Morpho-functional changes of cardiac telocytes in isolated atrial amyloidosis in patients with atrial fibrillation

Telocytes are interstitial cells with long, thin processes by which they contact each other and form a network in the interstitium. Myocardial remodeling of adult patients with different forms of atrial fibrillation (AF) occurs with an increase in fibrosis, age-related isolated atrial amyloidosis (IAA), cardiomyocyte hypertrophy and myolysis. This study aimed to determine the ultrastructural and immunohistochemical features of cardiac telocytes in patients with AF and AF + IAA. IAA associated with accumulation of atrial natriuretic factor was detected in 4.3-25% biopsies of left (LAA) and 21.7-41.7% of right (RAA) atrial appendage myocardium. Telocytes were identified at ultrastructural level more often in AF + IAA, than in AF group and correlated with AF duration and mitral valve regurgitation. Telocytes had ultrastructural signs of synthetic, proliferative, and phagocytic activity. Telocytes corresponded to CD117+, vimentin+, CD34+, CD44+, CD68+, CD16+, S100-, CD105- immunophenotype. No significant differences in telocytes morphology and immunophenotype were found in patients with various forms of AF. CD68-positive cells were detected more often in AF + IAA than AF group. We assume that in aged AF + IAA patients remodeling of atrial myocardium provoked transformation of telocytes into "transitional forms" combining the morphological and immunohistochemical features with signs of fibroblast-, histiocyte- and endotheliocyte-like cells.

Infective endocarditis caused by lactobacillus

Lactobacillus (LB) is a gram-positive rod-shaped bacterium that inhabits the oral cavity, gastrointestinal tract, vagina and nasal cavity. Although LB plays a role in the prevention of infections caused by pathogenic bacteria, it causes some critical infectious diseases such as infective endocarditis (IE). IE due to LB is rare; however, early diagnosis and early treatment are important because of its high mortality rate. We report the onset of IE after otologic treatment in a heavy drinker of alcohol, the second case of IE due to LB in Japan.

Impact of serum C-reactive protein elevation on the left ventricular spherical change and the development of mitral regurgitation after anterior acute myocardial infarction

BACKGROUND/AIMS

Mitral regurgitation (MR) is frequently observed in patients with acute myocardial infarction (AMI), and is known to convey an adverse prognosis. We sought to clarify the relationship between MR and left ventricular (LV) remodeling, in association with serum C-reactive protein (CRP) elevation.

METHODS/RESULTS

A total of 181 patients with first anterior ST-elevation AMI were examined. MR was detected in 68 patients by color Doppler echocardiography 2 weeks after AMI, and the patients with MR were associated with higher incidence of readmission for heart failure. Serum CRP was serially measured, and the peak serum CRP level was markedly increased in patients with MR compared with those without MR. Multiple logistic regression analysis showed that peak CRP tertile was an independent determinant of MR after AMI (p < 0.0001). In the substudy, the increases in LV end-diastolic volume and sphericity index were higher in patients with MR than in those without MR.

CONCLUSIONS

MR during the early phase of anterior AMI was associated with LV spherical change and late-phase heart failure, in association with increased serum CRP level. These findings suggest an important role of the inflammatory response in the development of ischemic MR and LV remodeling.

[The role of cytokines in the development of endothelial dysfunction in simple cardiac anomalies]

One hundred and twenty patients aged 18 to 32 years with echocardiographically verified simple cardiac anomalies (SCA) within the framework of non-differentiated connective tissue dysplasia (CTD). Immune-enzyme assay was used to measure serum levels of cytokines taking part in the regulation of endothelial function, such as the main factor of fibroblast growth, interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma). The study revealed that the levels of fibroblast growth factor and IL-1beta were increased, while the serum levels of TNF-alpha and IFN-gamma were lowered. The alterations were most evident in cases of multiple SCA, myxomatous degeneration of a prolapsing mitral valve, and mitral regurgitation of higher than I degree. The determination of cytokine profile in patients with SCA may be used to stratificate the risk of cardiovascular complications in the heterogenous group of patients with nondifferentiated CTD.

Relationship of antiphospholipid antibodies to cardiovascular manifestations of systemic lupus erythematosus

OBJECTIVE

Although antiphospholipid antibodies (aPL) are associated with arterial and venous thrombosis in systemic lupus erythematosus (SLE), the extent to which they influence other cardiovascular manifestations is either controversial or uncertain. We undertook this study to examine the relationships of aPL with valvular, myocardial, and arterial disease in SLE.

METHODS

Two hundred patients in an SLE registry, recruited at the time of outpatient visits, underwent comprehensive interviews, physical examinations, laboratory assessments, echocardiography to assess left ventricular (LV) and valvular status, carotid ultrasonography to detect atherosclerosis (discrete plaque), and radial applanation tonometry to measure arterial stiffness.

RESULTS

Antiphospholipid antibodies were present(defined as IgG or IgM anticardiolipin > or =40 IU/ml or the presence of lupus anticoagulant) in 42 patients (21%). Mitral valve nodules and moderate-to-severe mitral regurgitation were more common in aPL-positive patients (both 14.3% versus 4.4%; P = 0.02). Thirty-one percent of patients with high titers of IgG aPL (>80 IU/ml) had mitral valve nodules, compared with 20% of patients with mildly to moderately elevated levels of IgG aPL (16-80 IU/ml) and 4% of patients without IgG aPL (overall P < 0.001). Levels of soluble tumor necrosis factor receptors were higher in the presence of both aPL and mitral valve nodules. LV dimensions, systolic function, and carotid artery stiffness as well as prevalences of Raynaud's phenomenon, pulmonary hypertension, and atherosclerosis were similar in aPL-positive and aPL-negative patients.

CONCLUSION

Antiphospholipid antibodies in SLE are associated with mitral valve nodules and significant mitral regurgitation, possibly due to valvular endothelial cell activation. However, in this population, they are not associated with evidence of myocardial hypertrophy, systolic dysfunction, coronary or carotid atherosclerosis, or other vascular abnormalities.

HLA class II associations with rheumatic heart disease among clinically homogeneous patients in children in Latvia

Genetic control of immune reactions has a major role in the development of rheumatic heart disease (RHD) and differs between patients with rheumatic fever (RF). Some authors think the risk of acquiring RHD is associated with the HLA class II DR and DQ loci, but other views exist, due to the various HLA-typing methods and ways of grouping cases. Our goal was to determine the relations between HLA class II alleles and risk of or protection from RF in patients with relatively homogeneous clinical manifestations. A total of 70 RF patients under the age of 18 years were surveyed in Latvia. HLA genotyping of DRB1*01 to DRB1*18 and DQB1*0201-202, *0301-305, *0401-402, *0501-504, and *0601-608 was performed using polymerase chain reaction sequence-specific primers. Data for a control group of 100 healthy individuals typed for HLA by the same method were available from the databank of the Immunology Institute of Latvia. Of the RF patients, 47 had RHD and 8 had Sydenham's chorea. We concluded that HLA class II DRB1*07-DQB1*0401-2 and DRB1*07-DQB1*0302 could be the risk alleles and HLA class II DRB1*06 and DQB1*0602-8, the protective ones. Patients with mitral valve regurgitation more often had DRB1*07 and DQB1*0401-2, and patients with multivalvular lesions more often had DRB1*07 and DQB1*0302. In Sydenham's chorea patients, the DQB1*0401-2 allele was more frequent. Genotyping control showed a high risk of RF and RHD in patients with DRB1*01-DQB1*0301-DRB1*07-DQB1*0302 and DRB1*15-DQB1*0302-DRB1*07-DQB1*0303.

HLA-B27 positive juvenile arthritis with cardiac involvement preceding sacroiliac joint changes

While cardiovascular disease develops in up to 50% of adult patients with ankylosing spondylitis, it is very uncommon in its juvenile counterpart. Regarding the early stage of the disease, before onset of sacroiliac joint changes, only two cases with aortic incompetence have been published while reports of mitral valve involvement are not available. A 13 year old boy is described with an HLA-B27 positive asymmetric oligoarthritis and enthesitis, without back pain or radiographic evidence of sacroiliitis. Echocardiography showed an echogenic structure measuring 8 x 11 x 20 mm at the fibrous continuity between the aortic and mitral valves extending through a false tendon into an echogenic thickened posterior papillary muscle, causing a grade II aortic and grade I/II mitral regurgitation. Short term corticosteroid and long term non-steroidal anti-inflammatory drug and disease modifying antirheumatic drug treatments efficiently controlled the symptoms. The cardiac findings remained unchanged during a follow up of 20 months. Careful cardiac evaluation appears to be mandatory even in these young patients.

Cardiac involvement in Behçet's disease

To assess the prevalence and the extent of cardiac involvement in patients with Behçet's disease and to investigate the possible causes that may predispose to this involvement, 30 patients affected by Behçet's disease and 30 normal control subjects were submitted to M-mode, two-dimensional, and Doppler echocardiographic evaluation. Moreover, antinuclear and anticardiolipin autoantibodies were determined in the sera of both patients and control subjects. Finally, HLA-B51 positivity was assessed in the patients and in a historical control group. Mitral valve prolapse was observed in 50% and proximal aorta dilatation in 30% of the patients. There was a significant difference in the rate of these abnormalities in comparison with the control group. Left ventricular function parameters were similar between the two groups. The positivity rate of antinuclear and anticardiolipin autoantibodies was very low (7%), without differences between the groups. HLA-B51 was detected in 82.7% of the patients versus 21.7% in the control group (p < 0.00001). In conclusion, this study demonstrates a high rate of cardiac abnormalities in patients with Behçet's disease.

Mitral regurgitation may be related with previous streptococcal infection

We measured anti M protein antibody (AMPA) titres in children with idiopathic mitral regurgitation (MR), streptococcal infection, rheumatic fever (RF), post-streptococcal acute glomerulonephritis (AGN) and normal healthy children. We investigated the association of MR with streptococcal infection and whether high AMPA titres can be used as persisting evidence of previous streptococcal infection. AMPA titres were measured with an enzyme-linked immunosorbent assay. We found significantly higher antibody titres in patients with MR and in streptococcal infection, RF, and AGN than in healthy controls. In the MR group (n = 15), 54% patients had AMPA titres above the 90th percentile value that was found in normal controls. An elevated AMPA titre persisted for a long period even when the anti-streptolysin O titres had declined to normal in RF patients. Our data suggest that the high AMPA titres in MR should be further investigated to clarify the probable association with previous streptococcal infection.

CONCLUSION

High AMPA titre is a risk factor for developing complications after streptococcal infection. Our serological evidence suggests that in some patients, MR may be related to previous streptococcal infection.

Prevalence of anticardiolipin antibody in isolated mitral or aortic regurgitation, or both, and possible relation to cerebral ischemic events

Anticardiolipin antibodies (acLa) are associated with a thrombotic tendency (often involving cerebral ischemic events), are frequently present with systemic lupus erythematosus and have been found together with cardiac valve abnormalities. Previous studies evaluated patients characterized by the presence of acLa or lupus, precluding assessment of the frequency of acLa in those with valvular disease. This study aims to establish the prevalence of acLa in patients with valve disease in the absence of lupus and, furthermore, to determine the influence of acLa on the risk of cerebral events in valve disease. Eighty-seven consecutive patients with mitral or aortic regurgitation, or both, prospectively underwent enzyme-linked immunosorbent assay testing for immunoglobulin G (IgG) and M acLa, as did 24 normal subjects. AcLa values greater than or equal to 3 SD above the normal mean were considered "positive." Prior cerebral events were defined retrospectively. Of 87 patients with valvular disease, 26 had positive IgG acLa levels compared with 0 of 24 normal subjects (p less than 0.01). AcLa values did not vary with valve disease etiology. Focal cerebral events had occurred in 8 patients and were embolic or probably embolic in 7, including 7 of 26 IgG acLa-positive and 1 of 60 IgG acLa-negative patients (p less than 0.001). In the absence of lupus, IgG acLa is highly prevalent among patients with aortic or mitral regurgitation, or both; this association may indicate a relatively high risk for cerebral emboli.

Association of antibodies against phospholipids with heart valve disease in systemic lupus erythematosus

A prospective echocardiographic study was carried out on 132 consecutive patients with systemic lupus erythematosus (SLE) derived from three European university medical centres. The prevalence of valvular lesions in patients with SLE was 22.7% compared with 2.9% in a control group of 68 healthy volunteers. 50 SLE patients had antibodies against phospholipids. The prevalence of valve vegetations (8/50 [16%]) and of mitral regurgitation (19/50 [38%]) was significantly higher among the SLE patients with antiphospholipids than among those without (1 and 10/82 [1.2% and 12%], respectively). During follow-up of the patients with valvular lesions, haemodynamically significant clinical valve disease developed in 6 but surgery was required in only 1; 9 had cerebrovascular occlusions; and 7 died, although no death was due directly to the cardiac involvement. Thus, valvular heart disease, particularly affecting the mitral valve, is common in patients with SLE, and the presence of antibodies against phospholipids is associated with a higher prevalence of valvular abnormalities in these patients.

[Changes in the immune response in postoperative patients while running the ventricular assist device (VAD)]

We examined the immunological parameters in two patients who were assisted with LVAD in postoperative LOS. Both patients demonstrated transient consumption of complements immediately after running the LVAD. The serum concentrations of immunoglobulins (IgG, IgM, IgA) showed no significant decrease. Both patients had significant postoperative lymphopenia, but recovered in a week. A decrease in the number of T cells was observed in both patients. The OKT4/OKT8 ratio initially increased in one patient, but gradually declined postoperatively. In the other patient, the OKT4/OKT8 ratio decreased. The lymphocyte response to mitogen (PHA) remained significantly depressed when the number of lymphocytes returned to the normal level, suggesting that the lymphocytes were functionally impaired. Such findings are generally observed after cardiac surgery. Thus, LVAD does not affect the immune response.

[Manifestation of the sensitization to penicillin preparations in rheumatism patients with a history of adverse reactions to them]

Observation over 56 out-patients with rheumatism who had previously developed side responses to penicillin preparations indicated a longer preservation of the condition of sensitization to prolonged preparations of penicillin (bicillin-3) and a direct dependence of its preservation degree on the extent of aggravation of allergologic history.

Specificity of persistence of antibody to the streptococcal group A carbohydrate in rheumatic valvular heart disease

The specificity of the persistence of antibody to the streptococcal group A carbohydrate for mitral valve disease induced by rheumatic fever was examined. Levels of the antibody were determined in serum samples of 30 patients with rheumatic mitral insufficiency, 30 patients with mitral valve prolapse, and an equal number of normal individuals and patients with congenital heart disease. Antistreptolysin titers and anti-deoxyribonuclease B titers were also assayed in all sera. There were no differences in the incidence of elevated antibody titers or in the geometric means of the antibody titers for the normal individuals, the patients with congenital heart disease, and the patients with mitral valve prolapse. In contrast, the frequency of elevated anti-streptococcal group A carbohydrate titers and the geometric means of these titers were significantly higher in the patients with rheumatic mitral valve disease than in patients with mitral valve prolapse. This confirms the specificity of the persistent elevation of anti-streptococcal group A carbohydrate to patients with mitral valve disease induced by rheumatic fever and also suggests that the persistence of this antibody in patients with rheumatic valvular disease is not a result of a functional abnormality of the mitral valve.

Fate of a second porcine bioprosthetic valve

Since October, 1971, 744 porcine bioprosthetic valves were inserted in patients discharged from the hospital and were therefore at risk for primary valve failure or tissue degeneration. In this period of time, 41 valves have demonstrated spontaneous degeneration. The percentages of valve survival without degeneration are as follows: at 6 yeras, 93% +/- 1.5% (SE); 7 years, 88% +/- 2.0%; 8 years, 82% +/- 2.9%; 9 years, 80% +/- 3.4%. The incidence of degeneration appears to be decreasing even though the total number of valves at risk is increasing each year. Of the 41 valves removed for spontaneous degeneration, 25 valves in 24 patients have been replaced by a second bioprosthesis. These 24 patients have been followed up for from 2 to 61 months, and there has been no clinical evidence of degeneration of the second bioprosthesis. One patient has had a second bioprosthesis longer than the first. Although others have suggested that degeneration may be immunologic event, our experience suggests that there is no "second set" rejection. The absence of a "second set" rejection and the suggestion of a decreasing incidence of degeneration makes us continue to favor the bioprosthesis for primary and secondary valve replacement.

Cellular immunity in rheumatic heart disease

Cellular immunity to non-specific antigens (PPD, Candida albicans, and streptococcal antigens) and mitogen (PHA) was investigated in patients with valvular heart disease of rheumatic origin. The result disclosed that lowered response in cellular immunity exists in these patients. The possible significance of this finding in occurrence of rheumatic activity was discussed.

Differences in antibody response to streptococcal antigens in children with rheumatic and non-rheumatic mitral valve disease

The usefulness of streptococcal antibody tests — anti-streptolysin O (ASO), anti-desoxyribonuclease B (anti-DNAse B), and anti-group A carbohydrate (A-antibody) — in differentiating rheumatic from non-rheumatic mitral disease was explored. Sera from 154 children with mitral disease were studied. Fifteen of 17 patients with chronic mitral insufficiency (MI) following acute rheumatic fever manifested persistence of elevated A-antibody levels following the decline of ASO and anti-DNAse B titers to normal 18-36 months after their acute illness. This antibody pattern was not observed among sera from 35 patients with congenital mitral valve deformities. Serologic study of 71 children with mitral disease of obscure etiology identified three groups: subgroup A includes those 12 who demonstrated the antibody pattern associated with rheumatic MI, while subgroup B is comprised of 39 children with normal A-antibody levels. Twenty patients (subgroup C) manifested evidence of recent streptococcal infection. These data suggest that the use of the A-antibody test in conjunction with other streptococcal antibody tests is of potential value in differentiating rheumatic from non-rheumatic mitral disease.

Antiheart antibody in idiopathic hypertrophic subaortic stenosis

Images