Three-dimensional echocardiographic left ventricular strain analysis in Fabry disease: correlation with heart failure severity, myocardial scar, and impact on long-term prognosis

AIMS

Fabry disease (FD) is a multisystemic lysosomal storage disorder caused by a defect in the alpha-galactosidase A gene that manifests as a phenocopy of hypertrophic cardiomyopathy. We assessed the echocardiographic 3D left ventricular (LV) strain of patients with FD in relation to heart failure severity using natriuretic peptides, the presence of a cardiovascular magnetic resonance (CMR) late gadolinium enhancement scar, and long-term prognosis.

METHODS AND RESULTS

3D echocardiography was feasible in 75/99 patients with FD [aged 47 ± 14 years, 44% males, LV ejection fraction (EF) 65 ± 6% and 51% with hypertrophy or concentric remodelling of the LV]. Long-term prognosis (death, heart failure decompensation, or cardiovascular hospitalization) was assessed over a median follow-up of 3.1 years. A stronger correlation was observed for N-terminal pro-brain natriuretic peptide levels with 3D LV global longitudinal strain (GLS, r = -0.49, P < 0.0001) than with 3D LV global circumferential strain (GCS, r = -0.38, P < 0.001) or 3D LVEF (r = -0.25, P = 0.036). Individuals with posterolateral scar on CMR had lower posterolateral 3D circumferential strain (CS; P = 0.009). 3D LV-GLS was associated with long-term prognosis [adjusted hazard ratio 0.85 (confidence interval 0.75-0.95), P = 0.004], while 3D LV-GCS and 3D LVEF were not (P = 0.284 and P = 0.324).

CONCLUSION

3D LV-GLS is associated with both heart failure severity measured by natriuretic peptide levels and long-term prognosis. Decreased posterolateral 3D CS reflects typical posterolateral scarring in FD. Where feasible, 3D-strain echocardiography can be used for a comprehensive mechanical assessment of the LV in patients with FD.

Narrative review on Morbus Fabry: diagnosis and management of cardiac manifestations

Fabry disease (FD) is an X-linked lysosomal storage disorder due to reduced or undetectable α-galactosidase A (AGAL-A) enzyme activity caused by pathogenic variants in the AGAL-A gene (GLA). Tissue and organ changes are caused by widespread progressive accumulation of globotriaosylceramide (Gb₃) and globotriaosylsphingosine (lysoGb₃). The classical form of FD is multisystemic with cutaneous (angiokeratomas), neurological (peripheral neuropathy, premature stroke), renal (proteinuria and renal insufficiency), and cardiac involvement. Later onset variants may be limited to the heart. The objective of this review is to summarize the current knowledge on cardiac manifestations of FD and effects of targeted therapy. Cardiac involvement is characterized by progressive hypertrophy, fibrosis, arrhythmias, heart failure and sudden cardiac death (SCD). Targeted therapy is based on enzyme replacement therapy (ERT). Recently, small molecular chaperone, migalastat, became available for patients carrying amenable pathogenic GLA variants. The management of cardiac complications requires a complex approach. Several measures differ from standard clinical guidelines. Betablockers should be used with caution due to bradycardia risk, amiodarone avoided if possible, and anticoagulation used from the first appearance of atrial fibrillation. In Fabry cardiomyopathy SCD calculators are inappropriate. The awareness of FD manifestations is essential for early identification of patients and timely treatment initiation.

Fabry disease with cardiovascular manifestation in a patient with end-stage renal disease

Fabry disease is a rare X-linked hereditary storage disease caused by a mutation of the gene encoding alpha-galactosidase A. The clinical manifestation of the classical disease form is variable depending on the degree of individual organs involvement, including especially kidney, myocardium, central nervous system (CNS) and skin. We report a case of a 51-year-old man whose diagnostic manifestation was cardiac involvement leading to endomyocardial biopsy, which significantly contributed to the diagnosis. Although at that time he was already 9 years dependent on dialysis with terminal renal failure.

Hypocalcaemic cardiomyopathy: a description of two cases and a literature review

Hypocalcaemic cardiomyopathy is a rare form of dilated cardiomyopathy. The authors here present two cases in which symptomatic dilated cardiomyopathy was the result of severe hypocalcaemia. First, we report about a 26‐year‐old woman with primary hypoparathyroidism and then about a 74‐year‐old man with secondary hypoparathyroidism following a thyroidectomy. In both cases, the left ventricular systolic function improved after calcium supplementation. In the first case, a lack of compliance led to a repeated decrease of both serum calcium level and left ventricular systolic function. The authors also present a comprehensive summary of all cases of hypocalcaemic dilated cardiomyopathy that have been described in literature to date. The mean age of the affected patients was 48.3 years, of which 62% were female patients. The most common causes of hypocalcaemic cardiomyopathy are primary hypoparathyroidism (50%) and post‐thyroidectomy hypoparathyroidism (26%). In the post‐thyroidectomy subgroup, the median time for the development of hypocalcaemic cardiomyopathy is 10 years (range: 1.5 months to 36 years). Hypocalcaemic cardiomyopathy leads to heart failure with reduced ejection fraction in 87% of patients. Generally, the most common complications of hypoparathyroidism and/or hypocalcaemia are cerebral calcifications, cognitive deficit, and cataracts. Once calcium supplementation is administered, the disease has a good prognosis and, in most individuals, a significant improvement (21%) or even normalization (74%) of the left ventricular systolic function occurs.

Cardiac involvement in hypereosinophilia

Cardiac abnormalities associated with hypereosinophilia represent rare diseases and occurs most commonly due to hypersensitivity or allergic reactions, other possible etiologies cover infections, malignancy, vasculitis or hypereosinophilic syndromes. Three stages of cardiac involvement are usually described. Initially, myocardial inflammation occurs, that can continue with a thrombotic stage and eventually progress to the last irreversible stage called endomyocardial fibrosis, which represents one of the acquired forms of restrictive cardiomyopathy. In most patients, increased levels of eosinophils in the blood differential test; however, it may not be present in the initial stages of the disease. Of the imaging methods, magnetic resonance imaging and positron emission tomography combined with CT PET-CT are used in addition to echocardiography. Endomyocardial biopsy may be indicated for definitive evidence of eosinophilic myocarditis. The clarification of the cause of hypereosinophilia is necessary for specific treatment of this disorder.

Acute and recurrent pericarditis

Pericardial diseases have been until recently relatively neglected entity; however, there has been a markedly increased interest in these disorders in the last decade due to new diagnostic as well as therapeutic options. Various clinical manifestations of pericardial diseases may be generally grouped into pericardial syndromes including pericarditis, pericardial effusion, cardiac tamponade and constrictive pericarditis. In this review, the comprehensive analysis of acute and recurrent pericarditis is presented. Acute and recurrent pericarditis represent the most common pericardial disorders in clinical practice, in which major changes in therapeutic procedures occurred based on recently published trials, particularly the introduction of colchicine therapy.

Disparity between two-dimensional echocardiographic and electroanatomic left and right atrial volumes in patients undergoing catheter ablation for long-standing persistent atrial fibrillation

Left atrial (LA) volume (LAV) is used for the selection of patients with atrial fibrillation (AF) to rhythm control strategies. Calculation of LAV from the LA diameters and areas by two-dimensional (2D) echocardiography may result in significant error. Accuracy of atrial volume assessment has never been studied in patients with long-standing persistent AF (LSPAF) and significant atrial remodeling. This study investigated correlation and agreement between 2D echocardiographic (Simpson method) and electroanatomic (CARTO, Biosense Webster) left and right atrial (RA) volumes (LAV(ECHO) vs. LAV(CARTO) and RAV(ECHO) vs. RAV(CARTO)) in patients undergoing catheter ablation for LSPAF. The study enrolled 173 consecutive subjects (females: 21 %, age: 59+/-9 years). There was only modest correlation between LAV(ECHO) (92+/-31 ml) and LAV(CARTO) (178+/-37 ml) (R=0.57), and RAV(ECHO) (71+/-29 ml) and RAV(CARTO) (173+/-34 ml) (R=0.42), respectively. LAV(ECHO) and RAV(ECHO) underestimated LAV(CARTO) and RAV(CARTO) with the absolute bias (+/-1.96 standard deviation) of -85 (-148; -22) ml and -102 (-169; -35) ml, respectively, and with the relative bias of -48 (-75; -21) % and -59 (-88; -30) %, respectively (all P<0.000001 for their mutual difference). Significant confounders of this difference were not identified. In patients with LSPAF, 2D echocardiography significantly underestimated both LA and RA volumes as compared with electroanatomic reference. This disagreement was independent of clinical, echocardiographic and mapping characteristics.

[Arrhythmogenic left ventricular cardiomyopathy]

Arrhythmogenic left ventricular cardiomyopathy (ALVC) is a rare condition characterised by progressive fibrofatty replacement of the myocardium of the left ventricle in combination with arrhythmias of left ventricular origin. ALVC has been linked to autosomal dominant mutations of genes encoding desmosomal proteins, similarly to the classic arrhythmogenic right ventricular cardiomyopathy with which it also shares pathological and prognostic features. It seems that isolated left or right ventricular abnormalities represent two extremes of the spectrum of clinical manifestations of a single disease: arrhythmogenic cardiomyopathy. In addition to arrhythmias originating from the left ventricle, the diagnosis of ALVC is based on identification of morphological changes of the left ventricle including late gadolinium enhancement with subepicardial to midwall distribution, corresponding to fibrous or fibrofatty replacement on histopathology. The diagnosis is confirmed by detection of a causal mutation. ALVC should be kept in mind in the differential diagnosis of ventricular tachycardia of non-ischemic origin.Key words: arrhythmogenic cardiomyopathy - cardiac magnetic resonance - late gadolinium enhancement - ventricular tachycardia.

[The benefit of magnetic resonance for diagnosing cardiomyopathy and myocarditis]

Magnetic resonance is becoming an increasingly used examination in cardiology, since it greatly improves the accuracy of diagnosing of many heart diseases. At present magnetic resonance is the gold standard in assessing the volumes of the heart chambers and the systolic function of both ventricles. The possibility of detecting tissue characteristics to refine the diagnostics of different types of myocardial pathology is of essential importance. The authors summarize in the article the present knowledge about the use of magnetic resonance of the heart in the field of myocardial disease, i.e. cardiomyopathy and myocarditis. In the first of this article, a general overview of cardiac magnetic resonance examination has been given, followed by detailed description of its usefulness in dilated cardiomyopathy and myocarditis, in hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. The second part of the review summarizes the benefits of cardiac magnetic resonance examination in cardiac amyloidosis and other less common cardiomyopathies.Key words: fibrosis - cardiomyopathy - magnetic resonance - myocarditis - late contrast agent saturation.

[The benefit of magnetic resonance for diagnosing cardiomyopathy and myocarditis]

Magnetic resonance is becoming an increasingly used examination in cardiology, since it greatly improves the accuracy of diagnosing of many heart diseases. At present magnetic resonance is the gold standard in assessing the volumes of the heart chambers and the systolic function of both ventricles. The possibility of detecting tissue characteristics to refine the diagnostics of different types of myocardial pathology is of essential importance. The authors summarize in the article the present knowledge about the use of magnetic resonance of the heart in the field of myocardial disease, i.e. cardiomyopathy and myocarditis. The first part of the review gives a general introduction into the topic of magnetic resonance examination of myocardial diseases, which is followed by a detailed descrip-tion of the benefits of this imaging method in dilated cardiomyopathy and myocarditis,in hypertrophic cardio-myopathy, and arrhythmogenic right ventricular cardiomyopathy.Key words: fibrosis - cardiomyopathy - magnetic resonance - myocarditis - late contrast agent saturation.

Genetic variation screening of TNNT2 gene in a cohort of patients with hypertrophic and dilated cardiomyopathy

Mutations in troponin T (TNNT2) gene represent the important part of currently identified disease-causing mutations in hypertrophic (HCM) and dilated (DCM) cardiomyopathy. The aim of this study was to analyze TNNT2 gene exons in patients with HCM and DCM diagnosis to improve diagnostic and genetic consultancy in affected families. All 15 exons and their flanking regions of the TNNT2 gene were analyzed by DNA sequence analysis in 174 patients with HCM and DCM diagnosis. We identified genetic variations in TNNT2 exon regions in 56 patients and genetic variations in TNNT2 intron regions in 164 patients. Two patients were found to carry unique mutations in the TNNT2 gene. Limited genetic screening analysis is not suitable for routine testing of disease-causing mutations in patients with HCM and DCM as only individual mutation-positive cases may be identified. Therefore, this approach cannot be recommended for daily clinical practice even though, due to financial constraints, it currently represents the only available strategy in a majority of cardio-centers.