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Frustaci A, Borghetti V, Pentiricci S, Verardo R, Scialla R, Russo MA. Hypertrophic obstructive cardiomyopathy caused by Fabry disease: implications for surgical myectomy. ESC Heart Fail 2023; 10:3710-3713. [PMID: 37715354 PMCID: PMC10682850 DOI: 10.1002/ehf2.14427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/18/2023] [Accepted: 05/24/2023] [Indexed: 09/17/2023] Open
Abstract
Hypertrophic obstructive cardiomyopathy can be the phenotype of storage disorders as Fabry disease cardiomyopathy. In this instance, its recognition through GLA gene analysis and preventive administration of enzyme replacement therapy may reduce heart failure risk of surgical septal myectomy (SSM). A 59-year-old man was referred for SSM as dyspnoea and low threshold muscle fatigue associated to severe left ventricular outflow obstruction (gradient of 100 mmHg) due to both interventricular septal hypertrophy and mitral leaflet systolic anterior motion were not controlled by metoprolol 100 mg bid. Electrocardiogram showed sinus rhythm and a complete left bundle branch block. Cardiac magnetic resonance imaging showed a preserved left ventricular (LV) contractility (ejection fraction 70%) but failed to reveal reduced T1 mapping and fibrosis of postero-lateral LV wall suggesting Fabry disease cardiomyopathy. Cardiac catheterization and coronary angiography documented increased LV end-diastolic pressure but normal coronary arteries. SSM was followed by acute renal and heart failure with left ventricular ejection fraction declining to 35%. Histology of SSM showed regularly arranged severely enlarged cardiomyocytes containing extensive vacuoles that were intensely positive to immunofluorescence with anti-Gb3 antibodies and appeared at electron microscopy to consist of myelin bodies suggesting the diagnosis of FD. This entity was confirmed by low blood levels of alpha-galactosidase A (0.8 nmol/mL/h; NV > 1), high values of Lyso-Gb3 (5.85 nmol/L; NV < 2.3), and the presence of the pathogenic mutation c.644A>G in the exon 5 of GLA gene. This study emphasizes the importance of a genetic screening for FD before SSM be considered for hypertrophic obstructive cardiomyopathy.
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Affiliation(s)
| | - Valentino Borghetti
- Cardiac Surgery Complex Structure of the “S. Maria” Hospital of TerniTerniItaly
| | | | - Romina Verardo
- Cellular and Molecular Cardiology LabIRCCS L. SpallanzaniRomeItaly
| | - Rossella Scialla
- Cellular and Molecular Cardiology LabIRCCS L. SpallanzaniRomeItaly
| | - Matteo Antonio Russo
- MEBIC ConsortiumSan Raffaele Open University and (6) IRCCS San Raffaele PisanaRomeItaly
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Frustaci A, Verardo R, Magnocavallo M, Scialla R, Sansone L, Russo MA. Circulating Anti-GB3 Antibody as a Biomarker of Myocardial Inflammation in Patients with Fabry Disease Cardiomyopathy. J Clin Med 2023; 12:4068. [PMID: 37373761 DOI: 10.3390/jcm12124068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Fabry disease cardiomyopathy (FDCM) has manifested some resistance to enzyme replacement therapy (ERT), particularly in its advanced phase. Recently, myocardial inflammation of autoimmune origin has been demonstrated in FDCM. AIMS The objective of this study was the assessment of circulating anti-globotriaosylceramide (GB3) antibodies as potential biomarkers of myocardial inflammation in FDCM, defined by the additional presence of ≥CD3+ 7 T lymphocytes/low-power field associated with focal necrosis of adjacent myocytes. Its sensitivity was based on the evidence of overlapping myocarditis at left ventricular endomyocardial biopsy. METHODS AND RESULTS From January 1996 to December 2021, 85 patients received a histological diagnosis of FDCM in our department and 48 (56.5%) of them had an overlapping myocardial inflammation with negative PCR for common cardiotropic viruses, positive antiheart, and antimyosin abs. The presence of anti-GB3 antibodies was evaluated with an in-house ELISA assay (BioGeM scarl Medical Investigational Research, MIR-Ariano Irpino, Italy), along with antiheart and antimyosin abs, in the FDCM patients and compared with control healthy individuals. The correlation between levels of circulating anti-GB3 autoantibody myocardial inflammation and FDCM severity was assessed. Anti-Gb3 antibodies were above the positivity cut-off in 87.5% of FDCM subjects with myocarditis (42 out of 48), while 81.1% of FDCM patients without myocarditis were identified as negative for Gb3 antibodies. Positive anti-Gb3 abs correlated with positive antiheart and antimyosin abs. CONCLUSIONS The present study suggests a potential positive role of anti-GB3 antibodies as a marker of overlapping cardiac inflammation in patients with FDCM.
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Affiliation(s)
| | - Romina Verardo
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Roma, Italy
| | - Michele Magnocavallo
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, 00186 Rome, Italy
| | - Rossella Scialla
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Roma, Italy
| | - Luigi Sansone
- IRCCS San Raffaele Rome, 00166 Roma, Italy
- MEBIC Consortium, San Raffaele Open University, 00166 Rome, Italy
| | - Matteo Antonio Russo
- IRCCS San Raffaele Rome, 00166 Roma, Italy
- MEBIC Consortium, San Raffaele Open University, 00166 Rome, Italy
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Frustaci A, Galea N, Dominici L, Verardo R, Alfarano M, Scialla R, Richetta AG. Interleukin-17A-Correlated Myocarditis in Patients with Psoriasis: Cardiac Recovery following Secukinumab Administration. J Clin Med 2023; 12:4010. [PMID: 37373705 PMCID: PMC10299195 DOI: 10.3390/jcm12124010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/06/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: Psoriasis (PS) is a common immune-mediated disease of the skin with possible extension to joints, aorta and eye. Myocardial inflammation has rarely been suggested. (2) Aims: Report of PS-related myocarditis. (3) Methods and Results: One hundred consecutive patients with PS were screened for cardiac involvement. Among them, five male patients (aged 56 ± 9.5 years) with a moderate-severe form of PS showed dilated cardiomyopathy (LVEF < 35%) with normal coronary arteries and valves. They underwent a left-ventricular endomyocardial biopsy for evaluation of myocardial substrate. Endomyocardial samples were processed for histology and immunohistochemistry, including myocardial expression of Toll-Like Receptor 4 (TLR4) and interleukin-17A (IL-17A), which play a major role in PS pathogenesis. Real-time PCRs were carried out for cardiotropic viruses, and Western blot analysis was conducted for myocardial expression of IL-17A. Patients' sera were tested for anti-heart autoantibodies. Active lymphocytic myocarditis was revealed in all five patients, characterized by an absence of viral genomes with PCR, positive anti-heart autoantibodies, overexpression of TLR-4 and enhancement of IL-17-A during western blot analysis, showing a 2.48-fold increase in psoriatic myocarditis compared with no psoriatic myocarditis and a six-fold increase compared to myocardial controls. Treatment included combination of prednisone (1 mg/kg daily for 4 weeks, tapered to 0.33 mg/kg) and azathioprine (2 mg/kg, daily) in 3 pts or secukinumab (SK, 150 mg/weekly for 4 weeks followed by 150 mg/monthly) in 2 pts for 6 months. LVEDD and LVEF improved in the first 3 pts (-14% and + 118%, respectively), while they completely recovered (LVEF > 50%) in the last 2 pts on SK. (4) Conclusions: IL-17A-related myocarditis can occur in up to 5% of patients with PS. It manifests as progressive dilated cardiomyopathy. It may completely recover following SK administration.
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Affiliation(s)
| | - Nicola Galea
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, 00185 Rome, Italy; (N.G.); (L.D.); (M.A.); (A.G.R.)
| | - Lorenzo Dominici
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, 00185 Rome, Italy; (N.G.); (L.D.); (M.A.); (A.G.R.)
| | - Romina Verardo
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (R.S.)
| | - Maria Alfarano
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, 00185 Rome, Italy; (N.G.); (L.D.); (M.A.); (A.G.R.)
| | - Rossella Scialla
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (R.S.)
| | - Antonio Giovanni Richetta
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, 00185 Rome, Italy; (N.G.); (L.D.); (M.A.); (A.G.R.)
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Frustaci A, Verardo R, Galea N, Lavalle C, Bagnato G, Scialla R, Chimenti C. Hypersensitivity Myocarditis after COVID-19 mRNA Vaccination. J Clin Med 2022; 11:jcm11061660. [PMID: 35329986 PMCID: PMC8949349 DOI: 10.3390/jcm11061660] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/08/2022] [Accepted: 03/15/2022] [Indexed: 12/26/2022] Open
Abstract
Background: Myocarditis, even in a severe and lethal form, may occur after COVID-19 mRNA (BNT162b2) vaccination. However, its pathway, morphomolecular characterization and treatment are still unknown. Methods: Routine hematochemical screening, ECG, Holter monitoring, 2D echocardiogram cardiac magnetic resonance (CMR) and invasive cardiac studies (cardiac catheterization, selective coronary angiography, left ventriculography and left ventricular endomyocardial biopsy) are reported from three patients (39F-pt1, 78M-pt2, 52M-pt3) with severe compromise of conduction tissue (junctional rhythm and syncope, pt1) or cardiac function compromise (LVEF ≤ 35%, pt2 and pt3) after COVID-19 mRNA (BNT162b2). Results: Hematochemical data and coronary angiography were normal in the patients studied. Histology showed in all three patients extensive myocardial infiltration of degranulated eosinophils and elevation of serum cationic protein directly responsible for cardiomyocyte damage. These findings demonstrate myocarditis hypersensitivity to some component of the vaccine (spike protein?) acting as a hapten to some macromolecules of cardiomyocytes. Steroid administration (prednisone, 1 mg/kg die for 3 days, followed by 0.33 mg/kg for 4 weeks) was followed by complete recovery of cardiac contractility in pt2 and pt3. Conclusions: Eosinophilic myocarditis is a possible adverse reaction to the mRNA COVID-19 vaccine. Its pathway is mediated by release of cationic protein and responds to short courses of steroid administration.
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Affiliation(s)
- Andrea Frustaci
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, La Sapienza University, 00161 Rome, Italy;
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (G.B.); (R.S.)
- Correspondence: ; Tel.: +39-06-5517-052
| | - Romina Verardo
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (G.B.); (R.S.)
| | - Nicola Galea
- Department of Experimental Medicine, Sapienza University, 00161 Rome, Italy;
| | - Carlo Lavalle
- Department of DAI Cardio-Thoraco-Vascular and Organ Transplant Surgery, La Sapienza University, 00161 Rome, Italy;
| | - Giulia Bagnato
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (G.B.); (R.S.)
| | - Rossella Scialla
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (G.B.); (R.S.)
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, La Sapienza University, 00161 Rome, Italy;
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (G.B.); (R.S.)
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Frustaci A, Letizia C, Chimenti C, Verardo R, Alfarano M, Scialla R, Bagnato G, Miraldi F, Sansone L, Russo MA. Myocardial Aldosterone Receptor and Aquaporin 1 Up-Regulation Is Associated with Cardiomyocyte Remodeling in Human Heart Failure. J Clin Med 2021; 10:jcm10214854. [PMID: 34768373 PMCID: PMC8585058 DOI: 10.3390/jcm10214854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/06/2021] [Accepted: 10/19/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Abnormal aldosterone signaling is a recognized source of cardiovascular damage. Its influence on cardiomyocyte structure, function, and hormonal receptors when associated with heart failure is still unreported. Methods: Twenty-six consecutive patients with heart failure (LVEF < 40%) and normal coronaries and valves underwent left ventricular endomyocardial biopsy (EMB) for evaluation of myocardial substrate. Biopsy samples were processed for histology, electron microscopy, immunohistochemistry, and Western blot analysis of myocardial aldosterone receptor and aquaporin-1 correlated with plasma aldosterone (AD) and renin activity (PRA). Eight patients with virus-negative inflammatory cardiomyopathy (ICM) had a control EMB after 6 months of immunosuppressive therapy and recovery of cardiac function with re-evaluation of cardiomyocyte structure and receptor expression. Results: EMB in addition to the diagnosis of myocarditis (15 cases), dilated cardiomyopathy CM (6), alcohol CM (2), and diabetic CM (3) showed vacuolar degeneration and cloudy swelling of cardiomyocytes corresponding at electron microscopy to ions and water accumulation into cytosol, membrane-bound vesicles, nucleus, and other organelles, and was associated with an increased AD, PRA, and myocardial expression of aldosterone receptor (2.6 fold) and aquaporin 1 (2.7 fold). In the 8 patients recovered from ICM, cardiomyocyte diameter reduced with disappearance of intracellular vacuoles and normalization of cytosol, nucleus, and cell organelles’ electron-density, along with down-regulation of aldosterone receptor and aquaporin-1. Conclusion: Human heart failure is associated with overexpression of myocardial aldosterone receptor and aquaporin-1. These molecular changes are paralleled by intracellular water overloading and cardiomyocyte swelling and dysfunction. Cardiac recovery is accompanied by down-regulation of hormonal receptors and normalization of cell structure and composition.
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Affiliation(s)
- Andrea Frustaci
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, 00161 Rome, Italy; (C.C.); (M.A.); (F.M.)
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (R.S.); (G.B.)
- Correspondence: ; Tel.: +39-06-5517-0520
| | - Claudio Letizia
- Department of Translation Medicine and Precision, Sapienza University, 00161 Rome, Italy;
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, 00161 Rome, Italy; (C.C.); (M.A.); (F.M.)
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (R.S.); (G.B.)
| | - Romina Verardo
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (R.S.); (G.B.)
| | - Maria Alfarano
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, 00161 Rome, Italy; (C.C.); (M.A.); (F.M.)
| | - Rossella Scialla
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (R.S.); (G.B.)
| | - Giulia Bagnato
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, 00149 Rome, Italy; (R.V.); (R.S.); (G.B.)
| | - Fabio Miraldi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, 00161 Rome, Italy; (C.C.); (M.A.); (F.M.)
| | - Luigi Sansone
- Laboratory of Molecular and Cellular Pathology, IRCCS San Raffaele Pisana, 00163 Rome, Italy;
| | - Matteo Antonio Russo
- MEBIC Consortium, San Raffaele Open University, 00163 Rome, Italy;
- IRCCS San Raffaele Pisana, 00163 Rome, Italy
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Frustaci A, Francone M, Verardo R, Scialla R, Bagnato G, Alfarano M, Chimenti C, Frustaci E, Sansone L, Russo M. Pemphigus-associated cardiomyopathy: report of autoimmune myocarditis and review of literature. ESC Heart Fail 2021; 8:3690-3695. [PMID: 34432378 PMCID: PMC8497363 DOI: 10.1002/ehf2.13474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/11/2021] [Accepted: 06/01/2021] [Indexed: 01/05/2023] Open
Abstract
Pemphigus is a rare disease characterized by bullous lesions of the skin and mucous membranes. The aetiology is autoimmune and related to the formation of IgG autoantibodies against desmogleins, which are structural proteins of desmosomes that ensure the stability of contacts between cells. Cardiac involvement in patients with pemphigus is poorly documented. We report the data in the literature on this topic and a case of pemphigus-associated autoimmune myocarditis with damage of intercalated disc responding to immunosuppressive therapy. The occurrence of cardiomyopathy with left ventricular dysfunction in patients affected by pemphigus should be appropriately screened with endomyocardial biopsy as it could be the myocardial extension of a potentially reversible autoimmune disorder.
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Affiliation(s)
- Andrea Frustaci
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, Viale del Policlinico 155, Rome, 00161, Italy
| | - Marco Francone
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University, Rome, Italy
| | - Romina Verardo
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
| | - Rossella Scialla
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
| | - Giulia Bagnato
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
| | - Maria Alfarano
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, Viale del Policlinico 155, Rome, 00161, Italy
| | - Cristina Chimenti
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University, Viale del Policlinico 155, Rome, 00161, Italy
| | - Emanuela Frustaci
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Rome, Italy
| | - Luigi Sansone
- Laboratory of Molecular and Cellular Pathology, IRCCS San Raffaele Pisana, Rome, Italy
| | - Matteo Russo
- MEBIC Consortium, San Raffaele Open University and IRCCS San Raffaele Pisana, Rome, Italy
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