Outcomes of patients with left ventricular noncompaction and preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION 

Left ventricular noncompaction (LVNC) is a poorly defined entity with heterogeneous prognosis. LV ejection fraction (LVEF) is one of the main predictors of major adverse cardiovascular events (MACE). However, outcomes of LVNC patients with preserved LVEF (pEF) remain uncertain.

PURPOSE 

The aim of our study was to determine the incidence and predictors of MACE in LVNC patients with pEF as well as to assess the evolution of LVEF throughout follow-up. 

METHODS 

We conducted a retrospective, longitudinal, multicentre cohort study. Consecutive patients with transthoracic echocardiography (TTE) and/or cardiac magnetic resonance (CMR) diagnostic criteria for LVNC and initially pEF (LVEF≥50%) were recruited. MACE were defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality. Progressive systolic dysfunction was defined as an LVEF < 50% at last TTE and/or an absolute ≥10-point decrease in LVEF from first to last TTE. Lower limit of LVEF CMR values were considered 50-57% according to current recommendations. Cox-regression analysis was used for MACE and logistic regression was used for progressive systolic dysfunction (only first and last TTE were available).

RESULTS 

A total of 305 patients from 12 centres were included from 2000 to 2018. Age was 38 ± 19 years and 165 (54%) were men. LVEF was 62 ± 8% and 8% had late gadolinium enhancement (LGE). During a median follow-up of 4.7 (IQR 2.1-7.4) years, MACE occurred in 40 (13%) patients with an incidence rate of 2.73 (95% CI 2.00-3.72) events per 100 person-years: 8 HF, 27 VA, 3 SE and 5 deaths. LVEF by CMR (HR 0.95, 95% CI 0.91-0.99, p = 0.0048) and hypertension (HR 2.30, 95% CI 1.08-4.89, p = 0.031) were the only variables independently associated with the endpoint. Patients with lower limit LVEF values showed an increased risk of MACE (Figure 1). LGE was not associated.

Sixty-one (21%) patients experienced progressive systolic dysfunction: 31 (11%) had an LVEF < 50% and 48 (17%) an absolute ≥10-point decrease in LVEF at last follow-up. On multivariate analysis, LVEF by CMR was the only independent predictor (OR 0.93, 95% CI 0.89-0.98, p = 0.008). Patients with lower limit LVEF values had an increased risk (Figure 2). In this subgroup, LGE was also associated with the endpoint (HR 10.69, 95% CI 1.97-58.13, p = 0.006).

CONCLUSIONS 

Patients with left ventricular noncompaction and preserved ejection fraction carry a moderate risk of major adverse cardiovascular events and progressive systolic dysfunction. LVEF remains the main predictor of outcomes in this subgroup. Patients with lower limit LVEF values are at increased risk, probably suggesting subclinical systolic dysfunction. Therefore, they should be carefully monitored. Abstract Figure. Kaplan Meier cuves for MACE  Abstract Figure. Risk of progressive systolic dysfunction

Prognosis of left ventricular noncompaction with preserved ejection fraction

Introduction

Left ventricular noncompaction (LVNC) is a poorly defined entity with heterogeneous prognosis. LV ejection fraction (LVEF) is one of the main predictors of major adverse cardiovascular events (MACE). However, outcomes of LVNC patients with preserved LVEF (pEF) remain uncertain.

Purpose

The aim of our study was to determine the incidence and predictors of MACE in LVNC patients with pEF as well as to assess the evolution of LVEF throughout follow-up.

Methods

We conducted a retrospective, longitudinal, multicentre cohort study. Consecutive patients with transthoracic echocardiography (TTE) and/or cardiac magnetic resonance (CMR) diagnostic criteria for LVNC and initially pEF (LVEF≥50%) were recruited. MACE were defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality. Progressive systolic dysfunction was defined as an LVEF<50% at last TTE and/or an absolute ≥10-point decrease in LVEF from first to last TTE. Lower limit of LVEF values were considered 50–53% for TTE and 50–57% for CMR, according to current recommendations.

Results

A total of 305 patients from 12 centres were included from 2000 to 2018. Age was 38±19 years, 165 (54%) were men and 185 (61%) were probands. LVEF was 62±8% and 8% had late gadolinium enhancement (LGE). During a median follow-up of 4.7 (IQR 2.1–7.4) years, MACE occurred in 40 (13%) patients with an incidence rate of 2.96 (95% CI 2.17–4.04) events per 100 person-years: 8 HF, 27 VA, 3 SE and 5 deaths. LVEF by TTE (HR 0.95, 95% CI 0.90–0.99, p=0.035) and age (HR 1.02, 95% CI 1.01–1-04, p=0.04) were the only variables independently associated with the endpoint. Patients with lower limit LVEF values showed an increased risk of MACE (Figure 1). Among probands, those with family aggregation presented a higher incidence of MACE compared to nonfamilial cases (HR 2.74, p=0.043). A positive genotype was not associated.

Sixty-one (21%) patients experienced progressive systolic dysfunction: 31 (11%) had an LVEF<50% and 48 (17%) an absolute ≥10-point decrease in LVEF at last follow-up. On multivariate analysis, LVEF by CMR was the only independent predictor (HR 0.96, 95% CI 0.92–0.99, p=0.031). Patients with lower limit LVEF values had an increased risk (Figure 2). In this subgroup, LGE was also associated with the endpoint (HR 3.52, p=0.011). Family aggregation was not associated, while a positive genotype correlated with lower risk (HR 0.52, p=0.029).

Conclusions

Patients with left ventricular noncompaction and preserved ejection fraction carry a moderate risk of major adverse cardiovascular events and progressive systolic dysfunction. LVEF remains the main predictor of outcomes in this subgroup. Patients with lower limit LVEF values are at increased risk, probably suggesting subclinical systolic dysfunction. Therefore, they should be carefully monitored.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

209. The absence of betaglycan affects Sox9 m RNA expression at the time of sex determination in a mouse model

Betaglycan is a co-receptor that binds both TGF-β and inhibin, and thereby acts as a modulator of the activities of multiple members of the TGF-β superfamily. We have previously shown that the murine betaglycan gene is expressed in somatic cells within the interstitium of the fetal testis from 12.5 dpc-16.5 dpc. Betaglycan protein was predominantly localised to the interstitial cells surrounding the developing seminiferous cords which stained positive for Cyp11a (p450 Scc), a Leydig cell marker. In order to determine the impact of this receptor on fetal Leydig cell biology, RNA was extracted from two independently collected sets of betaglycan knockout and wildtype male and female gonads at 12.5 dpc and 13.5 dpc (n = 4 gonad pairs/set), and quantitative real time PCR was performed to determine changes in the expression levels of key genes involved in fetal Leydig cell differentiation and function. This analysis revealed that the levels of mRNA expression of SF1, Cyp11a and Cyp17a1 were downregulated between 12.5–13.5 dpc in the betaglycan knockout embryos compared with wildtype embryos immediately after the time of sex determination. Interestingly, the expression level of the key Sertoli cell marker SRY-(sex determining region Y)-box 9 (Sox9) was transiently decreased at 12.5 dpc by 50% in the knockout testis in comparison with that of the wildtype testis. No significant change was found one day later at 13.5 dpc. Our data show that betaglycan is predominantly expressed in the fetal Leydig cells of the murine testis and that the presence of this receptor is required for normal fetal Leydig cell differentiation. Furthermore, the transient downregulation of Sox9 expression in null testis suggests that Sertoli cell differentiation may also be affected in betaglycan knockout mice, and that this defect may precede the defect in Leydig cell development. Supported by: the NHMRC Australia (RegKeys 338516; 241000).

266. Loss of betaglycan expression contributes to malignant properties of human granulosa tumour cells

Betaglycan is a type III TGF-β receptor that binds to both inhibin and TGF-β with high affinity and determines cellular sensitivity to these ligands. Previous studies have suggested that betaglycan acts as a tumour suppressor in certain human epithelial cancers. However, the roles of betaglycan in ovarian granulosa cell tumours (GCTs) are poorly understood. The objective of this study was to determine whether human GCTs exhibit betaglycan expression, and if so, what impact this receptor has on tumour biology. Real-time PCR was used to quantify betaglycan transcripts in human GCTs (n = 18) and normal premenopausal ovaries (n = 11). This analysis established that GCTs exhibited a significant 2-fold reduction in mean betaglycan mRNA levels as compared with the normal ovary (P < 0.05). Similarly, two human GCT cell lines, the KGN and COV434, exhibited low betaglycan expression and poor responsiveness to TGF-β and inhibin in luciferase reporter assays. Stable transfection of GCT cell lines with a wildtype betaglycan (WT-BG) expression plasmid conveyed ligand responsiveness. FACS analysis was used to examine cell cycle progression and cell death in the GCT cell lines. This analysis revealed that WT-BG had no effect on the number of cells cycling or undergoing apoptosis. However, WT-BG significantly increased the adhesion of COV434 (P < 0.05) and KGN (P < 0.0001) cells to collagen IV and fibronectin, decreased cellular invasion through Matrigel COV434 (50%) and KGN (75%), and inhibited wound healing COV434 (70%) and KGN (80%). Collectively, the data establish that betaglycan is an important regulator of granulosa cell biology and suggest that a deficiency in betaglycan contributes to the pathogenesis of granulosa cell cancer. The work further suggests a role for betaglycan in the prevention of tumour invasion, possibly by increasing the adhesion of granulosa cells to matrix components. Supported by: the NHMRC of Australia (RegKeys 338516; 241000; 441101; 388904).

118. Regulation of inhibin binding and action via betaglycan expression in mouse Leydig-like TM3 cells

The actions of inhibin and transforming growth factor (TGF)-β2 are enhanced when their respective target cells express the TGF-β/inhibin co-receptor, betaglycan. In the present studies, we investigated the effects of multiple members of the TGF-β superfamily on betaglycan expression, and examined the consequences of such regulation for inhibin binding, and inhibin and TGF-β actions in mouse Leydig-like TM3 cells. Isoforms of activin (A and B), TGF-β (1 and 2) and BMP (2, 6 and 7) each suppressed the level of betaglycan mRNA in TM3 cells to 43–46%, 26–39% and 50–71% of control, respectively, during overnight treatment. Subsequent inhibin A binding was suppressed to 72–77%, 35–36% and 66–70% of control, respectively, with IC50s of 0.07–0.7, 0.05–0.5 and 0.4–0.6 nM, respectively. The effects of inhibiting betaglycan expression by TM3 cells on their responses to inhibin and TGF-β2 were examined by transfecting cells with a promoter construct that contains three copies of the activin-responsive sequence of the GnRHR promoter (3XpGRAS-PRL-lux) either alone or in the presence of small (21 bp) duplex siRNAs corresponding to the betaglycan gene. Activin A (0.5 nM) stimulated 3XpGRAS-PRL-lux expression 3–4 fold over control in TM3 cells, and inhibin dose-dependently abolished this stimulation, with no interference from the control siRNA (against BF-1 forkhead-like protein). However, inhibin suppression of activin-stimulated activity was antagonized in cells co-transfected with betaglycan siRNA. TGF-β (1 and 2) stimulated 3XpGRAS-PRL-lux expression 5–8 fold over control, and the action of TGF-β2, but not TGF-β1, was attenuated by the betaglycan siRNA. In summary, activin, TGF-β and BMP isoforms inhibit betaglycan expression by Leydig-like TM3 cells, and inhibin A binding is commensurately reduced. The ‘knock-down’ of betaglycan expression by specific siRNA inhibits TM3 responses to inhibin and TGF-β2. Whether the inhibition of betaglycan expression by activin, TGF-β and BMP has similar consequences for inhibin and/or TGF-β2 action is yet to be determined. These studies raise the possibility that multiple members of the TGF-β superfamily participate in cross-talk via the inhibin/TGF-β co-receptor, betaglycan. Funded by the NH&MRC of Australia (RegKey 241000 & 198705).

Screening for trauma history on an inpatient affective-disorders unit: a pilot study

Psychiatric inpatients (N = 343) admitted to an affective-disorders unit were administered a self-rating Trauma Questionnaire (TQ) to evaluate life history of traumatic experiences. Eighty four percent of the sample identified at least one traumatic-event category (M = 2.27 categories/patient). Symptoms consistent with posttraumatic stress disorder (PTSD), were highly prevalent. However, only six patients received a chart diagnosis of posttraumatic stress disorder. Female patients evidenced more PTSD symptoms than males, in contrast to an equal number of event categories identified by the two sexes. Age correlated negatively with number of symptoms endorsed. Implications for trauma screening in affective-disorder patients are discussed.

Time evolution of the caustics of a laser heated liquid film

The free surface of a liquid film of black oil is deformed by heating with a Gaussian laser beam, thus changing the intensity distribution in the reflected and transmitted beams. The time evolution of the caustics of those beams is numerically studied. The topological structure of the caustics abruptly changes at three critical instants of time. Measurement of the divergence of the caustics of the reflected and transmitted beams allows one to deduce the liquid refractive index.