Hemodynamic forces and myocardial deformation using cine MRI in Marfan syndrome

Funding Acknowledgements

Type of funding sources: None.

Introduction. Cardiovascular assessment of Marfan syndrome (MS) patients has normally focused on the aortic root and vascular manifestations due to the high risk of aortic dissection.

Although primary myocardial impairment has long been suspected, the evidence has been controversial. Advanced in CMR may support the early detection of cardiac dysfunction. Beyond left ventricle ejection fraction (EF) and myocardial strain (S), a new parameter is emerging, the hemodynamic forces (HF) exchanged between the blood flowing in the heart and the myocardium.  The application of these techniques to MS could be useful in demonstrating the presence of primary myocardial impairment.

Aim. The aim of this study is to explore myocardial function in MS through the evaluation in cine CMR of EF, S and cardiac HF exchanged between the blood and the myocardium and compare these data with those of a control group (C).

Methods. We retrospectively analysed CMR cine images of MS (diagnosed according revised Ghent criteria) without valvular disease or previous cardio surgery, and C, in standard long-axis projections, to define endocardial borders for subsequent quantification of left ventricular volumes, EF, longitudinal, circumferential and radial S, apex-to-base and lateral-to-septum HF (expressed in mN and as a percentage of gravity acceleration). The analysis were performed on Medical Imaging Systems (QStrain version 1.3.0.79; MEDIS) (Figure 1).

Results. 108 MS and 44 C had a good quality study, suitable for MEDIS analysis. The mean age was 33 ± 13 ys in MS, 35 ± 12 ys in C; 39% were male in MS, 50% in C.

The results of left ventricular function were: EF 63 ± 7% in MS vs 66 ± 5% in C group, p .008, global longitudinal S -24.5 ± 4.1% in MS vs -26.2 ± 4.1 in C, p .014; global circumferential S -30.6 ± 6.3% in MS vs -33.8 ± 4.4 in C, p .002; radial S 64.5 ± 16.2% in MS vs 72.7 ± 15.9 in C, p .005; apex-to-base HF 13.2 ± 4.7% in MS vs 17.8 ± 7.6% in C, p .000; lateral-to-septum 2.6 ± 1.3% in MS vs 3.1 ± 1.4% in C, p .048.

Moreover, 4.6% MS patients had mid reduced EF (40-50%); 9.2% had global longitudinal S reduction (cut off -19.3%); 7.4% had global circumferential S reduction (cut-off -21.7%).

Conclusion. These data provide support for the existence of a cardiomyopathy in MS. In our opinion, the term "primary cardiomyopathy" is not appropriate to describe this condition: patients with MS have changes in aortic stiffness and probably in cardiac afterload. The HF data are the most interesting of this study, both in the validation of this new parameter and in early detection a cardiomyopathy in MS

Moreover, the reduction of global circumferential S, as wall as global longitudinal S, in MS patients may help provide new elements to characterize the MS cardiomyopathy: sure enough, in literature, circumferential strain abnormalities are related to afterload increase. HF analysis is really a new challenge of cardiac imaging, as sensitive markers of subtle systolic dysfunction.

Abstract Figure. Figue 1. Analisis exemple.

Prognostic implications of myocardial work in patients with reduced left ventricular ejection fraction: a preliminary study

Funding Acknowledgements

Type of funding sources: None.

Background. Myocardial work (MW) is a new imaging technique to assess left ventricular (LV) systolic function. It incorporates both deformation parameters (global longitudinal strain -GLS-) and loading conditions and gives information on global constructive work (GCW), global wasted work (GWW), global LV myocardial work index (GWI) and global LV myocardial work efficiency (GWE).

Purpose. The aim of this study was to describe the prognostic role of MW in predicting major adverse cardiovascular events (MACE) in patients with reduced LV ejection fraction (LVEF), and to compare it with GLS and LVEF.

Methods. We retrospectively included consecutive patients from 2012 to 2019 with dilated LV and LVEF < 50% of any aetiology.  Clinical variables were collected and LVEF, GLS and MW were evaluated from baseline echocardiogram. MACE was defined as heart failure (HF) and/or ventricular arrhythmia (VA) and/or cardiac arrest and/or all cause death. 

Results. 99 patients were included, 26 were women (26.3%), mean age at diagnosis was 57 years (SD 23). Mean LVEF was 32.5% (SD 10.3). Baseline patients characteristics are described in Table 1. During a median follow-up of 25 months (IQR 12), 24 MACE were recorded (24.4%). Patients with MACE had worse MW parameters: significantly lower MWI (805 ± 360 % vs 638 ± 277 %, p = 0.04) and lower GCW (1116 ± 535 mmHg vs 874 ± 458 mmHg, p = 0.05), and a tendency to lower GWE (83 ± 11 % vs 77 ± 16 %, p = 0.084).  Of note, both LVEF (33 ± 10% vs 29 ± 9%, p = 0.123) and GLS (-9.99 ± 3.7% vs -8.8 ± 3.0, p = 0.170) showed a trend but were not significantly associated with outcomes. This might suggest that MW variables are stronger prognostic predictors than traditional imaging parameters.

Conclusions. In patients with reduced LVEF, MW parameters including global  MWI and GCW were associated with major adverse cardiovascular events. Of note, both EF and GLS seem to have less prognostic implications in this cohort when compared with MW. Our results are preliminary and larger studies are needed in order to fully understand the clinical utility of MW beyond traditional parameters.

Baseline patient characteristics GLOBAL EVENTS NO EVENTS p Hypertension, % 41 67 29 0.014 Ischaemic etiology, % 14 20 12 0.448 Creatinine, mean (SD) - mg/dL 0.96 (0.04) 1.11 (0.09) 0.90 (0.04) 0.021 Bblockers, % 98 100 97 0.514 Nitrates, % 4 13 0 0.025 Diuretics, % 65 93 53 0.006 SD standard deviation Abstract Figure. Results

Prognostic implications of myocardial work in patients with reduced left ventricular ejection fraction: a preliminary study

Background

Myocardial work (MW) is a new imaging technique to assess left ventricular (LV) systolic function. It incorporates both deformation parameters (global longitudinal strain -GLS-) and loading conditions and gives information on global constructive work (GCW), global wasted work (GWW), global LV myocardial work index (GWI) and global LV myocardial work efficiency (GWE).

Purpose

The aim of this study was to describe the prognostic role of MW in predicting major adverse cardiovascular events (MACE) in patients with reduced LV ejection fraction (LVEF), and to compare it with GLS and LVEF.

Methods

We retrospectively included consecutive patients from 2012 to 2019 with dilated LV and LVEF <50% of any aetiology. Clinical variables were collected and LVEF, GLS and MW were evaluated from baseline echocardiogram. MACE was defined as heart failure (HF) and/or ventricular arrhythmia (VA) and/or cardiac arrest and/or all cause death.

Results

99 patients were included, 26 were women (26.3%), mean age at diagnosis was 57 years (SD 23). Mean LVEF was 32.5% (SD 10.3). Baseline patients characteristics are described in Table 1. During a median follow-up of 25 months (IQR 12), 24 MACE were recorded (24.4%). Patients with MACE had worse MW parameters: significantly lower MWI (805±360% vs 638±277%, p=0.04) and lower GCW (1116±535 mmHg vs 874±458 mmHg, p=0.05), and a tendency to lower GWE (83±11% vs 77±16%, p=0.084). Of note, both LVEF (33±10% vs 29±9%, p=0.123) and GLS (−9.99±3.7% vs −8.8±3.0, p=0.170) showed a trend but were not significantly associated with outcomes. This might suggest that MW variables are stronger prognostic predictors than traditional imaging parameters.

Conclusions

In patients with reduced LVEF, MW parameters including global MWI and GCW were associated with major adverse cardiovascular events. Of note, both EF and GLS seem to have less prognostic implications in this cohort when compared with MW. Our results are preliminary and larger studies are needed in order to fully understand the clinical utility of MW beyond traditional parameters.

Results

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Universitary Hospital Vall d'Hebron

P1601 Relationship between aortic distensibility and aortic regurgitation assessed by CMR in bicuspid valve patients

Funding Acknowledgements

Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1, ISCIII PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

BACKGROUND

The severity of aortic regurgitation can be evaluated with cardiac magnetic resonance (CMR) through calculation of regurgitant fraction (RF) in phase contrast sequences acquired at the aortic root (as close as possible to the aortic valve). However, the impact of aortic distensibility in this evaluation remains unkown.

PURPOSE

The aim of the study was to evaluate the relation between aortic distensibility and RF valve in bicuspid aortic valve patients.

METHODS

We enrolled bicuspid aortic valve patients without significant aortic stenosis (maximum velocity <2.5 m/s) and connective tissue disease. All patients underwent a CMR study with phase contrast sequences for evaluation of regurgitant fraction at the level of the aortic valve. Aortic regurgitation was considered as mild, moderate or severe depending on RF value (mild <15%; moderate 15-30%; severe >30%). Furthermore we used cine-sequences of aortic root, ascending and proximal descending aorta to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

RESULTS

A total of 98 bicuspid aortic valve patients were included (30% female, 49.7 ± 14.5 years). 75 (76,5%) AR was mild, 17 (17,4%) moderate and 6 (6,1%) severe. RF valvewas significantly correlated with aortic root diameter (r= 0.430 y p < 0.001 )and aortic distensibility at the level of the ascending (r = 0.273 p =0.016) and descending aorta (r = 0.502 and p< 0.001). Aortic distensibility was positively correlated with RFvalve even after adjustment for aortic diameter ( p = 0.002 and p <0.001 respectively) . (Table) (IMG)

CONCLUSIONS

In our study, aortic regurgitation in bicuspid valve patients, evaluated by CMR using RF valve, is related to aortic distensibility. Thus, aortic distensibility should be included in the evaluation of aortic regurgitation by CMR as additional parameter. However, longitudinal studies are needed to evaluate the impact of including aortic distensibility in the evaluation of AR severity by CMR.

AR SEVERITY MILD MODERATE SEVERE Descending aorta distensibility(mean ± std. deviation) 2693,68 ± 997,5 3285,8 ±1952,7 5042,99 ±2873,44 Correlation between AR severity (by RFvalve) and descending aorta distensibility

Abstract P1601 Figure.

Complement and contact system activation in acute congestive heart failure patients

Recent experimental data indicate a pathogenic role of complement activation in congestive heart failure (CHF). The aim of this study was to evaluate contact and complement systems activation in patients hospitalized for an acute episode of CHF. Forty-two of 80 consecutive patients admitted at our hospital with confirmed diagnosis of acute CHF were enrolled. They underwent blood sampling within 24 h from admission (T0) and at clinical stability (T1). Patients were stratified for ejection fraction (EF) based on echocardiographic test. We measured plasma levels of C3, C4, sC5b-9 and cleaved high molecular weight kininogen (contact activation marker). At T1, C3 levels increased significantly compared to T0 (97 ± 2 versus 104 ± 3% of total pooled plasma, P < 0·01). Classifying patients according to EF, only patients with preserved EF presented a significant increase of C3 from T0 to T1 (99 ± 3 versus 108 ± 4%, P = 0·03). When the sample was stratified according to clinical outcome, C3 (98 ± 3 versus 104 ± 4%, P = 0·03) and sC5b-9 levels (204 ± 10 versus 230 ± 11 ng/ml, P = 0·03) were increased in patients who had positive outcome after hospitalization. CHF patients with preserved EF and positive outcome after hospitalization showed higher levels of sC5b-9 in the T1 period compared with T0 (211 ± 14 versus 243 ± 14 ng/ml, P = 0·04). Our results suggest that the complement system reacts differently if CHF occurs with preserved or reduced EF. This finding is interesting if we consider the difference in epidemiology, pathogenesis and possible therapeutic approaches of these two clinical entities.

Biochemical and genetic defects underlying human congenital hypotransferrinemia

INTRODUCTION

Human congenital hypotransferrinemia is a rare disorder characterized by the virtual absence of transferrin in the serum. No information on the causes of the disease is known.

MATERIALS AND METHODS

Here we describe the identification of a new case, its treatment and the biochemical and genetic defects underlying the disorder.

RESULTS

At diagnosis the patient had serum Tf levels equal to about 1% of the normal values. The treatment with plasma infusions each month allowed a good erythropoiesis and the prevention of iron overload with no need of red blood cell transfusions or iron chelators. In order to define the genetic basis of the disease, we performed a haplotype analysis of the Tf gene region in the 26 individuals forming the proband's family, and demonstrated that the genetic defect is located in the Tf gene and that it is inherited as a recessive trait. Protein analyses indicate that the proband serum contains two transferrin forms: one of 80 kD analogous to the normal one, and a smaller one of 50 kD, which may arise from a specific degradation or be the gene product of a modified allele.

CONCLUSION

These data suggest the presence of two Tf alleles carrying genetic defects that cause two distinct abnormalities. One allele causes low expression of an apparently normal protein that probably allowed the survival of the patient in the first years of age. The other allele produces a modified Tf with different biochemical characteristics compared to the normal one.

Nutritional status in untreated children with acute leukemia as compared with children without malignancy

We evaluated the nutritional status of 173 consecutive children with newly diagnosed leukemia compared with that of 307 children with benign acute diseases. Nutritional status was assessed by anthropometric measurements including weight, height, weight for height, midarm circumference (MAC) and triceps skin-fold (TSF), and by biochemical indices, in particular prealbumin (TBPA) and retinol-binding protein (RBP). On admission, no significant differences were found between groups in weight, height, weight for height, MAC, and TSF values. TBPA and RBP, lower than normal in most cases, were not significantly different in the two groups. Furthermore, no differences were observed when children with high-risk leukemia were compared with those at standard risk. In conclusion, children with newly diagnosed leukemia do not seem to present significant nutritional depletion, and their nutritional status is similar to that of children admitted for other nonmalignant acute diseases. However, nutritional indices should be monitored in children with high-risk leukemia because treatment intensity is likely to result in a malnutritional status later, which might be prevented by early adequate nutritional support.

Ultrasound guided percutaneous ethanol injection in the treatment of cystic thyroid nodules

OBJECTIVE

The management of cystic lesions in the thyroid remains controversial. We examined the efficacy and safety of ultrasound guided percutaneous ethanol injection for the treatment of benign cystic thyroid nodules in euthyroid patients.

STUDY DESIGN

(A) Preliminary randomized trial: 20 patients with predominantly cystic thyroid nodules were randomized in two groups and followed up for 1 month. Group 1 underwent fine needle aspiration of the fluid component of the nodules; Group 2 underwent percutaneous ethanol injection at the end of fine needle aspiration of the cyst fluid. (B) Prospective study: 32 patients with the same clinical characteristics (Group 3) were treated by fine needle aspiration and percutaneous ethanol injection, and followed up for 12 months.

METHODS

Groups 1 and 2: clinical evaluation, thyroid ultrasonography, thyroid scintiscan and serum thyroid hormone profile were performed before treatment and one month later. Group 3: clinical evaluation, thyroid ultrasonography and serum thyroid hormone profile were performed in basal conditions and 1, 3, 6, 9, 12 months after treatment. Thyroid scintiscan was performed before treatment and 3-6 months later.

RESULTS

(A) Randomized study: one month after treatment, nodule volume decrease in Group 2 was significantly higher than in Group 1 (Group 2: median 14.75 range 6-29.9 ml; Group 1: median 3.65 range 0.2-18.5 ml; P < 0.01). Nodule volume reduction was greater than 50% versus baseline in 8 (80%) patients in Group 2 and in 3 (30%) patients in Group 1 (P < 0.01). (B) Prospective study (Group 3): a significant nodule volume reduction (P < 0.01 vs pretreatment) was observed 1 and 12 months after percutaneous ethanol injection (pretreatment: median 14.5, range 1.5-65.8 ml; 1 month: median 3.5, range 0.4-38.9 ml; 12 months: median 2.5, range 0.4-34.5 ml). Nodule volume reduction greater than 50% was recorded in 24 (80%) patients. Groups 1-3: recurrence of cyst fluid was demonstrated by ultrasonography in 8 patients of Group 1, in 3 patients of Group 2 and in 1 patient of Group 3. No relevant adverse effects or significant biochemical changes were observed.

CONCLUSIONS

Ultrasound guided percutaneous ethanol injection of cystic thyroid nodules is a safe, low-cost and effective therapeutic procedure in patients with benign thyroid cystic nodules. Indeed, nodule volume reduction was significantly greater and more frequent in patients treated by percutaneous ethanol injection than in those patients who underwent fluid aspiration alone. These results were confirmed in a long-term prospective trial and only one fluid recurrence was observed during 12 months of follow-up.

Pulmonary sequestration in a child with acute myeloid leukemia

The article describes a relatively rare congenital anomaly that was difficult to diagnose in a 10-year-old child with acute nonlymphoblastic leukemia. Just at diagnosis of leukemia, the patient showed a pathologic chest radiograph because of a parenchymal thickening at the right lung apex. The presence of bronchopneumonia was suspected, and broad-spectrum antibiotic therapy was started with subsequent antifungal treatment for persistent fever and concurrent chemotherapy-induced marrow aplasia, which did not favor pulmonary infiltrate recovery. Continuous culture tests, including bronchial swab, proved negative for Koch-Weeks bacillus, fungal organisms, and other pathogens. Computed tomography, however, was suggestive of Aspergillus lung involvement, and apical segmentectomy was performed. The anatomic pathologist suggested the diagnosis of intralobar sequestration. In summary, when pulmonary pathology with an excavation is found in a leukemic child, one must consider the possibility of pulmonary sequestration complicated by an infectious disease.

Airborne Cupressaceae pollen in southern Italy

The allergenic airborne pollen of Cupressaceae was surveyed in the area of Bari (Southern Italy) over an 8-year period (1982-1989). A Burkard 7-day recording volumetric spore trap was used for the aerobiologic investigation. The results showed a notable annual pollinic presence of airborne Cupressaceae pollen, the largest amount recorded in winter and early spring. Remarkable fluctuations of the Cupressaceae pollen counts in a 2-year cycle were also observed. The features of the main pollen season are described. In particular, its duration was found to be on average 45 days. A study of Cupressaceae trees distribution indicated that the most widespread genus was Cupressus, represented in particular by the species Cupressus arizonica Green and Cupressus Sempervirens L. The employment of these trees for reforestation and garden-use has increased considerably in the last 40 years. These findings can also be of interest in other countries where Cupressaceae allergy has been reported, particularly in the Mediterranean basin and in North America.

CV 205-502 in acromegaly

In a series of acromegalic patients the effects of CV 205-502, a new long-acting dopamine-agonist drug, on growth hormone (GH), insulin-like growth factor I (IGF-I) and prolactin (PRL) levels were evaluated in an open study. After acute administration of CV 205-502 (0.0375 mg, po) in 12 patients. GH levels did not change, whereas PRL values significantly decreased and remained suppressed for 24 h. In the 14 patients who underwent chronic CV 205-502 treatment (at daily doses of 0.150-0.600 mg/day given at bedtime or b.i.d. for up to 12 months). GH and IGF-I levels fell significantly from 60 +/- 17 (mean +/- SEM) micrograms/l to 28 +/- 10 micrograms/l and from 1127 +/- 84 micrograms/l to 738 +/- 57 micrograms/l, respectively (p < 0.05). A retrospective comparison with the results obtained for the same patients during a previous chronic bromocriptine treatment (at daily doses of 5-20 mg given t.i.d. or q.i.d.) did not show any significant difference in the suppression of GH levels between the two treatments; no bromocriptine-resistant patient was CV 205-502 sensitive, even at the highest CV 205-502 dose used. We conclude that in acromegaly chronic treatment with this new dopaminergic drug has a GH- and PRL-lowering effect that is similar to but more prolonged than that of bromocriptine, and normal or near-normal GH and IGF-I levels may be obtained in a few patients with b.i.d. administration. However, no GH-lowering effect is observed in bromocriptine-resistant patients.

Changes in skin reactivity, specific IgE and IgG levels after one year of immunotherapy in olive pollinosis

Changes in specific skin reactivity, specific IgE and specific IgG after immunotherapy (IT) were investigated in olive pollinosis. Thirty patients, receiving IT with commercial extracts, were studied in comparison with a control group of seven patients, receiving only drug therapy. Skin reactivity, IgE and IgG were assessed before starting IT and 1 year later. Definite changes in the three considered parameters occurred in patients given IT with Olea europaea extracts; no variation was observed in the control group. The specific skin reactivity, evaluated by means of quantitative skin prick tests, significantly decreased (Skin Index geometrical mean from 2.73 to 0.88, P less than 0.001); the specific IgE, measured by RAST, were surprisingly decreased (from 7.76 to 4.74 PRU/ml, P less than 0.001); the specific IgG, measured by ELISA, in basic conditions were detectable only in nine patients of 30, while, after IT, they were found in almost all patients with a remarkable increase (from 5.48 to 266.89 AU/ml, P less than 0.001). No correlation was found among the changes in the considered parameters, suggesting that, at least in olive pollinosis, specific skin reactivity, specific IgE and specific IgG are three variables depending on IT but reciprocally independent.

Exaggerated cyclic AMP accumulation and glial cell reaction in the cerebellum during Purkinje cell degeneration in pcd mutant mice

The Purkinje cell degeneration mutant (pcd) is characterized by a complete loss of cerebellar Purkinje cells. Norepinephrine causes an accumulation of cyclic AMP in the cerebellum of pcd that is far greater than in normal mice. Experiments were conducted 1) to correlated changes in the cyclic-nucleotide response with a histologic examination of the cerebellum during neuronal loss and 2) to examine the role of cyclic AMP catabolism and adenosine receptor interactions in the phenomenon. The greatest elevation in cyclic AMP occurred between 30 and 128 days of age when a severe astrocytic response was demonstrated throughout the cerebellar cortex. Purkinje cells had degenerated by 45 days of age. Norepinephrine elicited a smaller increase in cyclic AMP from 155-day-old mice than at earlier ages, and the response continued to decrease with age; at 270 days, equal accumulation, and at 365 days. lower accumulation of cyclic AMP was detected in pcd cerebella. During this time, the Purkinje cell debris had been removed, the granule cell layer was depleted of granule cells, and the molecular layer was deprived of a large number of parallel fibers. However, although phagocytosis of neuronal debris was completed, large numbers of astrocytic processes were still seen in the neuropil. Biochemical experiments in vitro established that the exaggerated accumulation of cyclic AMP in the presence of norepinephrine was not due to lower catabolism of cyclic AMP, a synergistic interaction with adenosine, or a result of lower protein in the pcd cerebellum. The correlates of heightened norepinephrine-stimulated accumulation of cyclic AMP with neuronal loss and the glial cell reaction might indicate that cyclic nucleotides play a role in controlling some glial cell functions, ie, proliferation, migration, and phagocytosis.

Sonication as a tool for the study of adenylyl cyclase activity

The technique of sonication was applied in studying adenylyl cyclase activity of cultured fibroblasts. Exposure of BHK 21 c/13 to brief periods of low power sonication gives cell preparations with greater basal, fluoride and hormone sensitive adenylyl cyclase activites than those of broken cell preparations of homogenized cells. The sonicated cells provide a convenient method to study adenylyl cyclase since they are added directly to the adenylyl cyclase reaction vessels without further processing. Maximal epinephrine stimulated activity in sonicated cells is nearly equivalent to that activated by sodium fluoride, but the apparent affinity of the enzyme system is similar to that of broken cell preparations. Furthermore, broken cell preparations of sonicated cells possess greater adenylyl cyclase activity than broken cell preparations of unsonicated cells. This procedure may provide a useful tool for the analysis of the hormonal regulation of adenylyl cyclase activity of isolated cells.