Cryopreserved amniotic membrane in chronic nonhealing wounds: a series of case reports

A case series of the use of amniotic membrane (AM) for treating chronic nonhealing wounds. It presents five cases of polymorbid patients with a total of nine chronic nonhealing wounds. The patient group consisted of four men and one woman with various comorbidities, aged 45-72 years. The mean initial wound size was 15.8 cm2, and the mean time from the onset of the wound to the first application of AM was 122 weeks. The wounds were caused by chronic venous insufficiency and/or peripheral arterial disease. Wounds were treated in a standardized protocol. AM was applied weekly in the first month and then every two weeks. Photo documentation of the wound and microbiological colonization was carried out at each visit. In three out of five patients, the AM treatment effectively promoted healing up to complete wound closure. In two cases, the wounds stayed unhealed despite numerous AM applications. Pain relief was noted in all patients. The success of the treatment was closely tied to patient factors, such as adherence to the prescribed treatment regimen and individual patient characteristics. In some cases, treatment failure was observed, possibly due to underlying comorbidities, wound parameters, or poor patient compliance. AM treatment has the potential to become a viable treatment option for these nonhealing wounds. However, the effectiveness of the treatment may be influenced by various patient factors and the underlying cause of the wound. Therefore, it is crucial to have an individualized treatment plan that considers these particular factors.

Inter-placental variability is not a major factor affecting the healing efficiency of amniotic membrane when used for treating chronic non-healing wounds

This study aimed to evaluate the efficacy of cryopreserved amniotic membrane (AM) grafts in chronic wound healing, including the mean percentage of wound closure per one AM application, and to determine whether the healing efficiency differs between AM grafts obtained from different placentas. A retrospective study analyzing inter-placental differences in healing capacity and mean wound closure after the application of 96 AM grafts prepared from nine placentas. Only the placentas from which the AM grafts were applied to patients suffering from long-lasting non-healing wounds successfully healed by AM treatment were included. The data from the rapidly progressing wound-closure phase (p-phase) were analyzed. The mean efficiency for each placenta, expressed as an average of wound area reduction (%) seven days after the AM application (baseline, 100%), was calculated from at least 10 applications. No statistical difference between the nine placentas' efficiency was found in the progressive phase of wound healing. The 7-day average wound reduction in particular placentas varied from 5.70 to 20.99% (median from 1.07 to 17.75) of the baseline. The mean percentage of wound surface reduction of all analyzed defects one week after the application of cryopreserved AM graft was 12.17 ± 20.12% (average ± SD). No significant difference in healing capacity was observed between the nine placentas. The data suggest that if there are intra- and inter-placental differences in AM sheets' healing efficacy, they are overridden by the actual health status of the subject or even the status of its individual wounds.

Outcome of Application of Cryopreserved Amniotic Membrane Grafts in the Treatment of Chronic Nonhealing Wounds of Different Origins in Polymorbid Patients: A Prospective Multicenter Study

To compare the therapeutic efficacy of cryopreserved amniotic membrane (AM) grafts and standard of care (SOC) in treating nonhealing wounds (NHW) through a prospective multicenter clinical trial, 42 patients (76% polymorbid) with 54 nonhealing wounds of various etiologies (mainly venous) and an average baseline size of 20 cm2 were included. All patients were treated for at least 6 weeks in the center before they were involved in the study. In the SOC group, 29 patients (36 wounds) were treated. If the wound healed less than 20% of the baseline size after 6 weeks, the patient was transferred to the AM group (35 patients, 43 wounds). Weekly visits included an assessment of the patient's condition, photo documentation, wound debridement, and dressing. Quality of life and the pain degree were subjectively reported by patients. After SOC, 7 wounds were healed completely, 1 defect partially, and 28 defects remained unhealed. AM application led to the complete closure of 24 wounds, partial healing occurred in 10, and 9 remained unhealed. The degree of pain and the quality of life improved significantly in all patients after AM application. This study demonstrates the effectiveness of cryopreserved AM grafts in the healing of NHW of polymorbid patients and associated pain reduction.

The healing dynamics of non-healing wounds using cryo-preserved amniotic membrane

We evaluated the effect of the application of cryo‐preserved amniotic membrane on the healing of 26 non‐healing wounds (18 patients) with varying aetiologies and baseline sizes (average of 15.4 cm²), which had resisted the standard of care treatment for 6 to 456 weeks (average 88.8 weeks). Based on their average general responses to the application of cryo‐preserved AM, we could differentiate three wound groups. The first healed group was characterised by complete healing (100% wound closure, maximum treatment period 38 weeks) and represented 62% of treated wounds. The wound area reduction of at least 50% was reached for all wounds in this group within the first 10 weeks of treatment. Exactly 19% of the studied wounds responded partially to the treatment (partially healed group), reaching less than 25% of closure in the first 10 weeks and 90% at maximum for extended treatment period (up to 78 weeks). The remaining 19% of treated wounds did not show any reaction to the AM application (unhealed defects). The three groups have different profiles of wound area reduction, which can be used as a guideline in predicting the healing prognosis of non‐healing wounds treated with a cryo‐preserved amniotic membrane.

Metformin therapy and risk of cancer in patients after heart transplantation

BACKGROUND

Diabetes mellitus (DM) and malignancy are recognized among the most common complications increasing mortality in patients after heart transplantation (HTx). Clinical trials have shown a higher risk for different types of tumours in diabetic patients. This risk is potentiated by immunosuppressive therapy in transplant patients. Biguanide metformin has been shown to exhibit anti-tumour activity and we tried to find out whether this effect is valid for heart transplant patients.

METHODS

We retrospectively analysed a group of 497 patients, who undergone HTx in our centre between 1998 and 2019. The primary outcome was any malignancy during the 15-year follow-up period and patient's survival.

RESULTS

Out of the 497 patients enrolled in the study, 279 (56 %) had diabetes and 52 (19 %) were treated with metformin. Fifteen-year survival in treated patients without malignancy was 93 %, the remainder for the DM patients was 56 %, with survival in non-DM patients being 74 %. Untreated diabetic patients had 4.7 times higher chance of malignancy than those on metformin (p = 0.01). Fifteen-year survival in metformin treated patients was 53 %, in other DM patients 44 %, and in non-DM patients 51 %.

CONCLUSION

Our study showed a significantly lower incidence of malignancies in metformin-treated patients and slightly better overall survival (Tab. 2, Fig. 3, Ref. 19) Keywords: biguanide, heart graft, malignancy, diabetes mellitus, survival.

Diagnostic and prognostic impact of cardiac magnetic resonance, including scar quantification and strain imaging in patients with malignant ventricular arrhythmias and nonobstructed coronary arteries

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, National Research, Development and Innovation Office

Background

In case of malignant ventricular arrhythmias (VA) and nonobstructed coronary arteries, the differential diagnosis of the  underlying diseases is still challenging, due to the board spectrum of possible causes. Cardiac magnetic resonance (CMR) provides functional, morphological and tissue specific information, including necrotic and scar-tissue. 

Aims

  We aimed to assess the diagnostic and prognostic implications of CMR parameters including global strain values and myocardial scar in patients after ventricular fibrillation (VF) or sustained ventricular tachycardia (SVT) and nonobstructed coronary arteries.

Methods

Between 2011 and 2019, 99 patients (42 ±17 years, 54 male) presenting with VF or SVT and nonobstructed coronary arteries, who underwent CMR examination before secondary prevention implantable cardioverter defibrillator (ICD) implantation were included in our study. Post-processing included feature-tracking strain analysis and left ventricular (LV) scar quantification. Patients were followed for the combined endpoint of all-cause-mortality and appropriate ICD therapy.

Results

CMR examination proved structural myocardial disease in 72%: dilated (n = 21), arrhythmogenic (n = 11), hypertrophic cardiomyopathy (n = 7) and other cardiomyopathies (n = 3). We found LGE patterns showing chronic myocardial infarction (n = 4), suggesting chronic myocarditis (n = 4) and aspecific nonischemic scar formation (n = 14). In 7 cases aspecific structural alterations without scar formation were detected. Overall, myocardial scar was found in 52%, with an average extent of 12 ± 8% of the LV myocardium. The CMR examination changed the clinical diagnosis in 55% of the patients.  During a median follow-up at 2 years, 6 patients died and 42 experienced appropriate ICD therapy. We found an association between cardiac events and the presence of structural abnormality and myocardial scar (logrank: 4,553, p < 0.05 and 8.375, p <0.01).  On Cox proportional-hazards modell LV ejection fraction, LV stroke volume index, the presence of structural abnormality, the presence and extent of  myocardial scar, global LV strain parameters including longitudinal and circumferential strain, and a global left ventricular dssynchrony parameter (mechanical dispersion) were univariate predictors of the combined endpoint of all-cause-mortality and appropriate ICD therapy(p < 0.05). 

Conclusion

CMR performed in patients after malignant VA and nonobstructed coronary arteries not only establishes the diagnosis in a high proportion of patients, but may also provide additional prognostic factors. This may indicate that CMR could play a complementary role in the risk stratification in this patient population.

Abstract Figure.

Differentiation between physiological sport adaptation and hypertrophic cardiomyopathy in highly trained athletes using cardiac magnetic resonance

 

Differentiation between hypertrophic cardiomyopathy (HCM) patients and healthy athletes (HA) is a common clinical conundrum. We aimed to analyze cardiac magnetic resonance (CMR) characteristics of HA, sedentary HCM and athletic HCM patients and to determine CMR parameters which can help to diagnose HCM in athletes.

Male sedentary HCM patients with slightly elevated maximal end-diastolic wall thickness (EDWT 13–18 mm, n=40, 47.6±14.7y) and HA (n=30, 27.5±5.6y) were consecutively enrolled. Additionally, athletes with HCM were enrolled (n=16, 29.6±13.4 y), where a comprehensive investigation confirmed the diagnosis of HCM. We determined conventional CMR parameters (left ventricular (LV) ejection fraction (EF), end-diastolic (EDVi) and end-systolic volume index, mass index (Mi)), derived parameters such as EDWT/LVEDVi, LVM/LVEDV ratio and strain parameters such as global longitudinal (GLS), radial (GRS) and circumferential strain (GCS), SD of peak LS and CS using feature tracking. Presence of late gadolinium enhancement (LGE) was also determined. CMR parameters representing LV hypertrophy pattern or LV function were analyzed using a logistic regression to detect the best CMR parameters to predict HCM in athletes. To differentiate between HA and athletes with HCM optimal cut-off values for CMR parameters were calculated using receiver operating curve analysis.

Comparing the three groups significant differences were found regarding conventional and derived CMR parameters and strain values. None of the HA showed LGE, 75% of athletic HCM and 82% of sedentary HCM patients showed LGE. The univariate regression model showed that LVEF, EDWT, EDWT/LVMi, LVM/LVEDV, GCS, GRS, SD of peak LS and CS are determinants of the diagnosis of HCM among athletes. Multivariate regression revealed that EDWT/LVMi and GCS are independent disease predictors in athletes (p<0.05).

Cut-off value for GCS ≤−32.5 and for EDWT/LVEDVi >0.126 discriminate athletic HCM from HA with a sensitivity of 81.3 and 87.5% (AUC 0.93), and a specificity of 96.7 and 83.3% (AUC 0.95), respectively (Figure 1).

CMR characteristics of sedentary and athletic HCM may differ, therefore establishing diagnostic parameters based on comparison between athletic HCM and HA is essential. CMR based strain and derived parameters may help to differentiate between physiological and pathological left ventricular hypertrophy in athletes.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary (NKFIA) and National Research, Development and Innovation Office (NFKIH) of Hungary.

The influence of vigorous training on the structure and cardiorespiratory fitness in adolescent athletes

Introduction

The functional and morphological adaptation of the cardiovascular system to vigorous exercise in adolescents is less understood compared to adult athletes. Therefore, the differential diagnosis of normal cardiovascular adaptation from the possible pathological alterations is challenging. Cardiovascular magnetic resonance is an important method for assessing ventricular function and morphology. Maximal oxygen uptake (VO2 max) has been established as a reliable measure of the maximal ability to produce metabolic power aerobically.

Aims

The aim of this study was to examine left (LV) and right (RV) ventricular morphologic and functional remodeling in elite adolescent athletes using cardiac magnetic resonance imaging (CMR) and cardiopulmonary exercise test (CPET).

Methods

Between 2017 and 2019 116 asymptomatic adolescent (14–20 years) athletes (>6 training hour/week) underwent CMR and CPET as part of a detailed sports cardiology screening. Cine movie images were performed for the quantification of the LV and RV volumes, masses and ejection fraction, and advanced post processing included feature-tracking strain analysis. CPET was performed on a dedicated athlete protocol.

Results

All athletes participated in sports with a high dynamic component. Male athletes (n=74, 16±1 years) demonstrated higher LV and RV end –diastolic volume index (EDVi), stroke volume index (SVi) and mass index (Mi) compared with female athletes (p<0.001). We found significant difference regarding the global circumferential strain (GCS) and mechanical dispersion (MD) of male and female athletes (GCS −34±4 vs. −31±5%; MD 4±2 vs. 7±4% p<0.05). VO2 showed positive correlation with the LV and RV volumetric parameters (EDVi, SVi) and Mi (p<0.001) and the absolute value of GCS (p<0.05), and negative correlation with the MD (p<0.001). In 36 athletes the VO2 max exceeded the age-adjusted expected VO2 max by 130%, which was categorized as excellent. Besides gender, age, and body surface area CMR based LVEDVi and LVMi were independent predictors of VO2 max.

Conclusion

The functional and morphological adaptation of the adolescent cardiovascular system shows noteworthy differences between male and female athletes. VO2 max correlates with several CMR based values including LV and RV volumetric parameters, masses and strain parameters such as GCS and MD.

Strain analysis of an adolescent athlete

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. ÚNKP-19-3-I New National Excellence Program of the Ministry for Innovation and Technology.

Cardiac magnetic resonance features of acute myocarditis presenting as acute coronary syndrome

Background

Clinical presentation of myocarditis varies, one specific form of myocarditis appears with the clinical signs of acute coronary syndrome (ACS). Cardiac magnetic resonance (CMR) is an important method for assessing ventricular function and morphology, additionally provides accurate tissue specific and functional information of the heart.

Aims

Our aim was to investigate the characteristics, and prognosis of myocarditis presenting with ACS symptoms.

Methods

113 patients with the clinical signs of ACS but nonobstructed coronary arteries in whom the CMR revealed acute myocarditis were included in our study. CMR was performed in acute phase and at 3–6-month follow-up. Left ventricular (LV) volumes, mass and strain parameters expressing myocardial deformity were determined. Additional images were taken to represent tissue specific information. Relationships between laboratory and CMR parameters were investigated. Parameters predicting changes in LV ejection fraction (LVEF) were analyzed by logistic regression.

Results

A total of 113 patients with myocarditis (98 males, 31±11 years) underwent acute and follow-up CMR. Sixty two patients reported fever or infection before the beginning of their complaints, most commonly gastroenteritis (33%) and pharyngitis (32%). The creatinine kinase MB value measured in the acute phase showed positive correlation with the extent of necrosis, and the global longitudinal- and circumferential strain. The extent of the LV necrosis showed negative correlation with LVEF and positive correlation with global circumferential strain (GCS) (p<0.05). On the control CMR examination LVEF and all global strain values improved, fibrosis persisted in 82% of cases but shrank (15±11 vs 5±4 g) and LV mass decreased (p<0.01) compared to the acute phase. Compared to the acute phase, 21% of the patients had lower LVEF on the follow-up CMR. Lower initial LVEF, worse acute GCS, and greater LV necrosis were independent predictors of LVEF reduction in the logistic regression model. During a median follow-up of 6-years of patients treated at our clinic (n=39) no patient suffered cardiac death, heart failure, or documented ventricular arrhythmia but 21% of them had recurrent myocarditis.

Conclusion

Myocarditis mimicking ACS affects predominantly young men and shows functional improvement and good prognosis on follow-up, but it may reoccur in some cases. The reduction of LV function on control CMR may be predicted by worse initial LVEF, GCS, and a larger LV scar.

Strain, LGE in acute phase and follow-up

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Diagnostic impact of early cardiac magnetic resonance imaging in patients with the working diagnosis of MINOCA. Does the final diagnosis affect patients outcome?

Introduction

The diagnostic value of cardiac magnetic resonance (CMR) imaging has been suggested in determination of the cause in patients with the working diagnosis of Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). According to the current STEMI Guideline CMR is considered to have the best diagnostic performance, when CMR timing is within its optimal ≤2 weeks.

Aims

The aim of our study was to assess the diagnostic value of early (1–7 days) CMR examination in patients with signs of troponin positive acute coronary syndrome (ACS) but with nonobstructive coronary arteries. We also aimed to investigate how early CMR changes the provisional diagnosis. We investigated the mortality in each patient group.

Methods

273 consecutive patients (43±16 years, 64% male) with working diagnosis of MINOCA underwent CMR examination following coronary angiography in a mean length of time of 2.5 days between 2009–2020. Cine movie, T2-weighted and late gadolinium enhanced images (LGE) were performed. Left ventricular end-diastolic and end-systolic volumes (LVESVi), ejection fraction (LVEF), mass (LVM) and myocardial necrosis were evaluated. We analysed the risk factors and laboratory values of our patients. Patients were followed for all-cause mortality.

Results

CMR examination established a definitive diagnosis in 86% of the cases: acute myocardial infarction (MI) in 65 patients (47% male), acute myocarditis in 142 patients (87% male), Tako-Tsubo syndrome (TTS) in 27 woman, myocardial contusion in one case. The diagnosis of four patients remained inconclusive after CMR and in 34 pts (50% male) there was no CMR abnormality. CMR changed the provisional diagnosis in 53% of the patients. LVEF was lower, LVESVi was elevated in TTS patients compared to MI and myocarditis (LVEF: 43±9.5 vs 56±7.7 vs 54±6.7%; LVESVi: 52±12.8 vs 38±13.2 vs 42±9.1 ml/m2 p<0.001). Myocarditis patients were younger (myocarditis: 34±10 vs MI 47±14.8 vs TTS 66±10.7 years; p<0.001) and lower percentage had hypercholesterolaemia (myocarditis:18.8 vs MI: 40 vs TTS:54.5%, p<0.01) or hypertension (myocarditis: 20 vs MI: 49 vs TTS: 60%, p<0.001). Laboratory values showed significant elevation of hsTroponin and CKMB of MI and myocarditis patients compared to other groups (p<0.05), but there was no difference between these two groups. During the median follow-up of 3-years 13 patients died. Mortality rate in deaths per patient-year was as follows: MI 2.6 vs Myocarditis 0.4 vs TTS 7.4%. We found a strong association between CMR diagnosis and mortality (logrank 22.3 p<0.001).

Conclusion

Our study demonstrates the diagnostic value of early CMR in patients with the working diagnosis of MINOCA. It established a definite diagnosis in 86% of our patients and changed the provisional diagnosis in 53%. According to our results there is an association between CMR diagnosis and mortality.

Myocarditis, MI, TakoTsubo syndrome

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

P363 Cardiac magnetic resonance characteristics of patients in the grey zone of hypertrophy

Funding Acknowledgements

National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277); Project no. NVKP_16-1-2016-0017. Supported by the ÚNKP-18-3-IV

Background

Differentiation between athlete’s heart and hypertrophic cardiomyopathy (HCM) may cause difficulties especially in patients in the grey zone of hypertrophy.

Purpose

We aimed to analyse cardiac magnetic resonance (CMR) characteristics of healthy athletes, sedentary HCM and athletic HCM patients in the grey zone of hypertrophy.

Methods

Male HCM patients with slightly elevated maximal end-diastolic wall thickness (EDWT 13-18 mm) and highly trained healthy athletes (n = 34, 20.4 ± 2.3 training hrs/week) were consecutively enrolled. HCM patient group was divided to sedentary (n = 35, <7 training hrs/week) and athletic HCM group (n = 13; >7 h/week, 13.2 ± 5.0 h training hrs/week).We determined conventional CMR parameters (left ventricular (LV) ejection fraction (EF),BSA-corrected end-diastolic (EDVi) and end-systolic volume (ESVi), mass (Mi)), derived parameters such as EDWT/LVEDVi, LVM/LVEDV and CMR based strain parameters such as global longitudinal (GLS), radial (GRS) and circumferential strain (GCS), standard deviation of peak LS, RS and CS (SD LS peak, SD RS peak, SD CS peak), standard deviation of time to peak LS, RS and CS (TTP LS, TTP RS, TTP CS) using feature tracking. Presence of late gadolinium enhancement (LGE) was determined on delayed contrast enhanced images. Inter-observer analysis for strain values was performed in a subgroup of 20 patients conducted by two blinded observer.

Results

Healthy athletes showed lower LVEF, GCS and GRS than sedentary and athletic HCM patients, respectively (57.9 ± 5.2 vs 65.3 ± 7.4, 62.7 ± 5.1; -19.7 ± 7.0 vs -24.4 ± 4.6, -22.8 ± 4.8; 61.7 ± 11.2 vs 75.4 ± 21.4, 69.3 ± 19.8). Both healthy athletes and athletes with HCM showed higher LVEDVi, LVESVi, LVSVi and LVMi than sedentary HCM patients. Although sedentary athletes showed higher SD peak strain values and more pronounced intraventricular dyssynchrony than healthy athletes (TTP LS 15.4 ± 4.9 vs 11.7 ± 4.3), none of the global strain values, SD of peak strain values or TTP strain values showed any difference between athletic HCM and healthy athletes. EDWT/LVEDVi ratio was significantly lower in healthy athletes than in sedentary and athletic HCM, respectively (0.11 ± 0.02 vs 0.19±.0.04; 0.18 ± 0.04). Inter-observer analysis showed good agreement in GLS (κ=0.77), GRS (κ=0.69) and TTP LS (κ=0.74), moderate agreement in GCS (κ=0.54), and only fair or poor agreement in SD peak strain, TTP CS and TTP RS values. None of the healthy athletes showed LGE, 62% of athletic HCM and 71% of sedentary HCM patients showed LGE in the hypertrophic segments or in the insertion points.

Conclusions

Based on our results CMR characteristics of sedentary and athletic HCM differs significantly, therefore establishing diagnostic parameters and cut-off values based on comparison between athletic HCM and healthy athletes would be essential. Presence of late gadolinium enhancement and derived parameters may have an important role in the differential diagnosis.

P4429Cardiac magnetic resonance characteristics of professional athletes and hypertrophic cardiomyopathy patients in the grey zone of hypertrophy

Acknowledgement/Funding

National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277). Project no. NVKP_16-1-2016-0017

2388Differential diagnosis of MINOCA patients: the contribution of early cardiac magnetic resonance imaging to the final diagnosis in patients with normal coronary angiography

Introduction

The diagnostic value of cardiac magnetic resonance (CMR) imaging has been suggested in determination of the cause behind Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). According to the current STEMI Guideline CMR is considered to have the best diagnostic performance, when CMR timing is within its optimal ≤2 weeks.

Purpose

The aim of our study was to establish the prevalence of the underlying pathologies using early (1–7 days) CMR examination in patients with signs of troponin positive acute coronary syndrome (ACS) but normal coronary angiography (NCA). We also aimed to investigate how early CMR changes the provisional diagnosis, and to provide detailed information of CMR characteristics of our pts and to compare laboratory parameters and risk factors of each group.

Methods

Between 2010–2018 (n=234) consecutive pts (40.2±12.1y, 159 male) with troponin positive ACS underwent CMR examination following NCA (≤20% stenosis), in a mean length of time of 2.5 days. Cine movie, T2-weighted and late gadolinium enhanced images (LGE) were performed. Left ventricular end-diastolic and end-systolic volumes (LVESVi), ejection fraction (LVEF), mass (LVM) and myocardial necrosis were evaluated. We analysed the risk factors and laboratory values of our patients.

Results

CMR proved acute myocardial infarction (MI) in 42 pts (52% male), acute myocarditis in 138 pts (89% male), Tako-Tsubo cardiomyopathy (TTC) in 25 woman, myocardial contusion in one case, in three cases CMR raised the suspicion of sarcoidosis and in 25 pts (56% male) there was no CMR abnormality. LVEF was lower, LVESVi was elevated in TTC patients compared to MI and myocarditis (LVEF: 44±9.1 vs 56.5±7 vs 55±6.6%; LVESVi: 52.5±12.9 vs 41±16.8 vs 42.1±8.9 ml/m2 p<0.001). The most frequently affected areas of the myocardium by LGE were the basal and mid inferolateral segments in case of myocarditis (69% of pts). In MI pts the anterior wall was affected only in 16%, while the involvement of inferior wall was visible in 57% of the pts. Early CMR examination established a definitive diagnosis in 88% of the cases, in 11% there was no CMR abnormality and it remained inconclusive in only 1% of the cases. CMR changed the provisional diagnosis in 47% of the pts.

Myocarditis pts were younger (myocarditis: 32.5±10.8 vs MI 47.6±15.5 vs TTC 65.5±9.6 y; p<0.001) and lower percentage had hypercholesterinaemia (myocarditis: 18.8 vs MI: 40 vs TTC: 54.5%, p<0.01) or hypertension (myocarditis: 14.3 vs MI: 38.7 vs TTC: 55.6%, p<0.001). Laboratory values showed significant elevation of hsTroponin and CKMB of MI and myocarditis pts compared to other groups (p<0.05), but there was no difference between these two groups.

Underlying pathologies in MINOCA

Conclusion

In patients with the working diagnosis of MINOCA and normal coronary angiography early CMR established a definitive diagnosis in 88% of our patients and changed the provisional diagnosis in 47% of the pts.

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

P876Cardiac magnetic resonance based feature-tracking myocardial strain analysis in MINOCA patients

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

P3558Cardiac magnetic resonance characteristics of the transplanted heart: first results of the prospective Heart-TIming CMR substudy

Background

In case of heart transplantation (HTX) the heart is affected by several factors e.g. ischaemia/reperfusion, denervation, immunosuppression. During the adaptation, the heart may show marked temporal changes in terms of myocardial mechanics, function and tissue characteristics. To better understand temporal characteristics after orthotopic bicaval HTX we started the prospective Heart-TIming (Transplantation Imaging) trial in January 2018 including standard 12-lead ECG, 24-hour Holter monitor, endomyocardial biopsy, transthoracic echocardiography, invasive coronary angiography with intravascular ultrasound and optical coherence tomography and cardiac magnetic resonance (CMR).

Aim

In our CMR substudy we aimed to evaluate the physiological structural and functional left and right ventricular characteristics and their temporal changes after HTX using CMR.

Methods

As part of the study HTX patients underwent CMR at 1, 3 and 6 months after HTX (n=31; 52±10.5y, 25 male). Cine images, T2-weighted, late gadolinium enhancement (LGE) and adenosine stress perfusion (at 1 month) images were acquired. In order to describe physiological characteristics of the transplanted heart we excluded pts with significant coronary artery disease, ischaemic scar, ≥Grade II allograft rejection from this present study (n=6). We assessed the left (LV) and right ventricular (RV) ejection fractions, volumes, masses (M) and LV strain. We assessed the global strain values: longitudinal, circumferential (GCS) strain and the standard deviation (SD) of the peak longitudinal strain (LS) and the left ventricular mechanical dispersion. We compared baseline volumetric and strain parameters to age matched healthy controls (n=20; 47±11.4y, 15 male), and the temporal changes between one, three and 6 months.

Results

Comparing the HTX patients' CMR parameters at one month with normal controls, HTX patients had lower LV and RV end-diastolic volumes (LVEDVi: 76.6±15.9 vs 90.6±11.6ml/m2; RVEDVi 74.5±17.5 vs 90.3±12.1ml/m2, p<0.05),stroke volumes (p<0.05) and higher LVMi (67.6±14.4 vs 57.2±11g/m2, p<0.05). CMR based strain analysis of the HTX pts showed hyperkinetic GCS (−40,5±6.3% vs −35.2±4.8%, p<0.05), increased SD of peak LS and more pronounced mechanical dispersion (p<0.001) compared to the controls. Examining temporal changes in HTX pts we found a decrease in LVMi (69.57±16.4 vs 61.7±9.8g/m2, p<0.05) already at three months, normalization of GCS (−37.7±5.5% vs −32.6±4.9%, p<0.05) and decrease in SD of peak LS (13.5±2.3 vs 11.4±2.4, p<0.05) at 6 months. Oedema was present in all pts at one month after HTX, and disappeared after three months. LGE with aspecific pattern was present in 42%.

LGE with aspecific pattern in HTX pts

Conclusions

Understanding the temporal changes of LV mechanics, function and tissue characteristics, furthermore the establishment of physiological values may help in the early, noninvasive identification of pathological changes in HTX pts.

NCT number: NCT03499197

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

Myeloid but not epithelial tissue factor exerts protective anti-inflammatory effects in acid aspiration-induced acute lung injury

Essentials Tissue factor (TF) represents a central link between hemostasis and inflammation. We studied the roles of myeloid and airway epithelial TF in acid-caused acute lung injury (ALI). TF on myeloid cells displays a non-coagulatory role regulating the inflammatory response in ALI. Airway epithelial TF contributes to hemostatic functions, but is dispensable in ALI pathogenesis.

SUMMARY

Introduction Acute lung injury (ALI) is a life-threatening condition characterized by damaged alveolar-capillary structures and activation of inflammatory and hemostatic processes. Tissue factor (TF) represents a crucial link between inflammation and coagulation, as inflammatory mediators induce myeloid TF expression, and TF initiates extrinsic coagulation. Objective As pulmonary inflammation stimulates TF expression and TF modulates immune responses, we aimed to elucidate its impact on ALI. In particular, we wanted to distinguish the contributions of TF expressed on airway epithelial cells and TF expressed on myeloid cells. Methods Mice with different cell type-specific TF deficiency and wild-type littermates were intratracheally treated with hydrochloric acid, and leukocyte recruitment, cytokine levels, thrombin-antithrombin (TAT) complexes and pulmonary protein-rich infiltrates were analyzed. Results Our data demonstrate that a lack of epithelial TF did not influence acute responses, as bronchoalveolar neutrophil accumulation 8 h after ALI induction was unaltered. However, it led to mild, prolonged inflammation, as pulmonary leukocyte and erythrocyte numbers were still increased after 24 h, whereas those in wild-type mice had returned to basal levels. In contrast, myeloid TF was primarily involved in regulating the acute phase of ALI without affecting local coagulation, as indicated by increased bronchoalveolar neutrophil infiltration, pulmonary interleukin-6 levels, and edema formation, but equal TAT complex formation, 8 h after ALI induction. This augmented inflammatory response associated with myeloid TF deficiency was confirmed in vitro, as lipopolysaccharide-stimulated TF-deficient alveolar macrophages released increased levels of chemokine (C-X-C motif) ligand 1 and tumor necrosis factor-α as compared with wild-type macrophages. Conclusion We conclude that myeloid TF dampens inflammation in acid-induced ALI.

Association between the heart rate early after heart transplantation and the long term clinical outcomes

BACKGROUND

A strong correlation between a lower heart rate and survival has been demonstrated in various patient populations. The optimal heart rate for heart transplant patients is still unknown. The aim of our study was to evaluate the association between an early heart rate and survival after heart transplantation.

MATERIAL AND METHODS

We retrospectively analysed a group of 330 patients, who underwent heart transplantation in our institution from 1994 to 2014 and complete datasets, including 24-hour heart rate monitoring one month after the heart transplantation. Patients were divided in 2 groups: Group A (n = 278) with the average 24-hour heart rate <90 bpm, and Group B (n = 52) with ≥ 90 bpm.

RESULTS

The average period of monitoring was 7.5 ± 5.3 years. No differences in baseline characteristics were observed in both groups of recipients and respective donors. One-year survival in groups A and B was 92 % and 81 %, respectively; 5-year survival was 79 % and 60 %, respectively; and 10-year survival was 66 % and 50 %, respectively (p = 0.001).

CONCLUSION

Increased heart rate in the early post-transplant period was significantly associated with a poorer survival rate in patients after heart transplantation (Tab. 2, Fig. 1, Ref. 25).

Importance of Reversible Attachment in Predicting E. Coli Transport in Saturated Aquifers From Column Experiments

Drinking water wells indiscriminatingly placed adjacent to fecal contaminated surface water represents a significant but difficult to quantify health risk. Here we seek to understand mechanisms that limit the contamination extent by scaling up bacterial transport results from the laboratory to the field in a well constrained setting. Three pulses of E. coli originating during the early monsoon from a freshly excavated pond receiving latrine effluent in Bangladesh were monitored in 6 wells and modeled with a two-dimensional (2-D) flow and transport model conditioned with measured hydraulic heads. The modeling was performed assuming three different modes of interaction of E. coli with aquifer sands: 1) irreversible attachment only (best-fit ki=7.6 day-1); 2) reversible attachment only (ka=10.5 and kd=0.2 day-1); and 3) a combination of reversible and irreversible modes of attachment (ka=60, kd=7.6, ki=5.2 day-1). Only the third approach adequately reproduced the observed temporal and spatial distribution of E. coli, including a 4-log10 lateral removal distance of ∼9 m. In saturated column experiments, carried out using aquifer sand from the field site, a combination of reversible and irreversible attachment was also required to reproduce the observed breakthrough curves and E. coli retention profiles within the laboratory columns. Applying the laboratory-measured kinetic parameters to the 2-D calibrated flow model of the field site underestimates the observed 4-log10 lateral removal distance by less than a factor of two. This is promising for predicting field scale transport from laboratory experiments.

Lineage specific composition of cyclin D-CDK4/CDK6-p27 complexes reveals distinct functions of CDK4, CDK6 and individual D-type cyclins in differentiating cells of embryonic origin

Abstract. Objectives: This article is to study the role of G₁/S regulators in differentiation of pluripotent embryonic cells. Materials and methods: We established a P19 embryonal carcinoma cell‐based experimental system, which profits from two similar differentiation protocols producing endodermal or neuroectodermal lineages. The levels, mutual interactions, activities, and localization of G₁/S regulators were analysed with respect to growth and differentiation parameters of the cells. Results and Conclusions: We demonstrate that proliferation parameters of differentiating cells correlate with the activity and structure of cyclin A/E–CDK2 but not of cyclin D–CDK4/6–p27 complexes. In an exponentially growing P19 cell population, the cyclin D1–CDK4 complex is detected, which is replaced by cyclin D2/3–CDK4/6–p27 complex following density arrest. During endodermal differentiation kinase‐inactive cyclin D2/D3–CDK4–p27 complexes are formed. Neural differentiation specifically induces cyclin D1 at the expense of cyclin D3 and results in predominant formation of cyclin D1/D2–CDK4–p27 complexes. Differentiation is accompanied by cytoplasmic accumulation of cyclin Ds and CDK4/6, which in neural cells are associated with neural outgrowths. Most phenomena found here can be reproduced in mouse embryonic stem cells. In summary, our data demonstrate (i) that individual cyclin D isoforms are utilized in cells lineage specifically, (ii) that fundamental difference in the function of CDK4 and CDK6 exists, and (iii) that cyclin D–CDK4/6 complexes function in the cytoplasm of differentiated cells. Our study unravels another level of complexity in G₁/S transition‐regulating machinery in early embryonic cells.

Which molecularly imprinted polymer is better?

Molecularly imprinted polymers (MIP) have been successfully synthesized toward many different compounds in the last decades. The mechanistic details of selective binding at binding sites are not yet well understood. For this reason the characterization of MIP binding has been mostly phenomenological and this makes the transfer of results between different laboratories or between different types of applications difficult. In this paper we analyze the relationship between different types of characterization like isotherms, binding site models, chromatographic k and alpha values, etc. as they relate to different applications like HPLC, solid phase extraction (SPE), binding assays, batch extraction and sensors. It is shown that alpha values determined by elution chromatography depend on seemingly irrelevant factors as the length and diameter of the column, respectively. The determination of distribution ratios or partition coefficients is proposed as an easily understandable and useful quantity in the characterization of novel MIPs. Data used for the characterization of a MIP should be transferable between different applications but the qualification of MIPs as better or worse will depend on the application in case.

Oldie but goldie: Bristow-Latarjet procedure for anterior shoulder instability

PURPOSE

To analyse the functional and radiological outcomes of the Bristow-Latarjet procedure in patients with recurrent anterior glenohumeral instability.

METHODS

Records of 29 patients were reviewed retrospectively. Date of first dislocation, injury mechanism, and number of recurring dislocations before and after surgery were recorded. The overall function and stability of the shoulder was evaluated.

RESULTS

24 (83%) of the glenohumeral instabilities were caused by trauma. The mean number of recurring dislocations was 8 (95% confidence interval [CI], 0-18); one patient had had 40 recurrences. No dislocation ensued postoperatively. The overall functional outcome was good, with a mean Rowe score of 90 points (95% CI, 78-100). Scores of 17 (59%) of the patients were excellent, 7 (24%) were good, 3 (10%) were fair, and 2 (7%) were poor.

CONCLUSION

The Bristow-Latarjet procedure is a good surgical treatment for recurrent anterior-inferior instability of the glenohumeral joint.

Nonlinear adsorption isotherm as a tool for understanding and characterizing molecularly imprinted polymers

Molecularly imprinted polymers (MIPs) have frequently been characterized by quantities which are easily determined from experiments but have no theoretical foundation. This makes it difficult to compare different MIP preparations or to transfer MIP based methods to different experimental conditions. Since the adsorption isotherms of MIPs are markedly nonlinear, one can build a better characterization strategy on isotherms as shown by examples in this paper.

Increased apoptosis in differentiating p27-deficient mouse embryonic stem cells

In mouse embryonic stem (mES) cells, the expression of p27 is elevated when differentiation is induced. Using mES cells lacking p27 we tested the importance of p27 for the regulation of three critical cellular processes: proliferation, differentiation, and apoptosis. Although cell cycle distribution, DNA synthesis, and the activity of key G1/S-regulating cyclin-dependent kinases remained unaltered in p27-deficient ES cells during retinoic acid-induced differentiation, the amounts of cyclin D2 and D3 in such cells were much lower compared with normal mES cells. The onset of differentiation induces apoptosis in p27-deficient cells, the extent of which can be reduced by artificially increasing the level of cyclin D3. We suggest that the role of p27 in at least some differentiation pathways of mES cells is to prevent apoptosis, and that it is not involved in slowing cell cycle progression. We also propose that the pro-survival function of p27 is realized via regulation of metabolism of D-type cyclin(s).

[Assessment of functional capability of liver parenchyma using indocyanine green before liver resection]

During the period from 1997 to 2000, the total of 129 liver operations were performed at the 2nd Surgical Department of the Masaryk's University in Brno. Malignant tumours were present in 91 cases. In-hospital mortality in patients operated on for malignant liver tumours was 2.1%. No case of death was caused by liver insufficiency. Examination of liver function by use of indocyanine green (ICG) enabling the determination of the extent of possible resection, contributes to the lowering of postoperative morbidity and mortality. The rate of indocyanine green retention up to 6% does not limit the extent of resection, the retention rate up to 15% allows bisegmentectomy or a minor surgery, the retention rate up to 20% allows segmentectomy at the most, and the retention rate up to 30% enables superficial excisions only.

Liposome flow injection immunoassay: model calculations of competitive immunoreactions involving univalent and multivalent ligands

The use of liposomes as detectable reagents in solid-phase immunoassays has been explored in a flow injection immunoanalysis (FIIA) system. Model calculations are presented for FIIA based on the competitive binding of univalent analyte and multivalent liposomes to immobilized antibodies. Parameters such as binding constants, concentrations of liposomes and antibody, and steric hindrance are considered for their relative effects on detectable liposome signal response to analyte concentrations. Qualitative comparisons of the model with the experimental data are made.

Maintenance of normoglycemia in pancreatectomized dogs with a controlled release micropump

A diffusion-based insulin micropump was capable of sustaining normoglycemia in diabetic, pancreatectomized dogs for as long as 10 months. Basal insulin delivery was provided by diffusion into the peritoneal cavity from the insulin reservoir across a silicone rubber porous outlet, while the delivery of insulin was augmented for 35 minutes at mealtimes by repeated squeezing of a polyurethane foam disk; the latter was initiated 15 minutes prior to the start of the meal. In the best implant, which functioned for more than 10 months before it was deliberately terminated, the mean glucose level was 126 +/- 24.7 mg/dl (+/- SD) and the mean Schlichtkrull M value was 2.8. In the other three implants, the mean and standard deviations were a little higher. The basal insulin supply was sufficient to restore normoglycemia each morning, while the augmented supply substantially reduced the size of the postprandial period of hyperglycemia. Over the 10 month period studied, the maximum concentration was 150 mg/dl approximately 6 hours after the beginning of the meal, based on the mean of the approximately 200 glucose profiles determined for this implant. Despite this ability to maintain reasonable normoglycemic profiles for long periods, the pump performance deteriorated over this time period, presumably from a tissue reaction to the porous outlet of the implant. This deterioration was evident in the higher levels of glycemia associated with an insulin delivery program that was maintained for too long or in the need to readjust the program to achieve similar levels of glycemia. Nevertheless, the biocompatibility and efficacy of the controlled release micropump demonstrates the feasibility of this approach.