Increased myocardial extracellular volume in active idiopathic systemic capillary leak syndrome

Unlocking endothelial barrier restoration: FX06 in systemic capillary leak syndrome and beyond

Increased vascular permeability is a prevalent feature in a wide spectrum of clinical conditions, but no effective treatments to restore the endothelial barrier are available. Idiopathic systemic capillary leak syndrome (ISCLS) is a life-threatening Paroxysmal Permeability Disorder characterized by abrupt, massive plasma extravasation. This condition serves as a robust model for investigating therapeutic approaches targeting interendothelial junctions. We conducted a single-center, interventional in vitro study at the Referral Center for ISCLS in Italy, involving four diagnosed ISCLS patients, aiming at investigating the effects of FX06, a Bβ15-42 fibrin-derived peptide binding to VE-Cadherin, on endothelial barrier exposed to intercritical and acute ISCLS sera. The Transwell Permeability Assay was used to assess the permeability of human umbilical vein endothelial cells (HUVECs) exposed to ISCLS sera with or without FX06 (50 µg/ml). Acute ISCLS serum was also tested in a three-dimensional microfluidic device. Nitric oxide (NO), VE-Cadherin localization, and cytoskeletal organization were also assessed. In two and three-dimensional systems, ISCLS sera increased endothelial permeability, with a more pronounced effect for acute sera. Furthermore, acute sera altered VE-Cadherin localization and cytoskeletal organization. NO levels remained unchanged. FX06 restored the endothelial barrier function by influencing cellular localization rather than VE-Cadherin levels. In conclusion, FX06 prevents and reverts the hyperpermeability induced by ISCLS sera. These preliminary yet promising results provide initial evidence of the in vitro efficacy of a drug targeting the underlying pathophysiological mechanisms of ISCLS. Moreover, this approach may hold potential for addressing hyperpermeability in a spectrum of clinical conditions beyond ISCLS.

Cardiac MRI Assessment of Mouse Myocardial Infarction and Regeneration

Small animal models are indispensable for cardiac regeneration research. Studies in mouse and rat models have provided important insights into the etiology and mechanisms of cardiovascular diseases and accelerated the development of therapeutic strategies. It is vitally important to be able to evaluate the therapeutic efficacy and have reliable surrogate markers for therapeutic development for cardiac regeneration research. Magnetic resonance imaging (MRI), a versatile and noninvasive imaging modality with excellent penetration depth, tissue coverage, and soft-tissue contrast, is becoming a more important tool in both clinical settings and research arenas. Cardiac MRI (CMR) is versatile, noninvasive, and capable of measuring many different aspects of cardiac functions, and, thus, is ideally suited to evaluate therapeutic efficacy for cardiac regeneration. CMR applications include assessment of cardiac anatomy, regional wall motion, myocardial perfusion, myocardial viability, cardiac function assessment, assessment of myocardial infarction, and myocardial injury. Myocardial infarction models in mice are commonly used model systems for cardiac regeneration research. In this chapter, we discuss various CMR applications to evaluate cardiac functions and inflammation after myocardial infarction.

The role of cardiovascular imaging for myocardial injury in hospitalized COVID-19 patients

Recent EACVI recommendations described the importance of limiting cardiovascular imaging during the COVID-19 pandemic in order to reduce virus transmission, protect healthcare professionals from contamination, and reduce consumption of personal protective equipment. However, an elevated troponin remains a frequent request for cardiac imaging in COVID-19 patients, partly because it signifies cardiac injury due to a variety of causes and partly because it is known to convey a worse prognosis. The present paper aims to provide guidance to clinicians regarding the appropriateness of cardiac imaging in the context of troponin elevation and myocardial injury, how best to decipher the mechanism of myocardial injury, and how to guide patient management.

Myocardial edema in paroxysmal permeability disorders: The paradigm of Clarkson's disease

PURPOSE

Paroxysmal Permeability Disorders (PPDs) comprise a variety of diseases characterized by recurrent and transitory increase of endothelial permeability. Idiopathic Systemic Capillary Leak Syndrome (ISCLS) is a rare PPD that leads to an abrupt massive shift of fluids and proteins from the intravascular to the interstitial compartment. In some cases, tissue edema may involve the myocardium, but its role in the development of shock has not been elucidated so far.

MATERIALS AND METHODS

Assessment of cardiac involvement during ten life-threatening ISCLS episodes admitted to ICU.

RESULTS

Transthoracic echocardiographic examination was performed in eight episodes, whereas a poor acoustic window prevented cardiac ultrasound assessment in two episodes. Myocardial edema was detected by echocardiography in eight episodes and marked pericardial effusion in one-episode. Cardiac magnetic resonance showed diffuse myocardial edema in another episode. In one case, myocardial edema caused fulminant left ventricular dysfunction, which required extracorporeal life support. The mean septum thickness was higher during the shock phase compared to the recovery phase [15.5 mm (13.1-21 mm) vs. 9.9 mm (9-11.3 mm), p = .0003]. Myocardial edema resolved within 72 h.

CONCLUSIONS

During early phases of ISCLS, myocardial edema commonly occurs and can induce transient myocardial dysfunction, potentially contributing to the pathogenesis of shock.

Key Regulatory Effect of Activated HIF-1α/VEGFA Signaling Pathway in Systemic Capillary Leak Syndrome Confirmed by Bioinformatics Analysis

Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by capillary leakage of plasma fluids throughout the endothelium. The mechanism of SCLS is still unknown. Vascular endothelial growth factor (VEGF), an inducer or barrier disruption, is markedly upregulated in SCLS. This study was to investigate the molecular mechanisms involving SCLS-related inflammation and neuron damage in SCLS remain unclear. Data files of GSE97287 dataset were extracted and processed for identification of differentially expressed genes (DEGs), including upregulated adrenomedullin (ADM) gene, hypoxia-inducible factor-1α (HIF-1α) and VEGFA; and downregulated aldehyde dehydrogenase 1A1 (ALDH1A1) gene and interleukin (IL)-2 receptor β (IL-2RB) gene. Weighted gene coexpression network analysis (WGCNA) was performed for DEGs and four significant modules were identified and were enriched Gene Ontology (GO) biological processes and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways related to immune response, angiogenesis, neuroblast proliferation, HIF-1 signaling pathway, and Parkinson's disease. The activated HIF-1α/VEGFA signaling in SCLS patients might well be responsible for the impaired inflammatory, nervous, and immune systems.

Handling shock in idiopathic systemic capillary leak syndrome (Clarkson's disease): less is more

Idiopathic systemic capillary leak syndrome (ISCLS) presents with recurrent potentially life-threatening episodes of hypovolemic shock associated with severe hemoconcentration and hypoproteinemia. Timely recognition is of paramount importance because ISCLS, despite resembling other kinds of hypovolemic shock, requires a peculiar approach, to prevent life-threatening iatrogenic damage. Due to the rarity of this condition with only scattered cases described worldwide, evidence-based recommendations are still lacking. Here, we summarize our 40 years' experience in treating shock in ISCLS patients to derive a therapeutic algorithm. Records from 12 ISCLS patients (mean follow-up is 6 years, with a mean age at symptoms' onset of 51.5 years) were informative for treatment modalities and outcome of 66 episodes of shock. Episodes are divided in three phases and treatment recommendations are the following: prodromal symptoms-signs (growing malaise, oligo-anuria, orthostatic dizziness) last 6-12 h and patients should maintain rigorous bed rest. The acute shock phase lasts 24-36 h. Patients should be admitted to ICU, placed on restrictive infusion of fluids favoring cautious boluses of high-molecular-weight plasma expanders when SAP < 70 mmHg; monitored for cerebral/cardiac perfusion, myocardial edema and signs of compartment syndrome. The post-acute (recovery) phase may last from 48 h to 1 week. Monitor for cardiac overload to prevent cardiac failure; in case of persistent renal failure, hemodialysis may be necessary; consider albumin infusion. Complications listed by frequency in our patients were acute renal failure, compartment syndrome and neuropathy, rhabdomyolysis, myocardial edema, pericardial-pleural-abdominal effusion, cerebral involvement, acute pulmonary edema and deep vein thrombosis.

Myocardial oedema in an 8-year-old Chinese boy with Idiopathic systemic capillary leak syndrome

Background

Idiopathic systemic capillary leak syndrome (ISCLS) is rare, and there has been about 32 cases reported in children worldwide since this disorder was first described in 1960. Clinical guidelines on the management approach stemming from robust scientific evidence are lacking. This case report presents the first reported paediatric case of severe ISCLS with significant myocardial oedema and emphasizes this disease’s impact on a child’s cardiac function.

Case presentation

A Chinese boy had his first attack of severe hypovolaemic shock that responded to fluid resuscitation when he was 6 years of age. His second attack developed at 8 years of age. He was then transferred to our cardiac unit for refractory hypotensive shock. The patient’s echocardiogram revealed ventricular wall thickening with significant cardiac dysfunction requiring extracorporeal membrane oxygenation support. Subsequently, he made a full recovery, including his myocardial wall thickness and function. The echocardiographic findings suggested myocardial oedema that was transient in nature. Clinical and laboratory investigation from both episodes were compatible with ISCLS.

Conclusion

ISCLS is rare, and therefore there is only a limited understanding on the pathophysiology of this disorder. The current treatment approach is based on a few case reports and series. During the acute phase, optimal supportive management is paramount. Our case highlights the importance of early recognition and consideration for extracorporeal membrane oxygenation support in patients with a life-threatening presentation, as it was lifesaving for this child who suffered myocardial oedema and ventricular dysfunction.

Myocardial Extracellular Volume Quantification by Cardiovascular Magnetic Resonance and Computed Tomography

PURPOSE OF REVIEW

This review article discusses the evolution of extracellular volume (ECV) quantification using both cardiovascular magnetic resonance (CMR) and computed tomography (CT).

RECENT FINDINGS

Visualizing diffuse myocardial fibrosis is challenging and until recently, was restricted to the domain of the pathologist. CMR and CT both use extravascular, extracellular contrast agents, permitting ECV measurement. The evidence base around ECV quantification by CMR is growing rapidly and just starting in CT. In conditions with high ECV (amyloid, oedema and fibrosis), this technique is already being used clinically and as a surrogate endpoint. Non-invasive diffuse fibrosis quantification is also generating new biological insights into key cardiac diseases. CMR and CT can estimate ECV and in turn diffuse myocardial fibrosis, obviating the need for invasive endomyocardial biopsy. CT is an attractive alternative to CMR particularly in those individuals with contraindications to the latter. Further studies are needed, particularly in CT.

Review of Journal of Cardiovascular Magnetic Resonance (JCMR) 2015-2016 and transition of the JCMR office to Boston

The Journal of Cardiovascular Magnetic Resonance (JCMR) is the official publication of the Society for Cardiovascular Magnetic Resonance (SCMR). In 2016, the JCMR published 93 manuscripts, including 80 research papers, 6 reviews, 5 technical notes, 1 protocol, and 1 case report. The number of manuscripts published was similar to 2015 though with a 12% increase in manuscript submissions to an all-time high of 369. This reflects a decrease in the overall acceptance rate to <25% (excluding solicited reviews). The quality of submissions to JCMR continues to be high. The 2016 JCMR Impact Factor (which is published in June 2016 by Thomson Reuters) was steady at 5.601 (vs. 5.71 for 2015; as published in June 2016), which is the second highest impact factor ever recorded for JCMR. The 2016 impact factor means that the JCMR papers that were published in 2014 and 2015 were on-average cited 5.71 times in 2016.In accordance with Open-Access publishing of Biomed Central, the JCMR articles are published on-line in the order that they are accepted with no collating of the articles into sections or special thematic issues. For this reason, over the years, the Editors have felt that it is useful to annually summarize the publications into broad areas of interest or themes, so that readers can view areas of interest in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes with previously published JCMR papers to guide continuity of thought in the journal. In addition, I have elected to open this publication with information for the readership regarding the transition of the JCMR editorial office to the Beth Israel Deaconess Medical Center, Boston and the editorial process.Though there is an author publication charge (APC) associated with open-access to cover the publisher's expenses, this format provides a much wider distribution/availability of the author's work and greater manuscript citation. For SCMR members, there is a substantial discount in the APC. I hope that you will continue to send your high quality manuscripts to JCMR for consideration. Importantly, I also ask that you consider referencing recent JCMR publications in your submissions to the JCMR and elsewhere as these contribute to our impact factor. I also thank our dedicated Associate Editors, Guest Editors, and reviewers for their many efforts to ensure that the review process occurs in a timely and responsible manner and that the JCMR continues to be recognized as the leading publication in our field.

Idiopathic systemic capillary leak syndrome (Clarkson disease)

In 1960, Dr Bayard Clarkson described a woman experiencing sporadic recurrent episodes of shock and anasarca. Plasma from an acute attack induced a shock-like syndrome when injected into rats. The enigmatic systemic capillary leak syndrome (SCLS) named for Dr Clarkson is characterized by transient and severe but reversible hemoconcentration and hypoalbuminemia caused by leakage of fluids and macromolecules into tissues. Although less than 500 cases of SCLS have been reported in the literature since 1960, the condition is probably underdiagnosed because of a lack of awareness and a high mortality without treatment. Allergists should be vigilant of this diagnosis because its presentation can resemble more common plasma leakage syndromes, including angioedema or systemic anaphylaxis. Although the precise molecular cause of SCLS remains unknown, substantial advances over the last 5 years have increased our understanding of SCLS pathogenesis.

Review of Journal of Cardiovascular Magnetic Resonance 2015

There were 116 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2015, which is a 14 % increase on the 102 articles published in 2014. The quality of the submissions continues to increase. The 2015 JCMR Impact Factor (which is published in June 2016) rose to 5.75 from 4.72 for 2014 (as published in June 2015), which is the highest impact factor ever recorded for JCMR. The 2015 impact factor means that the JCMR papers that were published in 2013 and 2014 were cited on average 5.75 times in 2015. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, the progress of the journal's impact over the last 5 years has been impressive. Our acceptance rate is <25 % and has been falling because the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors have felt that it is useful once per calendar year to summarize the papers for the readership into broad areas of interest or theme, so that areas of interest can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality papers to JCMR for publication.