The impact of Wilson disease on myocardial tissue and function: a cardiovascular magnetic resonance study

Effect of primary copper metabolism disturbance on elemental, protein, and lipid composition of the organs in Jackson toxic milk mouse

Toxic milk (txJ) is an autosomal recessive mutation in the Atp7b gene in the C3H/HeJ strain, observed at The Jackson Laboratory in Maine, USA. TxJ mice exhibit symptoms similar to those of human Wilson's disease (WD). The study aimed to verify organ involvement in a mouse model of WD. TxJ mice and control animals were sacrificed at 2, 4, 8, and 14 months of age. Total X-ray Fluorescence Spectroscopy (TXRF) was used to determine the elemental concentration in organs. Tissue chemical composition was measured by Fourier Transform Infrared Spectroscopy (FTIR). Additionally, hybrid mapping of FTIR and microXRF was performed. Elevated concentrations of Cu were observed in the liver, striatum, eye, heart, and duodenum of txJ mice across age groups. In the striatum of the oldest txJ mice, there was lower lipid content and a higher fraction of saturated fats. The secondary structure of striatum proteins was disturbed in txJ mice. In the livers of txJ mice, higher concentrations of saturated fats and disturbances in the secondary structure of proteins were observed. The concentration of neurofilaments was significantly higher in txJ serum. The distribution of Cu deposits in brains was uniform with no prevalence in any anatomic structure in either group, but significant protein structure changes were observed exclusively in the striatum of txJ. In this txJ animal model of WD, pathologic copper accumulation occurs in the duodenum, heart, and eye tissues. Increased copper concentration in the liver and brain results in increased saturated fat content and disturbances in secondary protein structure, leading to hepatic injury and neurodegeneration.

Liver transplantation for Wilson disease: Current knowledge and future perspectives

Liver transplantation currently represents a therapeutic option for patients with Wilson disease presenting with end-stage liver disease or acute liver failure. Indeed, it has been associated with excellent postoperative survival curves in view of young age at transplant and absence of recurrence. Attention has shifted over the past decades to a wise expansion of indications for liver transplantation. Evidence has emerged supporting the transplantation of carefully selected patients with primarily neuropsychiatric symptoms and compensated cirrhosis. The rationale behind this approach is the potential for surgery to improve copper homeostasis and consequently ameliorate neuropsychiatric symptoms. However, several questions remain unanswered, such as how to establish thresholds for assessing pretransplant neuropsychiatric impairment, how to standardize preoperative neurological assessments, and how to define postoperative outcomes for patients meeting these specific criteria. Furthermore, a disease-specific approach will be proposed both for the liver transplant evaluation of candidates with Wilson disease and for patient care during the transplant waiting period, highlighting the peculiarities of this systemic disease.

Safety of dobutamine stress cardiovascular magnetic resonance in patients with prior coronary artery bypass grafting

BACKGROUND

Patients with coronary artery bypass grafts (CABG) face an elevated risk of major adverse cardiac events. High-dose dobutamine stress cardiovascular magnetic resonance (DCMR) imaging is a well-established technique to detect hemodynamically significant coronary artery disease. However, there is a lack of data regarding the safety of DCMR in patients with CABG. This study aims to evaluate the safety of DCMR in patients with CABG.

METHODS

We retrospectively studied patients after CABG who subsequently underwent DCMR between November 2008 and July 2018. Side effects, defined as adverse events and minor symptoms, during DCMR were analyzed and compared to 200 individuals matched for age, sex, and body mass index without prior CABG undergoing DCMR.

RESULTS

Three hundred and thirty-six patients (70 ± 9 years, 85% men (284/336)) were identified. Adverse events occurred in 35 CABG patients (10% (35/336)) and 18 controls (9% (18/200), p = 0.595). A drop of systolic blood pressure (SBP) >40 mmHg (12 patients), non-sustained ventricular tachycardia (6 patients), increase in SBP >200 mmHg (5 patients), monomorphic premature ventricular contractions (PVC) (2 patients), bigeminy (2 patients), left bundle-branch block (2 patients), as well as tachycardiac paroxysmal atrial fibrillation, bradycardia, supraventricular tachycardia, couplets/triplets, and sinus arrhythmia in 1 patient each occurred in the study group. In addition, one patient was hospitalized due to tachycardiac paroxysmal atrial fibrillation and transient ischemic attack. Twenty-nine (8.7% (29/336)) examinations in the study group were aborted because of either chest pain, dyspnea, nausea, dizziness, a drop of SBP, arrhythmias, tachycardiac paroxysmal atrial fibrillation, monomorphic PVCs, or non-sustained ventricular tachycardia. The rate of aborted examination was comparable to the control group (7.5% (15/(200), p = 0.631). Univariable logistic regression analysis revealed that female sex (odds ratio [OR] 2.21, 95% confidence intervals [CI] 1.2-4.3, p = 0.017) and inducible ischemia (OR 3.50, 95% CI 2.0-6.0, p < 0.001) were associated with an increased risk of side effects during DCMR.

CONCLUSION

Dobutamine stress CMR did not show a relevant increase in adverse events in patients with prior CABG compared to patients without prior CABG. Female sex and dobutamine-induced myocardial ischemia are associated with side effects during DCMR.

Myocardial involvement characteristics by cardiac MR imaging in neurological and non-neurological Wilson disease patients

OBJECTIVES

To explore the characteristics of myocardial involvement in Wilson Disease (WD) patients by cardiac magnetic resonance (CMR).

METHODS

We prospectively included WD patients and age- and sex-matched healthy population. We applied CMR to analyze cardiac function, strain, T1 maps, T2 maps, extracellular volume fraction (ECV) maps, and LGE images. Subgroup analyzes were performed for patients with WD with predominantly neurologic manifestations (WD-neuro +) or only hepatic manifestations (WD-neuro -).

RESULTS

Forty-one WD patients (age 27.9 ± 8.0 years) and 40 healthy controls (age 25.4 ± 2.9 years) were included in this study. Compared to controls, the T1, T2, and ECV values were significantly increased in the WD group (T1 1085.1 ± 39.1 vs. 1046.5 ± 33.1 ms, T2 54.2 ± 3.3 ms vs. 51.5 ± 2.6 ms, ECV 31.8 ± 3.6% vs. 24.3 ± 3.7%) (all p < 0.001). LGE analysis revealed that LGE in WD patients was predominantly localized to the right ventricular insertion point and interventricular septum. Furthermore, the WD-neuro + group showed more severe myocardial damage compared to WD-neuro - group. The Unified Wilson Disease Rating Scale score was significantly correlated with ECV (Pearson's r = 0.64, p < 0.001).

CONCLUSIONS

CMR could detect early myocardial involvement in WD patients without overt cardiac function dysfunction. Furthermore, characteristics of myocardial involvement were different between WD-neuro + and WD-neuro - , and myocardial involvement might be more severe in WD-neuro + patients.

CRITICAL RELEVANCE STATEMENT

Cardiac magnetic resonance enables early detection of myocardial involvement in Wilson disease patients, contributing to the understanding of distinct myocardial characteristics in different subgroups and potentially aiding in the assessment of disease severity.

KEY POINTS

• CMR detects WD myocardial involvement with increased T1, T2, ECV. • WD-neuro + patients show more severe myocardial damage and correlation with ECV. • Differences of myocardial characteristics exist between WD-neuro + and WD-neuro - patients.

Radiomic and clinical nomogram for cognitive impairment prediction in Wilson's disease

Objective

To investigate potential biomarkers for the early detection of cognitive impairment in patients with Wilson's disease (WD), we developed a computer-assisted radiomics model to distinguish between WD and WD cognitive impairment.

Methods

Overall, 136 T1-weighted MR images were retrieved from the First Affiliated Hospital of Anhui University of Chinese Medicine, including 77 from patients with WD and 59 from patients with WD cognitive impairment. The images were divided into training and test groups at a ratio of 70:30. The radiomic features of each T1-weighted image were extracted using 3D Slicer software. R software was used to establish clinical and radiomic models based on clinical characteristics and radiomic features, respectively. The receiver operating characteristic profiles of the three models were evaluated to assess their diagnostic accuracy and reliability in distinguishing between WD and WD cognitive impairment. We combined relevant neuropsychological test scores of prospective memory to construct an integrated predictive model and visual nomogram to effectively assess the risk of cognitive decline in patients with WD.

Results

The area under the curve values for distinguishing WD and WD cognitive impairment for the clinical, radiomic, and integrated models were 0.863, 0.922, and 0.935 respectively, indicative of excellent performance. The nomogram based on the integrated model successfully differentiated between WD and WD cognitive impairment.

Conclusion

The nomogram developed in the current study may assist clinicians in the early identification of cognitive impairment in patients with WD. Early intervention following such identification may help improve long-term prognosis and quality of life of these patients.

T1 Mapping Values May Be Associated with Early Myocardial Involvement in Young Patients with Wilson Disease

In young Asian patients with Wilson disease and no cardiac abnormalities or late gadolinium enhancement, cardiac MRI depicted elevated native T1, T2, and extracellular volume, suggesting early cardiac involvement.

Cardiac involvement in Wilson’s disease: a retrospective cohort study

Background and objectives

Wilson’s disease (WD) is an inherited disorder with perturbations in copper metabolism and can cause multiorgan damage. This study aims to explore cardiac findings mainly based on electrocardiography (ECG) in WD patients.

Methods

We retrospectively enrolled adult patients who were diagnosed with WD between January 2011 and December 2020. Demographic and clinical data were collected and reevaluated.

Results

A total of 126 patients were included. There were 71 men and 55 women. The mean age was 27.2 years. Ninety-nine had hepatic presentation as the initial symptom and 27 had neuropsychiatric presentation as the initial symptom. Thirty-seven patients (29.4%) had cardiac manifestations. Of these patients, nine presented apparent cardiac symptoms (three with discontinuous chest tightness, three with dizziness, two with palpitation and one with atypical chest pain) and 28 had asymptomatic electrocardiography (ECG) abnormalities. Among the nine patients, four had second- or third-degree atrioventricular block, three had ST-segment change and two had ventricular tachycardia. ECG abnormalities in the 28 patients included increase in the width of the QRS complex in 8, atrial premature beats in 8, T-wave inversion in 5, P-wave inversion in 2, sinus bradycardia in 2, ST-segment change in 2, and coexistence of sinus bradycardia and T-wave inversion in 1. No statistical difference (P = 0.32) existed in the occurrence of ECG abnormalities between patients with hepatic presentation (27/99) and those with neuropsychiatric presentation (10/27).

Conclusion

Cardiac involvement is not rare in adult WD patients. We suggest that cardiac evaluation should be routinely performed in the population.

Prevalence and features of non-motor symptoms in Wilson's disease

INTRODUCTION

Wilson's Disease (WD) is an autosomal recessive disorder caused by excessive copper deposition in liver, brain and other organs. The clinical picture is characterized by hepatic, psychiatric and neurological dysfunction. Movement disorders are the core neurological features, although non-motor symptoms (NMS), as cognitive/affective, autonomic and sleep disorders, may occur over time. We aimed to assess the frequency of NMS in WD patients compared with healthy subjects.

METHODS

Twenty-seven patients affected with genetically proven WD (12 F, 15 M) and 35 healthy controls (Ctrl; 17 F, 18 M), comparable for age and education, were enrolled. Eighteen patients presented with the neurological form of the disease (NV) and nine with the non-neurological variant (NNV). NMS were assessed in all subjects by the following clinical scales: Mini-Mental State Examination (MMSE), Non-Motor Symptoms Scale (NMSS), SCOPA-AUT Questionnaire, Apathy Evaluation Scale (AES), Beck Depression Inventory (BDI), Epworth Sleepiness Scale (ESS), Restless Legs Syndrome Rating Scale (RLSRS), REM Sleep Behavior Disorder Screening Questionnaire (RBDSQ), Questionnaire for Impulsive-Compulsive Disorders in Parkinson's disease (QUIP-RS).

RESULTS

We found that the patients showed more severe and frequent NMS and daytime sleepiness, and lower MMSE than Ctrl. In comparison to healthy subjects, NV subjects showed statistically significant higher ESS, NMSS, and RLSRS scores, and a lower MMSE score. Subtle and subclinical extrapyramidal/pyramidal signs and brain MRI signal abnormalities were detected in patients considered as asymptomatic for neurological disturbances.

CONCLUSIONS

NMS are common among WD patient, in particular those with NV, likely due to the widespread pathological changes throughout the central nervous system.