.7% of patient in the LOW-INR group and in 7.0% in the CONV group (p = .0255). Linearized event rate were significantly lower in the LOW-INR group (primary endpoint: rate difference - 12.0 per 1000 patient/years, p = .0052; haemorrhage: -5.8 per 1000 patient/years, p = .0330; neurological events: -7.6 per 1000 patient/years, p = .0140). Conventional target INR was associated with an increased hazard of the composite endpoint (HR 11.193, 95% CI 1.424-88.003, p = .0217).

CONCLUSIONS

Lowering the intensity of oral anticoagulation resulted in a relevant clinical benefit of reduced rates of haemorrhagic and neurological adverse events in the mid-term follow-up. This report confirms the safety profile of the low INR regimen in an all comer population undergoing aortic valve replacement with an Abbott mechanical valve.

Unravelling the Biology of Adult Cardiac Stem Cell-Derived Exosomes to Foster Endogenous Cardiac Regeneration and Repair

Cardiac remuscularization has been the stated goal of the field of regenerative cardiology since its inception. Along with the refreshment of lost and dysfunctional cardiac muscle cells, the field of cell therapy has expanded in scope encompassing also the potential of the injected cells as cardioprotective and cardio-reparative agents for cardiovascular diseases. The latter has been the result of the findings that cell therapies so far tested in clinical trials exert their beneficial effects through paracrine mechanisms acting on the endogenous myocardial reparative/regenerative potential. The endogenous regenerative potential of the adult heart is still highly debated. While it has been widely accepted that adult cardiomyocytes (CMs) are renewed throughout life either in response to wear and tear and after injury, the rate and origin of this phenomenon are yet to be clarified. The adult heart harbors resident cardiac/stem progenitor cells (CSCs/CPCs), whose discovery and characterization were initially sufficient to explain CM renewal in response to physiological and pathological stresses, when also considering that adult CMs are terminally differentiated cells. The role of CSCs in CM formation in the adult heart has been however questioned by some recent genetic fate map studies, which have been proved to have serious limitations. Nevertheless, uncontested evidence shows that clonal CSCs are effective transplantable regenerative agents either for their direct myogenic differentiation and for their paracrine effects in the allogeneic setting. In particular, the paracrine potential of CSCs has been the focus of the recent investigation, whereby CSC-derived exosomes appear to harbor relevant regenerative and reparative signals underlying the beneficial effects of CSC transplantation. This review focuses on recent advances in our knowledge about the biological role of exosomes in heart tissue homeostasis and repair with the idea to use them as tools for new therapeutic biotechnologies for "cell-less" effective cardiac regeneration approaches.

Topical rifampicin for prevention of deep sternal wound infections in patients undergoing coronary artery bypass grafting

Deep sternal wound infections (DSWI), although an infrequent complication, significantly impair postoperative outcomes after coronary artery bypass grafting (CABG) surgery. Among several preventive strategies, topical antibiotic therapy immediately before sternal closure has been strongly advocated. In this retrospective analysis, the incidence of DSWI in 517 patients undergoing isolated CABG and receiving rifampicin irrigation of mediastinum, sternum and suprasternal tissues was compared to an historical consecutive cohort of 448 patients. To account for the inherent selection bias, a 1:1 propensity matched analysis was performed. Patients receiving topical rifampicin experienced significantly less occurrence of postoperative DSWI (0.2% vs 2.5%, p = 0.0016 in the unmatched analysis; 0.3% vs 2.1%, p = 0.0391 in the matched analysis). Intensive care unit stay, hospital stay, and operative mortality were similar between groups. This study shows that topical rifampicin in combination with commonly prescribed preventative strategies significantly reduces the incidence of DSWI to less than 0.3% in unselected patients undergoing a full median sternotomy for CABG. Further studies, including a larger number of patients and with a randomization design, would establish the potential preventative role of topical rifampicin in reducing the occurrence of DSWI.

The Impact of Anesthetic Regimen on Outcomes in Adult Cardiac Surgery: A Narrative Review

Despite improvements in surgical techniques and perioperative care, cardiac surgery still is burdened by relatively high mortality and frequent major postoperative complications, including myocardial dysfunction, pulmonary complications, neurologic injury, and acute kidney injury. Although the surgeon's skills and volume and patient- and procedure-related risk factors play a major role in the success of cardiac surgery, there is growing evidence that also optimizing perioperative care may improve outcomes significantly. The present review focuses on the aspects of perioperative care that are strictly related to the anesthesia regimen, with special reference to volatile anesthetics and neuraxial anesthesia, whose effect on outcome in adult cardiac surgery has been investigated extensively.

Pericoronary fat inflammation and Major Adverse Cardiac Events (MACE) in prediabetic patients with acute myocardial infarction: effects of metformin

Background/objectives

Pericoronary adipose tissue inflammation might lead to the development and destabilization of coronary plaques in prediabetic patients. Here, we evaluated inflammation and leptin to adiponectin ratio in pericoronary fat from patients subjected to coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI). Furthermore, we compared the 12-month prognosis of prediabetic patients compared to normoglycemic patients (NG). Finally, the effect of metformin therapy on pericoronary fat inflammation and 12-months prognosis in AMI-prediabetic patients was also evaluated.

Methods

An observational prospective study was conducted on patients with first AMI referred for CABG. Participants were divided in prediabetic and NG-patients. Prediabetic patients were divided in two groups; never-metformin-users and current-metformin-users receiving metformin therapy for almost 6 months before CABG. During the by-pass procedure on epicardial coronary portion, the pericoronary fat was removed from the surrounding stenosis area. The primary endpoints were the assessments of Major-Adverse-Cardiac-Events (MACE) at 12-month follow-up. Moreover, inflammatory tone was evaluated by measuring pericoronary fat levels of tumor necrosis factor-α (TNF-α), sirtuin 6 (SIRT6), and leptin to adiponectin ratio. Finally, inflammatory tone was correlated to the MACE during the 12-months follow-up.

Results

The MACE was 9.1% in all prediabetic patients and 3% in NG-patients. In prediabetic patients, current-metformin-users presented a significantly lower rate of MACE compared to prediabetic patients never-metformin-users. In addition, prediabetic patients showed higher inflammatory tone and leptin to adiponectin ratio in pericoronary fat compared to NG-patients (P < 0.001). Prediabetic never-metformin-users showed higher inflammatory tone and leptin to adiponectin ratio in pericoronary fat compared to current-metformin-users (P < 0.001). Remarkably, inflammatory tone and leptin to adiponectin ratio was significantly related to the MACE during the 12-months follow-up.

Conclusion

Prediabetes increase inflammatory burden in pericoronary adipose tissue. Metformin by reducing inflammatory tone and leptin to adiponectin ratio in pericoronary fat may improve prognosis in prediabetic patients with AMI.

Trial registration Clinical Trial NCT03360981, Retrospectively Registered 7 January 2018

New imaging techniques project the cellular and molecular alterations underlying bicuspid aortic valve development

Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation associated with an increased lifetime risk and a high rate of surgically-relevant valve deterioration and aortic dilatation. Genomic data revealed that different genes are associated with BAV. A dominant genetic factor for the recent past was the basis to the recommendation for a more extensive aortic intervention. However very recent evidence that hemodynamic stressors and alterations of wall shear stress play an important role independent from the genetic trait led to more conservative treatment recommendations. Therefore, there is a current need to improve the ability to risk stratify BAV patients in order to obtain an early detection of valvulopathy and aortopathy while also to predict valve dysfunction and/or aortic disease development. Imaging studies based on new cutting-edge technologies, such us 4-dimensional (4D) flow magnetic resonance imaging (MRI), two-dimensional (2D) or three-dimensional (3D) speckle-tracking imaging (STI) and computation fluid dynamics, combined with studies demonstrating new gene mutations, specific signal pathways alterations, hemodynamic influences, circulating biomarkers modifications, endothelial progenitor cell impairment and immune/inflammatory response, all detected BAV valvulopathy progression and aortic wall abnormality. Overall, the main purpose of this review article is to merge the evidences of imaging and basic science studies in a coherent hypothesis that underlies and thus projects the development of both BAV during embryogenesis and BAV-associated aortopathy and its complications in the adult life, with the final goal to identifying aneurysm formation/rupture susceptibility to improve diagnosis and management of patients with BAV-related aortopathy.

Role of c-Kit in Myocardial Regeneration and Aging

c-Kit, a type III receptor tyrosine kinase (RTK), is involved in multiple intracellular signaling whereby it is mainly considered a stem cell factor receptor, which participates in vital functions of the mammalian body, including the human. Furthermore, c-kit is a necessary yet not sufficient marker to detect and isolate several types of tissue-specific adult stem cells. Accordingly, c-kit was initially used as a marker to identify and enrich for adult cardiac stem/progenitor cells (CSCs) that were proven to be clonogenic, self-renewing and multipotent, being able to differentiate into cardiomyocytes, endothelial cells and smooth muscle cells in vitro as well as in vivo after myocardial injury. Afterwards it was demonstrated that c-kit expression labels a heterogenous cardiac cell population, which is mainly composed by endothelial cells while only a very small fraction represents CSCs. Furthermore, c-kit as a signaling molecule is expressed at different levels in this heterogenous c-kit labeled cardiac cell pool, whereby c-kit low expressers are enriched for CSCs while c-kit high expressers are endothelial and mast cells. This heterogeneity in cell composition and expression levels has been neglected in recent genetic fate map studies focusing on c-kit, which have claimed that c-kit identifies cells with robust endothelial differentiation potential but with minimal if not negligible myogenic commitment potential. However, modification of c-kit gene for Cre Recombinase expression in these Cre/Lox genetic fate map mouse models produced a detrimental c-kit haploinsufficiency that prevents efficient labeling of true CSCs on one hand while affecting the regenerative potential of these cells on the other. Interestingly, c-kit haploinsufficiency in c-kit-deficient mice causes a worsening myocardial repair after injury and accelerates cardiac aging. Therefore, these studies have further demonstrated that adult c-kit-labeled CSCs are robustly myogenic and that the adult myocardium relies on c-kit expression to regenerate after injury and to counteract aging effects on cardiac structure and function.

Heterogeneity of Adult Cardiac Stem Cells

Cardiac biology and heart regeneration have been intensively investigated and debated in the last 15 years. Nowadays, the well-established and old dogma that the adult heart lacks of any myocyte-regenerative capacity has been firmly overturned by the evidence of cardiomyocyte renewal throughout the mammalian life as part of normal organ cell homeostasis, which is increased in response to injury. Concurrently, reproducible evidences from independent laboratories have convincingly shown that the adult heart possesses a pool of multipotent cardiac stem/progenitor cells (CSCs or CPCs) capable of sustaining cardiomyocyte and vascular tissue refreshment after injury. CSC transplantation in animal models displays an effective regenerative potential and may be helpful to treat chronic heart failure (CHF), obviating at the poor/modest results using non-cardiac cells in clinical trials. Nevertheless, the degree/significance of cardiomyocyte turnover in the adult heart, which is insufficient to regenerate extensive damage from ischemic and non-ischemic origin, remains strongly disputed. Concurrently, different methodologies used to detect CSCs in situ have created the paradox of the adult heart harboring more than seven different cardiac progenitor populations. The latter was likely secondary to the intrinsic heterogeneity of any regenerative cell agent in an adult tissue but also to the confusion created by the heterogeneity of the cell population identified by a single cell marker used to detect the CSCs in situ. On the other hand, some recent studies using genetic fate mapping strategies claimed that CSCs are an irrelevant endogenous source of new cardiomyocytes in the adult. On the basis of these contradictory findings, here we critically reviewed the available data on adult CSC biology and their role in myocardial cell homeostasis and repair.

miRNA Regulation of the Hyperproliferative Phenotype of Vascular Smooth Muscle Cells in Diabetes

Harnessing the mechanisms underlying the exacerbated vascular remodeling in diabetes mellitus (DM) is pivotal to prevent the high toll of vascular diseases in patients with DM. miRNA regulates vascular smooth muscle cell (VSMC) phenotypic switch. However, miRNA modulation of the detrimental diabetic VSMC phenotype is underexplored. Streptozotocin-induced type 1 DM (T1DM) Wistar rats and type 2 DM (T2DM) Zucker rats underwent right carotid artery experimental angioplasty, and global miRNA/mRNA expression profiling was obtained by RNA sequencing (RNA-Seq). Two days after injury, a set of six miRNAs were found to be uniquely downregulated or upregulated in VSMCs both in T1DM and T2DM. Among these miRNAs, miR-29c and miR-204 were the most significantly misregulated in atherosclerotic plaques from patients with DM. miR-29c overexpression and miR-204 inhibition per se attenuated VSMC phenotypic switch in DM. Concomitant miR-29c overexpression and miR-204 inhibition fostered an additive reduction in VSMC proliferation. Epithelial membrane protein 2 (Emp2) and Caveolin-1 (Cav1) mRNAs were identified as direct targets of miR-29c and miR-204, respectively. Importantly, contemporary miR-29c overexpression and miR-204 inhibition in the injured artery robustly reduced arterial stenosis in DM rats. Thus, contemporaneous miR-29c activation and miR-204 inhibition in DM arterial tissues is necessary and sufficient to prevent the exaggerated VSMC growth upon injury.

Molecular basis of functional myogenic specification of Bona Fide multipotent adult cardiac stem cells

Ischemic Heart Disease (IHD) remains the developed world's number one killer. The improved survival from Acute Myocardial Infarction (AMI) and the progressive aging of western population brought to an increased incidence of chronic Heart Failure (HF), which assumed epidemic proportions nowadays. Except for heart transplantation, all treatments for HF should be considered palliative because none of the current therapies can reverse myocardial degeneration responsible for HF syndrome. To stop the HF epidemic will ultimately require protocols to reduce the progressive cardiomyocyte (CM) loss and to foster their regeneration. It is now generally accepted that mammalian CMs renew throughout life. However, this endogenous regenerative reservoir is insufficient to repair the extensive damage produced by AMI/IHD while the source and degree of CM turnover remains strongly disputed. Independent groups have convincingly shown that the adult myocardium harbors bona-fide tissue specific cardiac stem cells (CSCs). Unfortunately, recent reports have challenged the identity and the endogenous myogenic capacity of the c-kit expressing CSCs. This has hampered progress and unless this conflict is settled, clinical tests of repair/regenerative protocols are unlikely to provide convincing answers about their clinical potential. Here we review recent data that have eventually clarified the specific phenotypic identity of true multipotent CSCs. These cells when coaxed by embryonic cardiac morphogens undergo a precisely orchestrated myogenic commitment process robustly generating bona-fide functional cardiomyocytes. These data should set the path for the revival of further investigation untangling the regenerative biology of adult CSCs to harness their potential for HF prevention and treatment.

Combining cell and gene therapy to advance cardiac regeneration

INTRODUCTION

The characterization of multipotent endogenous cardiac stem cells (eCSCs) and the breakthroughs of somatic cell reprogramming to boost cardiomyocyte replacement have fostered the prospect of achieving functional heart repair/regeneration.

AREAS COVERED

Allogeneic CSC therapy through its paracrine stimulation of the endogenous resident reparative/regenerative process produces functional meaningful myocardial regeneration in pre-clinical porcine myocardial infarction models and is currently tested in the first-in-man human trial. The in vivo test of somatic reprogramming and cardioregenerative non-coding RNAs revived the interest in gene therapy for myocardial regeneration. The latter, together with the advent of genome editing, has prompted most recent efforts to produce genetically-modified allogeneic CSCs that secrete cardioregenerative factors to optimize effective myocardial repair.

EXPERT OPINION

The current war against heart failure epidemics in western countries seeks to find effective treatments to set back the failing hearts prolonging human lifespan. Off-the-shelf allogeneic-genetically-modified CSCs producing regenerative agents are a novel and evolving therapy set to be affordable, safe, effective and available at all times for myocardial regeneration to either prevent or treat heart failure.

Perioperative myocardial injury after adult heart transplant: determinants and prognostic value

Background and Aim of the Study

Implications of Cardiac troponin (cTnI) release after cardiac transplantation are still unclear. This study disclosed risk factors and prognostic implication of cTnI early levels in a single centre cohort operated on between January 1999 and December 2010.

Methods

Data on 362 consecutive recipients (mean age: 47.8±13.7, 20.2% female, 18.2% diabetics, 22.1% with previous cardiac operations, 27.6% hospitalized, 84.9±29.4 ml/min preoperative glomerular filtration rate) were analyzed using multivariable logistic regression modeling. Target outcomes were determinants of troponin release, early graft failure (EGF), acute kidney injury (AKI) and operative death.

Results

Mean cTnI release measured 24 hours after transplant was 10.9±11.6 μg/L. Overall hospital mortality was 10.8%, EGF 10.5%, and AKI was 12.2%. cTnI release>10 μg/L proved an independent predictor of EGF (OR 2.2; 95% CI, 1.06–4.6) and AKI (OR 1.031; 95% CI, 1.001-1.064). EGF, in turn, proved a determinant of hospital mortality. Risk factors for cTnI>10 μg/L release were: status 2B (OR 0.35; 95% CI, 0.18-0.69, protective), duration of the ischemic period (OR 1.006; 95% CI, 1.001-1.011), previous cardiac operation (OR 2.9; 95% CI, 1.67-5.0), and left ventricular hypertrophy (OR 3.3; 95% CI, 1.9-5.6).

Conclusions

Myocardial enzyme leakage clearly emerged as an epiphenomenon of more complicated clinical course. The complex interplay between surgical procedure features, graft characteristics and recipient end-organ function highlights cTnI release as a risk marker of graft failure and acute kidney injury. The search for optimal myocardial preservation is still an issue.

Possible role of perineal ultrasound in the diagnosis of cystocele

OBJECTIVE

Perineal ultrasound has not yet been adequately evaluated in relation to the diagnosis of anatomical descensus of pelvic organs. Therefore, the aim of the present study was to assess whether it is possible to carry out a topographical comparison between bladders in normal seat and prolapsed ones and to quantify the extent of descensus.

MATERIALS AND METHODS

The authors selected 140 women, divided into three groups (two control groups and one case group). All patients underwent urogynaecological examination, according to the Pelvic Organ Prolapse Quantification (POP-Q), and perineal ultrasound to evaluate pubo-bladder distance.

RESULTS

Considering the data recorded in the two control groups, the authors established the physiological pubo-bladder distance between 27-33 mm at rest and 25-30 mm under stress. In the group with cystocele, the pubo-bladder distance was significantly lower: 20 mm at rest and three mm under stress (mean value). The authors also performed a classification of ultrasound cystocele in four stages, in accordance with clinical staging.

CONCLUSIONS

In conclusion, the present data show the excellent potential role of perineal ultrasound in the diagnosis of cystocele, but it is necessary to perform randomized studies to standardize the method.

The genetic ablation or pharmacological inhibition of TRPV1 signalling is beneficial for the restoration of quiescent osteoclast activity in ovariectomized mice

BACKGROUND AND PURPOSE

Osteoporosis is a condition characterized by a decrease in bone density, which decreases its strength and results in fragile bones. The endocannabinoid/endovanilloid system has been shown to be involved in the regulation of skeletal remodelling. The aim of this study was to investigate the possible modulation of bone mass mediated by the transient receptor potential vanilloid type 1 channel (TRPV1) in vivo and in vitro.

EXPERIMENTAL APPROACH

A multidisciplinary approach, including biomolecular, biochemical and morphological analysis, was used to investigate the involvement of TRPV1 in changes in bone density in vivo and osteoclast activity in vitro, in wild-type and Trpv1(-/-) mice, that had undergone ovariectomy or had a sham operation.

KEY RESULTS

Genetic deletion of Trpv1 as well as pharmacological inhibition/desensitization of TRPV1 signalling dramatically reduced the osteoclast activity in vitro and prevented the ovariectomy-induced bone loss in vivo, whereas the expression of cannabinoid type 2 (CB2 ) receptors was increased.

CONCLUSIONS AND IMPLICATIONS

These findings highlight the pivotal role TRPV1 channels play in bone resorption and suggest a possible cross-talk between TRPV1 and CB2 receptors. Based on these results, hybrid compounds acting on both TRPV1 and CB2 receptors in an opposite manner could provide a future pharmacological tool for the treatment of diseases associated with disturbances in the bone remodelling process.

Sexual function in patients who underwent surgery for stress urinary incontinence

AIM

Stress urinary incontinence (SUI) has been reported to have a negative impact on sexual relations in up to 68% of women. The effect of suburethral sling on sexual functioning has been studies, but the results are still inhomogeneous. This study was undertaken to assess the effect of the transvaginal tension free vaginal tape (TVT), transvaginal tension free vaginal tape - obturate (TVT-O) and minisling procedures (SIS) on sexual function and to also evaluate the male experience respect to sexual activity before and after surgery of partners of women underwent surgery.

METHODS

We enrolled 150 patients underwent a TVT/TVT-O or SIS for female stress urinary incontinence. All patients enrolled were invited to fill out the Female Sexual Function Index (FSFI) Questionnaire, before surgery and 12 months after surgery. We also evaluate the male experience, through questionnaire, respect to sexual activity before and after surgery of female partner.

RESULTS

At month 12, the mean follow-up FSFI total score in SIS group improved from baseline 22.7±3.83 to 26.2±4.01 (P=0.001), in the TVT group from baseline 22.5±4.11 to 28.5±3.87 (P=0.001) and in the TVT-O group from baseline 23.5±4.48 to 27.7±3.68. The male questionnaires reported an improvement of the sexual function of 84% for TVT group, 82.9% for SIS group and 80,9% for TVT-O group.

CONCLUSION

In our present study, patients underwent TVT, TVT-O or SIS showed comparable significant improvement of sexual function after sling procedure as evaluated by FSFI.

Long-term outcomes of perineal rehabilitation

AIM

Pelvic floor muscle training (PFMT) is classified with a level 1 evidence and a grade A recommendation, but long term effects have not been studied thoroughly. This study aims at assessing the long-term effectiveness of perineal rehabilitation on patients with mild prolapse and pure stress urinary incontinence (IUS) symptoms.

METHODS

Retrospective observational study on 49 patients examined at the beginning of the observation and 60 months after receiving biofeedback assisted PFMT. We created two groups. Group A: 27 women with mild symptoms of prolapse and pure mild IUS; Group B: 22 symptomatic patients postsurgery. We considered as therapeutic success a 50% general reduction of the symptoms experienced by the patients in terms of reduction of leakage episodes, number of pads used, strength and endurance of the pubococcygeus muscle and initial prolapse signs/symptoms.

RESULTS

Group A (follow-up 60 months): Reduction of prolapse symptoms: cured/much improved: 65% (17 patients); worsened: 22.4% (6 patients); unchanged: 18.5% (5 patients); reduction of urinary symptoms: cured/much improved: 59.3% (16 patients); surgery: 40.7% (11 patients); group B (follow-up 60 months); cured: 55.5% (12 patients); much improved: 44% (10 patients).

CONCLUSION

In conclusion, as for the treatment of menopausal patients with symptoms of mild disorders of the urinary/genital system, excellent results were reported in women underwent rehabilitation, as a first approach or after failed TVT-O.

Carbonic anhydrase activation is associated with worsened pathological remodeling in human ischemic diabetic cardiomyopathy

Background

Diabetes mellitus (DM) has multifactorial detrimental effects on myocardial tissue. Recently, carbonic anhydrases (CAs) have been shown to play a major role in diabetic microangiopathy but their role in the diabetic cardiomyopathy is still unknown.

Methods and Results

We obtained left ventricular samples from patients with DM type 2 (DM‐T2) and nondiabetic (NDM) patients with postinfarct heart failure who were undergoing surgical coronary revascularization. Myocardial levels of CA‐I and CA‐II were 6‐ and 11‐fold higher, respectively, in DM‐T2 versus NDM patients. Elevated CA‐I expression was mainly localized in the cardiac interstitium and endothelial cells. CA‐I induced by high glucose levels hampers endothelial cell permeability and determines endothelial cell apoptosis in vitro. Accordingly, capillary density was significantly lower in the DM‐T2 myocardial samples (mean±SE=2152±146 versus 4545±211/mm²). On the other hand, CA‐II was mainly upregulated in cardiomyocytes. The latter was associated with sodium‐hydrogen exchanger‐1 hyperphosphorylation, exaggerated myocyte hypertrophy (cross‐sectional area 565±34 versus 412±27 μm²), and apoptotic death (830±54 versus 470±34 per 10⁶ myocytes) in DM‐T2 versus NDM patients. CA‐II is activated by high glucose levels and directly induces cardiomyocyte hypertrophy and death in vitro, which are prevented by sodium‐hydrogen exchanger‐1 inhibition. CA‐II was shown to be a direct target for repression by microRNA‐23b, which was downregulated in myocardial samples from DM‐T2 patients. MicroRNA‐23b is regulated by p38 mitogen‐activated protein kinase, and it modulates high‐glucose CA‐II–dependent effects on cardiomyocyte survival in vitro.

Conclusions

Myocardial CA activation is significantly elevated in human diabetic ischemic cardiomyopathy. These data may open new avenues for targeted treatment of diabetic heart failure.

The possible role of zinc in the etiopathogenesis of endometriosis

PURPOSE OF INVESTIGATION

Aim of the study was to evaluate the possible involvement of zinc in the complex pathogenic process behind the onset and perpetuation of endometriotic lesions. To study the level of zinc serum between a group of patients affected by endometriosis and a group of healthy patients.

MATERIALS AND METHODS

The study included 86 women: 42 patients whose histodiagnosis had revealed pelvic endometriosis and 44 healthy patients. The authors measured the serum zinc concentration for all patients.

RESULTS

The group of patients with endometriosis presented serum zinc concentration of 1010 +/- 59.24 microg/l. The observation group presented a serum zinc concentration of 1294 +/- 62.22 microg/l.

CONCLUSION

The results showed that serum zinc levels in women with endometriosis are decreased and this seems to actually confirm that this microelement can possibly affect the multifactorial pathogenesis of the disease. As a matter of fact, zinc interferes with many biological processes, among which inflammation and immunity, which seem to be the base of the development of the lesions. Therefore, the authors believe that this hypothesis requires more attention and further investigation to determine its reasonableness. If the results are confirmed, this study opens up future prospects as for the treatment of endometriosis, taking into account also the role of zinc in the onset of male sterility and the development of testicles. Zinc could in fact be used as marker to detect women at high risk of endometriosis and for the elaboration of a new treatment for sterility, from which these women often suffer.

Risk of pelvic floor dysfunctions in young athletes

PURPOSE OF INVESTIGATION

Numerous epidemiological studies have shown a correlation between sport and the development of pelvic floor dysfunction. Therefore, the aim of the present study was to evaluate the prevalence of urinary incontinence in female young athletes.

MATERIALS AND METHODS

The epidemiological study was conducted on 105 female volleyball players, who were given a questionnaire, self-compiled, consisting of four main domains (personal data and medical history, urinary incontinence, urinary disorders, and judgment on the questionnaire).

RESULTS

In a total of 105 athletes, the present authors observed that 65.7% had reported at least one symptom of stress urinary incontinence (SUI) and/or urgency, during sport or in daily life situations. In particular, the 49.52% reported urge urinary incontinence, 20% urine loss for urgency, and 29.52% SUI. In addition, the present authors observed that nocturia was reported in 70.48% of cases, incomplete bladder emptying in 55.24%, urinary hesitancy in the 36.19%, and pelvic pain in 52.38%. In all cases, the symptoms were occasional and low. In relation to the coexistence of symptoms, the present authors observed that 22.85% of athletes had only symptoms of urge urinary incontinence, 6.66% mixed incontinence, and 6.66% symptoms of urge urinary incontinence associated to urine loss for SUI.

CONCLUSION

The present authors observed a relationship between the sport and the pelvic floor dysfunction, in particular urinary incontinence.

Asymptomatic large bladder diverticulum

The authors report a case of a 61-year-old woman diagnosed with large bladder diverticulum. Diagnosis was performed only after a series of investigations carried out for the occasional finding of hypercreatininaemia. Although the significant volumes of post void residual (PVR) and the relevant urine stagnation in the diverticulum, subjective symptomatology was absent and urinalysis and urine culture were negative. The scheduled therapeutic plan consisted of fosfomycin three grams every ten days for sixmonths, self-catheterization twice a day, voiding on a time schedule, and adequate fluid intake. The monthly scheduled follow-up at one year showed good general health, good compliance with the therapy, no urinary tract infections, a decrease in creatininemia to 1.2 mg/dl, and regression of nephrohydrosis to a mild stage. In conclusion, the absence of symptoms and negative urinalysis or urine culture allows expectant management despite the considerable size of the bladder diverticulum.

Screening for trisomy 21 by maternal age fetal nuchal translucency thickness and maternal serum sample

AIM

The aim of this paper was to examine the performance of two-stage first-trimester combined screening based on maternal age, fetal nuchal translucency (NT) thickness and maternal serum sample "free beta-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A)".

METHODS

A combined screening for chromosomal anomalies was performed in 713 singleton pregnancies. We performed a two-stage screening with the blood taken at 8+0 to 10+6 weeks and the measurement of NT performed at 12+0 to 12+6 weeks. The maternal age related risk for trisomy 21 was calculated and adjusted according to the gestational age at the time of screening to derive the a-priori risk. The measured free beta-human chorionic gonadotropin (β-hCG) and pregnancy-associated plasma protein-A (PAPP-A) were converted into a multiple of the median (MoM) for gestational age, adjusted for maternal weight, smoking status, ethnicity, method of conception (spontaneous or IVF) and parity. The measured NT was assessed in relationship of mesasure of CRL. Finally, the risk resulting by NT thickness and biochemical markers were multiplied by the a-priori risk to derive the patient-specific risk.

RESULTS

The ultrascreen was considered positive in the case where the risk was greater than 1:250. In this case it was suggested the study of the fetal karyotype through an invasive test. In our study we had 23 positive cases after the combined screening: all patients have opted for the study of fetal karyotype, and in 5 cases the result was abnormal (trisomy 21). We had 1 case where the test was negative but the fetal karyotype was abnormal (trisomy 21). We have calculated sensitivity and false positive rate of the test.

CONCLUSION

In our study there were 707 cases with a normal karyotype or delivery of a phenotypically normal baby and 6 cases with trisomy 21. The detection rate of the first trimester screening for chromosomal anomalies was 83% with a false positive rate of 3,2%. The aim of the study was estimated the performance of two-step strategy screening. In our study, the performance of the screening model, based on the two-stage, was not higher than the performance of screening based on a single-step reported in literature. In our opinion, there is no potential advantage in terms of detection rate.

Betulinic acid and possible influence on the clearance of Human Papilloma Virus: cytological and virological follow-up

AIM

Persistent infection with high-risk Human Papilloma Virus (HPV) types is considered necessary for the development of cervical cancer. No such efficient antiviral agent exists at the present time. The aim of this study was to assess whether the use of topical products, vaginal ovules, containing betulinic acid and betulin may influence viral replication in vivo by promoting its negativity.

METHODS

We enrolled 62 patients at the colposcopy ambulatory with negative colposcopy or with congenital ectopic or normal transformation zone, but with HPV-test positive for high risk. We divided the patients into two groups: group A had no kind of treatment, group B has undergone a treatment with vaginal ovules containing betulinic acid and betulin. All patients have taken a new HPV-test six months after the first control.

RESULTS

After six months, we compared the percentage of negative HPV-test. We observed a percentage of negativity of 93% in group B versus 68% in group A. The data was statistically significant at χ2 test (P<0,05).

CONCLUSION

We believe that the results should be investigated further to confirm if there is a correlation between these substances and the increase in the rate of viral negativity.

[Phytoestrogens and menopause]

Menopause is the interruption of menstrual and reproductive capacity, therefore, that occurs naturally in all women between 48 and 55 years, due to a lower production of gonadal steroids. The period becomes progressively irregular and lack of ovulation and menstrual flow decrease, and finally disappears. The time between the first symptoms and the cessation of the menstrual cycle is called menopause. With the onset of menopause the woman undergoes a series of changes related to estrogen deficiency, which occur in all tissues of the body. In this period one can distinguish an early stage, characterized by hot flashes, mood swings, night sweats and insomnia, and a late phase in which we highlight more symptoms related to the interruption of hormonal such as osteoporosis, obesity, at urogenital and increased incidence of cardiovascular disease. In Italy, only 5.2% of women aged 45-64 years used hormone replacement therapy, and only 20-30% follow a therapy for more than two years, both for psychological reasons, and for fear of side effects. Not surprisingly, therefore, phytoestrogens are given a high importance, as they are considered a natural alternative tank to to their plant origin. Interest in phytoestrogens was born from the observation that postmenopausal women who live in the East have a lower incidence of symptoms, cardiovascular disease, cancer and osteoporosis hormone use, compared to Western women.