1
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Griffiths CD, Shah M, Shao W, Borgman CA, Janes KA. Three Modes of Viral Adaption by the Heart. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.28.587274. [PMID: 38585853 PMCID: PMC10996681 DOI: 10.1101/2024.03.28.587274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Viruses elicit long-term adaptive responses in the tissues they infect. Understanding viral adaptions in humans is difficult in organs such as the heart, where primary infected material is not routinely collected. In search of asymptomatic infections with accompanying host adaptions, we mined for cardio-pathogenic viruses in the unaligned reads of nearly one thousand human hearts profiled by RNA sequencing. Among virus-positive cases (~20%), we identified three robust adaptions in the host transcriptome related to inflammatory NFκB signaling and post-transcriptional regulation by the p38-MK2 pathway. The adaptions are not determined by the infecting virus, and they recur in infections of human or animal hearts and cultured cardiomyocytes. Adaptions switch states when NFκB or p38-MK2 are perturbed in cells engineered for chronic infection by the cardio-pathogenic virus, coxsackievirus B3. Stratifying viral responses into reversible adaptions adds a targetable systems-level simplification for infections of the heart and perhaps other organs.
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Affiliation(s)
- Cameron D. Griffiths
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Millie Shah
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - William Shao
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Cheryl A. Borgman
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Kevin A. Janes
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
- Department of Biochemistry & Molecular Genetics, University of Virginia, Charlottesville, VA 22908, USA
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2
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Panagiotides NG, Poledniczek M, Andreas M, Hülsmann M, Kocher AA, Kopp CW, Piechota-Polanczyk A, Weidenhammer A, Pavo N, Wadowski PP. Myocardial Oedema as a Consequence of Viral Infection and Persistence-A Narrative Review with Focus on COVID-19 and Post COVID Sequelae. Viruses 2024; 16:121. [PMID: 38257821 PMCID: PMC10818479 DOI: 10.3390/v16010121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Microvascular integrity is a critical factor in myocardial fluid homeostasis. The subtle equilibrium between capillary filtration and lymphatic fluid removal is disturbed during pathological processes leading to inflammation, but also in hypoxia or due to alterations in vascular perfusion and coagulability. The degradation of the glycocalyx as the main component of the endothelial filtration barrier as well as pericyte disintegration results in the accumulation of interstitial and intracellular water. Moreover, lymphatic dysfunction evokes an increase in metabolic waste products, cytokines and inflammatory cells in the interstitial space contributing to myocardial oedema formation. This leads to myocardial stiffness and impaired contractility, eventually resulting in cardiomyocyte apoptosis, myocardial remodelling and fibrosis. The following article reviews pathophysiological inflammatory processes leading to myocardial oedema including myocarditis, ischaemia-reperfusion injury and viral infections with a special focus on the pathomechanisms evoked by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In addition, clinical implications including potential long-term effects due to viral persistence (long COVID), as well as treatment options, are discussed.
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Affiliation(s)
- Noel G. Panagiotides
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
| | - Michael Poledniczek
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria;
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.A.); (A.A.K.)
| | - Martin Hülsmann
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
| | - Alfred A. Kocher
- Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.A.); (A.A.K.)
| | - Christoph W. Kopp
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria;
| | | | - Annika Weidenhammer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
| | - Noemi Pavo
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (N.G.P.); (M.P.); (M.H.); (A.W.); (N.P.)
| | - Patricia P. Wadowski
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria;
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3
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Piewbang C, Lohavicharn P, Nguyen TV, Punyathi P, Kasantikul T, Techangamsuwan S. Carnivore chaphamaparvovirus-1 (CaChPV-1) infection in diarrheic dogs reveals viral endotheliotropism in intestine and lung. Vet Q 2023; 43:1-10. [PMID: 36846895 PMCID: PMC10013547 DOI: 10.1080/01652176.2023.2185696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Carnivore chaphamaparvovirus-1 (CaChPV-1) is a parvovirus identified in dogs and association of infection with diarrhea is controversial. Information on whether tissue tropism persists is lacking. OBJECTIVES To determine the disease association of CaChPV-1 in dogs with diarrhea and to investigate viral tropism and genetic diversity. ANIMALS AND METHODS CaChPV-1 infection was investigated in five recently deceased puppies and designed a retrospective study to determine whether the presence of CaChPV-1 is associated with diarrhea. The retrospective study was conducted in 137 intestinal tissue samples and 168 fecal samples obtained from 305 dogs. CaChPV-1 tissue localization was determined using in situ hybridization, and CaChPV-1 complete genomes obtained from dead puppies and retrospective study were sequenced and analyzed. RESULTS CaChPV-1 was detected in 6.56% (20/305) of tested dogs, including 14 diarrheic- and 6 non-diarrheic dogs, and was significant in puppies with diarrhea (p = 0.048). Among the CaChPV-1-positive diarrheic dogs, one sample was obtained from intestinal tissue and 13 samples were fecal samples. However, six CaChPV-1 positive non-diarrheic dogs were based on fecal samples but not on intestinal tissue. Within the age range, the presence of CaChPV-1 was significant in puppies (p < 0.00001) and was mainly localized in the stromal and endothelial cells of intestinal villi and pulmonary alveoli. Phylogenetic analysis indicated genetic diversity of CaChPV-1 Thai strains that were mostly clustered within the sequences found in China. CONCLUSIONS Although definitive pathogenesis of CaChPV-1 remains undetermined, this study provides evidence supporting that CaChPV-1 localizes in canine cells and could play a potential role as an enteric pathogen.
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Affiliation(s)
- Chutchai Piewbang
- Department of Pathology, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand.,Animal Virome and Diagnostic Development Research Unit, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
| | - Pattiya Lohavicharn
- Department of Pathology, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand.,Animal Virome and Diagnostic Development Research Unit, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
| | - Tin Van Nguyen
- Animal Virome and Diagnostic Development Research Unit, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand.,The International Graduate Course of Veterinary Science and Technology (VST), Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
| | - Panitnan Punyathi
- Department of Pathology, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
| | - Tanit Kasantikul
- Clemson Veterinary Diagnostic Center, Clemson University, Columbia, South Carolina, USA
| | - Somporn Techangamsuwan
- Department of Pathology, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand.,Animal Virome and Diagnostic Development Research Unit, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
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4
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Huang CL, Chen DY, Tzang CC, Lin JW, Tzang BS, Hsu TC. Celastrol attenuates human parvovirus B19 NS1‑induced NLRP3 inflammasome activation in macrophages. Mol Med Rep 2023; 28:193. [PMID: 37654202 PMCID: PMC10502933 DOI: 10.3892/mmr.2023.13080] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023] Open
Abstract
Human parvovirus B19 (B19V) has been strongly associated with a variety of inflammatory disorders, such as rheumatoid arthritis (RA), inflammatory bowel disease and systemic lupus erythematosus. Non‑structural protein 1 (NS1) of B19V has been demonstrated to play essential roles in the pathological processes of B19V infection due to its regulatory properties on inflammatory cytokines. Celastrol, a quinone methide isolated from Tripterygium wilfordii, has displayed substantial potential in treating inflammatory diseases, such as psoriasis and RA. However, little is known about the effects of celastrol on B19V NS1‑induced inflammation. Therefore, cell viability assay, migration assay, phagocytosis analysis, zymography assay, ELISA and immunoblotting were conducted to verify the influences of celastrol on macrophages. The present study reported the attenuating effects of celastrol on B19V NS1‑induced inflammatory responses in macrophages derived from human acute monocytic leukemia cell lines, U937 and THP‑1. Although the migration was not significantly decreased by celastrol in both U937 and THP‑1 macrophages, significantly decreased viability, migration and phagocytosis were detected in both B19V NS1‑activated U937 and THP‑1 macrophages in the presence of celastrol. Additionally, celastrol significantly decreased MMP‑9 activity and the levels of inflammatory cytokines, including IL‑6, TNF‑α and IL‑1β, in B19V NS1‑activated U937 and THP‑1 cells. Notably, significantly decreased levels of NLR family pyrin domain‑containing 3, apoptosis‑associated speck‑like, caspase‑1 and IL‑18 proteins were observed in both B19V NS1‑activated U937 and THP‑1 cells in the presence of celastrol, indicating the involvement of the inflammasome pathway. To the best of our knowledge, the present study is the first to report on the attenuating effects of celastrol on B19V NS1‑induced inflammatory responses in macrophages, suggesting a therapeutic role for celastrol in B19V NS1‑related inflammatory diseases.
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Affiliation(s)
- Chang-Lun Huang
- Division of Thoracic Surgery, Department of Surgery, Changhua Christian Medical Foundation Changhua Christian Hospital, Changhua 500, Taiwan, R.O.C
| | - Der-Yuan Chen
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan, R.O.C
- College of Medicine, China Medical University, Taichung 404, Taiwan, R.O.C
- Rheumatology and Immunology Center, China Medical University Hospital, Taichung 404, Taiwan, R.O.C
- Translational Medicine Laboratory, Rheumatology and Immunology Center, China Medical University Hospital, Taichung 404, Taiwan, R.O.C
| | - Chih-Chen Tzang
- School of Medicine, College of Medicine, National Taiwan University, Taipei 100, Taiwan, R.O.C
| | - Jhen-Wei Lin
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan, R.O.C
| | - Bor-Show Tzang
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan, R.O.C
- Immunology Research Center, Chung Shan Medical University, Taichung 402, Taiwan, R.O.C
- Department of Clinical Laboratory, Chung Shan Medical University Hospital, Taichung 402, Taiwan, R.O.C
- Department of Biochemistry, School of Medicine, Chung Shan Medical University, Taichung 402, Taiwan, R.O.C
| | - Tsai-Ching Hsu
- Institute of Medicine, Chung Shan Medical University, Taichung 402, Taiwan, R.O.C
- Immunology Research Center, Chung Shan Medical University, Taichung 402, Taiwan, R.O.C
- Department of Clinical Laboratory, Chung Shan Medical University Hospital, Taichung 402, Taiwan, R.O.C
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5
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Baumeier C, Harms D, Aleshcheva G, Gross U, Escher F, Schultheiss HP. Advancing Precision Medicine in Myocarditis: Current Status and Future Perspectives in Endomyocardial Biopsy-Based Diagnostics and Therapeutic Approaches. J Clin Med 2023; 12:5050. [PMID: 37568452 PMCID: PMC10419903 DOI: 10.3390/jcm12155050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
The diagnosis and specific and causal treatment of myocarditis and inflammatory cardiomyopathy remain a major clinical challenge. Despite the rapid development of new imaging techniques, endomyocardial biopsies remain the gold standard for accurate diagnosis of inflammatory myocardial disease. With the introduction and continued development of immunohistochemical inflammation diagnostics in combination with viral nucleic acid testing, myocarditis diagnostics have improved significantly since their introduction. Together with new technologies such as miRNA and gene expression profiling, quantification of specific immune cell markers, and determination of viral activity, diagnostic accuracy and patient prognosis will continue to improve in the future. In this review, we summarize the current knowledge on the pathogenesis and diagnosis of myocarditis and inflammatory cardiomyopathies and highlight future perspectives for more in-depth and specialized biopsy diagnostics and precision, personalized medicine approaches.
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Affiliation(s)
- Christian Baumeier
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (D.H.); (G.A.); (U.G.); (H.-P.S.)
| | - Dominik Harms
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (D.H.); (G.A.); (U.G.); (H.-P.S.)
- Department of Infectious Diseases, Robert Koch Institute, 13353 Berlin, Germany
| | - Ganna Aleshcheva
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (D.H.); (G.A.); (U.G.); (H.-P.S.)
| | - Ulrich Gross
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (D.H.); (G.A.); (U.G.); (H.-P.S.)
| | - Felicitas Escher
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, 13353 Berlin, Germany;
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Heinz-Peter Schultheiss
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany; (D.H.); (G.A.); (U.G.); (H.-P.S.)
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6
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Badrinath A, Bhatta S, Kloc A. Persistent viral infections and their role in heart disease. Front Microbiol 2022; 13:1030440. [PMID: 36504781 PMCID: PMC9730422 DOI: 10.3389/fmicb.2022.1030440] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 11/02/2022] [Indexed: 11/25/2022] Open
Abstract
Viral infections are the culprit of many diseases, including inflammation of the heart muscle, known as myocarditis. Acute myocarditis cases have been described in scientific literature, and viruses, such as parvovirus B19, coxsackievirus B3, or more recently, SARS-CoV-2, were the direct cause of cardiac inflammation. If not treated, myocarditis could progress to dilated cardiomyopathy, which permanently impairs the heart and limits a person's lifespan. Accumulated evidence suggests that certain viruses may persist in cardiac tissue after the initial infection, which could open up the door to reactivation under favorable conditions. Whether this chronic infection contributes to, or initiates, cardiac damage over time, remains a pressing issue in the field of virus-induced heart pathology, and it is directly tied to patients' treatment. Previously, large case studies found that a few viruses: parvovirus B19, coxsackievirus, adenovirus, human herpesvirus 6, cytomegalovirus and Epstein-Barr virus, are most commonly found in human endomyocardial biopsy samples derived from patients experiencing cardiac inflammation, or dilated cardiomyopathy. SARS-CoV-2 infection has also been shown to have cardiovascular consequences. This review examines the role of viral persistence in cardiac inflammation and heart disease, and discusses its implications for patients' outcomes.
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7
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Xuan Y, Chen C, Wen Z, Wang DW. The Roles of Cardiac Fibroblasts and Endothelial Cells in Myocarditis. Front Cardiovasc Med 2022; 9:882027. [PMID: 35463742 PMCID: PMC9022788 DOI: 10.3389/fcvm.2022.882027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 03/16/2022] [Indexed: 11/13/2022] Open
Abstract
In myocarditis caused by various etiologies, activated immune cells and the immune regulatory factors released by them play important roles. But in this complex microenvironment, non-immune cells and non-cardiomyocytes in the heart, such as cardiomyocytes (CMs), cardiac fibroblasts (CFs) and endothelial cells (ECs), play the role of “sentinel”, amplify inflammation, and interact with the cardiomyocytes. The complex interactions between them are rarely paid attention to. This review will re-examine the functions of CFs and ECs in the pathological conditions of myocarditis and their direct and indirect interactions with CMs, in order to have a more comprehensive understanding of the pathogenesis of myocarditis and better guide the drug development and clinical treatment of myocarditis.
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Affiliation(s)
- Yunling Xuan
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
| | - Chen Chen
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
| | - Zheng Wen
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
- *Correspondence: Zheng Wen
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Genetics and Molecular Mechanisms of Cardiological Disorders, Wuhan, China
- Dao Wen Wang
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8
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Pereira JDJ, Ikegami RN, Kawakami JT, Garavelo SM, Reis MM, Palomino SAP, Mangini S, Moreno CR, de Barros SF, Souza AR, Higuchi MDL. Distinct Microbial Communities in Dilated Cardiomyopathy Explanted Hearts Are Associated With Different Myocardial Rejection Outcomes. Front Cell Infect Microbiol 2021; 11:732276. [PMID: 34912727 PMCID: PMC8668412 DOI: 10.3389/fcimb.2021.732276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/05/2021] [Indexed: 11/27/2022] Open
Abstract
Background Idiopathic dilated cardiomyopathy (IDCM) myocardial inflammation may be associated with external triggering factors such as infectious agents. Here, we searched if moderate/severe heart transplantation rejection is related to the presence of myocardial inflammation in IDCM explanted hearts, associated with microbial communities. Method Receptor myocardial samples from 18 explanted hearts were separated into groups according to post-transplant outcome: persistent moderate rejection (PMR; n = 6), moderate rejection (MR; n = 7) that regressed after pulse therapy, and no rejection (NR; n = 5)/light intensity rejection. Inflammation was quantified through immunohistochemistry (IHC), and infectious agents were evaluated by IHC, molecular biology, in situ hybridization technique, and transmission electron microscopy (TEM). Results NR presented lower numbers of macrophages, as well as B cells (p = 0.0001), and higher HLA class II expression (p ≤ 0.0001). PMR and MR showed higher levels of Mycoplasma pneumoniae (p = 0.003) and hepatitis B core (p = 0.0009) antigens. NR presented higher levels of parvovirus B19 (PVB19) and human herpes virus 6 (HHV6) and a positive correlation between Borrelia burgdorferi (Bb) and enterovirus genes. Molecular biology demonstrated the presence of M. pneumoniae, Bb, HHV6, and PVB19 genes in all studied groups. TEM revealed structures compatible with the cited microorganisms. Conclusions This initial study investigating on infectious agents and inflammation in the IDCM explanted hearts showed that the association between M. pneumoniae and hepatitis B core was associated with a worse outcome after HT, represented by MR and PMR, suggesting that different IDCM microbial communities may be contributing to post-transplant myocardial rejection.
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Affiliation(s)
- Jaqueline de Jesus Pereira
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Renata Nishiyama Ikegami
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Joyce Tiyeko Kawakami
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Shérrira Menezes Garavelo
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Marcia Martins Reis
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Suely Aparecida Pinheiro Palomino
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Sandrigo Mangini
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Camila Rodrigues Moreno
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Samar Freschi de Barros
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Aline Rodrigues Souza
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Maria de Lourdes Higuchi
- Instituto do Coração (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Laboratório de Patologia Cardíaca, Departamento de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
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9
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Schultheiss HP, Baumeier C, Aleshcheva G, Bock CT, Escher F. Viral Myocarditis-From Pathophysiology to Treatment. J Clin Med 2021; 10:jcm10225240. [PMID: 34830522 PMCID: PMC8623269 DOI: 10.3390/jcm10225240] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 12/17/2022] Open
Abstract
The diagnosis of acute and chronic myocarditis remains a challenge for clinicians. Characterization of this disease has been hampered by its diverse etiologies and heterogeneous clinical presentations. Most cases of myocarditis are caused by infectious agents. Despite successful research in the last few years, the pathophysiology of viral myocarditis and its sequelae leading to severe heart failure with a poor prognosis is not fully understood and represents a significant public health issue globally. Most likely, at a certain point, besides viral persistence, several etiological types merge into a common pathogenic autoimmune process leading to chronic inflammation and tissue remodeling, ultimately resulting in the clinical phenotype of dilated cardiomyopathy. Understanding the underlying molecular mechanisms is necessary to assess the prognosis of patients and is fundamental to appropriate specific and personalized therapeutic strategies. To reach this clinical prerequisite, there is the need for advanced diagnostic tools, including an endomyocardial biopsy and guidelines to optimize the management of this disease. The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has currently led to the worst pandemic in a century and has awakened a special sensitivity throughout the world to viral infections. This work aims to summarize the pathophysiology of viral myocarditis, advanced diagnostic methods and the current state of treatment options.
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Affiliation(s)
| | - Christian Baumeier
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany
| | - Ganna Aleshcheva
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany
| | - C-Thomas Bock
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, 13353 Berlin, Germany
- Institute of Tropical Medicine, University of Tuebingen, 72074 Tuebingen, Germany
| | - Felicitas Escher
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, 12203 Berlin, Germany
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité-Universitaetsmedizin Berlin, Corporate Member of Freie Universitaet Berlin and Humboldt-Universitaet zu Berlin, 13353 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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10
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Jud P, Gressenberger P, Muster V, Avian A, Meinitzer A, Strohmaier H, Sourij H, Raggam RB, Stradner MH, Demel U, Kessler HH, Eller K, Brodmann M. Evaluation of Endothelial Dysfunction and Inflammatory Vasculopathy After SARS-CoV-2 Infection-A Cross-Sectional Study. Front Cardiovasc Med 2021; 8:750887. [PMID: 34722682 PMCID: PMC8549830 DOI: 10.3389/fcvm.2021.750887] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/15/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Rising data suggest that COVID-19 affects vascular endothelium while the underlying mechanisms promoting COVID-19-associated endothelial dysfunction and inflammatory vasculopathy are largely unknown. The aim was to evaluate the contribution of COVID-19 to persisting vascular injury and to identify parameters linked to COVID-19-associated endothelial dysfunction and inflammatory vasculopathy. Methods: In a cross-sectional design, flow-mediated dilation (FMD), nitroglycerine-related dilation (NMD), pulse-wave velocity (PWV), augmentation index, intima-media thickness (IMT), compounds of the arginine and kynurenine metabolism, homocysteine, von Willebrand factor (vWF), endothelial microparticles (EMP), antiendothelial cell antibodies, inflammatory, and immunological parameters, as well as nailfold capillary morphology were measured in post-COVID-19 patients, patients with atherosclerotic cardiovascular diseases (ASCVD) and healthy controls without prior or recent SARS-CoV-2 infection. Results: Post-COVID-19 patients had higher values of PWV, augmentation index, IMT, asymmetric and symmetric dimethylarginine, vWF, homocysteine, CD31+/CD42b- EMP, C-reactive protein, erythrocyte sedimentation rate, interleukin-6, and β-2-glycoprotein antibodies as well as lower levels of homoarginine and tryptophan compared to healthy controls (all with p < 0.05). A higher total number of pathologically altered inflammatory conditions and higher rates of capillary ramifications, loss, caliber variability, elongations and bushy capillaries with an overall higher microangiopathy evolution score were also observed in post-COVID-19 patients (all with p < 0.05). Most parameters of endothelial dysfunction and inflammation were comparably altered in post-COVID-19 patients and patients with ASCVD, including FMD and NMD. Conclusion: COVID-19 may affect arterial stiffness, capillary morphology, EMP and selected parameters of arginine, kynurenine and homocysteine metabolism as well as of inflammation contributing to COVID-19-associated endothelial dysfunction and inflammatory vasculopathy.
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Affiliation(s)
- Philipp Jud
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Paul Gressenberger
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Viktoria Muster
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Andreas Meinitzer
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Heimo Strohmaier
- Department Center of Medical Research, Medical University of Graz, Graz, Austria
| | - Harald Sourij
- Division of Endocrinology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Reinhard B Raggam
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Martin Helmut Stradner
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ulrike Demel
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Harald H Kessler
- Diagnostic and Research Institute of Hygiene, Microbiology and Environmental, Medical University of Graz, Graz, Austria
| | - Kathrin Eller
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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11
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Schultheiss HP, Baumeier C, Pietsch H, Bock CT, Poller W, Escher F. Cardiovascular consequences of viral infections: from COVID to other viral diseases. Cardiovasc Res 2021; 117:2610-2623. [PMID: 34609508 PMCID: PMC8500164 DOI: 10.1093/cvr/cvab315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 09/28/2021] [Indexed: 12/15/2022] Open
Abstract
Infection of the heart muscle with cardiotropic viruses is one of the major aetiologies of myocarditis and acute and chronic inflammatory cardiomyopathy (DCMi). However, viral myocarditis and subsequent dilated cardiomyopathy is still a challenging disease to diagnose and to treat and is therefore a significant public health issue globally. Advances in clinical examination and thorough molecular genetic analysis of intramyocardial viruses and their activation status have incrementally improved our understanding of molecular pathogenesis and pathophysiology of viral infections of the heart muscle. To date, several cardiotropic viruses have been implicated as causes of myocarditis and DCMi. These include, among others, classical cardiotropic enteroviruses (Coxsackieviruses B), the most commonly detected parvovirus B19, and human herpes virus 6. A newcomer is the respiratory virus that has triggered the worst pandemic in a century, SARS-CoV-2, whose involvement and impact in viral cardiovascular disease is under scrutiny. Despite extensive research into the pathomechanisms of viral infections of the cardiovascular system, our knowledge regarding their treatment and management is still incomplete. Accordingly, in this review, we aim to explore and summarize the current knowledge and available evidence on viral infections of the heart. We focus on diagnostics, clinical relevance and cardiovascular consequences, pathophysiology, and current and novel treatment strategies.
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Affiliation(s)
| | - Christian Baumeier
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, Berlin, Germany
| | - Heiko Pietsch
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, Berlin, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany, partner site
| | - C Thomas Bock
- Division of Viral Gastroenteritis and Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, Berlin, 13353 Germany.,Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Wolfgang Poller
- DZHK (German Centre for Cardiovascular Research), Berlin, Germany, partner site.,Department of Cardiology, Campus Benjamin Franklin.,Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Felicitas Escher
- Institute of Cardiac Diagnostics and Therapy, IKDT GmbH, Berlin, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Berlin, Germany, partner site
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12
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Balbi C, Burrello J, Bolis S, Lazzarini E, Biemmi V, Pianezzi E, Burrello A, Caporali E, Grazioli LG, Martinetti G, Fusi-Schmidhauser T, Vassalli G, Melli G, Barile L. Circulating extracellular vesicles are endowed with enhanced procoagulant activity in SARS-CoV-2 infection. EBioMedicine 2021; 67:103369. [PMID: 33971404 PMCID: PMC8104913 DOI: 10.1016/j.ebiom.2021.103369] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/26/2021] [Accepted: 04/14/2021] [Indexed: 12/29/2022] Open
Abstract
Background Coronavirus-2 (SARS-CoV-2) infection causes an acute respiratory syndrome accompanied by multi-organ damage that implicates a prothrombotic state leading to widespread microvascular clots. The causes of such coagulation abnormalities are unknown. The receptor tissue factor, also known as CD142, is often associated with cell-released extracellular vesicles (EV). In this study, we aimed to characterize surface antigens profile of circulating EV in COVID-19 patients and their potential implication as procoagulant agents. Methods We analyzed serum-derived EV from 67 participants who underwent nasopharyngeal swabs molecular test for suspected SARS-CoV-2 infection (34 positives and 33 negatives) and from 16 healthy controls (HC), as referral. A sub-analysis was performed on subjects who developed pneumonia (n = 28). Serum-derived EV were characterized for their surface antigen profile and tested for their procoagulant activity. A validation experiment was performed pre-treating EV with anti-CD142 antibody or with recombinant FVIIa. Serum TNF-α levels were measured by ELISA. Findings Profiling of EV antigens revealed a surface marker signature that defines circulating EV in COVID-19. A combination of seven surface molecules (CD49e, CD209, CD86, CD133/1, CD69, CD142, and CD20) clustered COVID (+) versus COVID (-) patients and HC. CD142 showed the highest discriminating performance at both multivariate models and ROC curve analysis. Noteworthy, we found that CD142 exposed onto surface of EV was biologically active. CD142 activity was higher in COVID (+) patients and correlated with TNF-α serum levels. Interpretation In SARS-CoV-2 infection the systemic inflammatory response results in cell-release of substantial amounts of procoagulant EV that may act as clotting initiation agents, contributing to disease severity. Funding Cardiocentro Ticino Institute, Ente ospedaliero Cantonale, Lugano-Switzerland.
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Affiliation(s)
- Carolina Balbi
- Laboratory of Cellular and Molecular Cardiology, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland; Center for Molecular Cardiology, Zurich, Switzerland
| | - Jacopo Burrello
- Laboratory for Cardiovascular Theranostics, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale Lugano, Switzerland
| | - Sara Bolis
- Laboratory of Cellular and Molecular Cardiology, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland; Laboratory for Cardiovascular Theranostics, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale Lugano, Switzerland
| | - Edoardo Lazzarini
- Laboratory for Cardiovascular Theranostics, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale Lugano, Switzerland
| | - Vanessa Biemmi
- Laboratory for Cardiovascular Theranostics, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale Lugano, Switzerland
| | - Enea Pianezzi
- Laboratory of Microbiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Alessio Burrello
- Department of Electrical, Electronic and Information Engineering (DEI), University of Bologna, Bologna, Italy
| | - Elena Caporali
- Cardiology Department, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Lorenzo Gauthier Grazioli
- Internal Medicine Department, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Gladys Martinetti
- Laboratory of Microbiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Tanja Fusi-Schmidhauser
- Internal Medicine Department, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Giuseppe Vassalli
- Laboratory of Cellular and Molecular Cardiology, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland; Center for Molecular Cardiology, Zurich, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
| | - Giorgia Melli
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland; Laboratory for Biomedical Neurosciences, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Lucio Barile
- Laboratory for Cardiovascular Theranostics, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale Lugano, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland; Institute of Life Science, Scuola Superiore Sant'Anna, Pisa, Italy.
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13
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Abstract
Platelets play an essential role in maintaining vascular integrity after injury. In addition, platelets contribute to the immune response to pathogens. For instance, they express receptors that mediate binding of viruses, and toll-like receptors that activate the cell in response to pathogen-associated molecular patterns. Platelets can be beneficial and/or detrimental during viral infections. They reduce blood-borne viruses by engulfing the free virus and presenting the virus to neutrophils. However, platelets can also enhance inflammation and tissue injury during viral infections. Here, we discuss the roles of platelets in viral infection.
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Affiliation(s)
- Silvio Antoniak
- UNC Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel Mackman
- UNC Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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14
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Raadsen M, Du Toit J, Langerak T, van Bussel B, van Gorp E, Goeijenbier M. Thrombocytopenia in Virus Infections. J Clin Med 2021; 10:jcm10040877. [PMID: 33672766 PMCID: PMC7924611 DOI: 10.3390/jcm10040877] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/10/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023] Open
Abstract
Thrombocytopenia, which signifies a low platelet count usually below 150 × 109/L, is a common finding following or during many viral infections. In clinical medicine, mild thrombocytopenia, combined with lymphopenia in a patient with signs and symptoms of an infectious disease, raises the suspicion of a viral infection. This phenomenon is classically attributed to platelet consumption due to inflammation-induced coagulation, sequestration from the circulation by phagocytosis and hypersplenism, and impaired platelet production due to defective megakaryopoiesis or cytokine-induced myelosuppression. All these mechanisms, while plausible and supported by substantial evidence, regard platelets as passive bystanders during viral infection. However, platelets are increasingly recognized as active players in the (antiviral) immune response and have been shown to interact with cells of the innate and adaptive immune system as well as directly with viruses. These findings can be of interest both for understanding the pathogenesis of viral infectious diseases and predicting outcome. In this review, we will summarize and discuss the literature currently available on various mechanisms within the relationship between thrombocytopenia and virus infections.
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Affiliation(s)
- Matthijs Raadsen
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
| | - Justin Du Toit
- Department of Haematology, Wits University Donald Gordon Medical Centre Johannesburg, Johannesburg 2041, South Africa;
| | - Thomas Langerak
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
| | - Bas van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center Plus, 6229 HX Maastricht, The Netherlands;
- Care and Public Health Research Institute (CAPHRI), Maastricht University, 6229 GT Maastricht, The Netherlands
| | - Eric van Gorp
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
- Department of Internal Medicine, Erasmus MC Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Marco Goeijenbier
- Department of Viroscience, Erasmus MC Rotterdam, Doctor molewaterplein 40, 3015 GD Rotterdam, The Netherlands; (M.R.); (T.L.); (E.v.G.)
- Department of Internal Medicine, Erasmus MC Rotterdam, 3000 CA Rotterdam, The Netherlands
- Correspondence:
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15
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Hazebroek MR, Henkens MTHM, Raafs AG, Verdonschot JAJ, Merken JJ, Dennert RM, Eurlings C, Abdul Hamid MA, Wolffs PFG, Winkens B, Brunner-La Rocca HP, Knackstedt C, van Paassen P, van Empel VPM, Heymans SRB. Intravenous immunoglobulin therapy in adult patients with idiopathic chronic cardiomyopathy and cardiac parvovirus B19 persistence: a prospective, double-blind, randomized, placebo-controlled clinical trial. Eur J Heart Fail 2021; 23:302-309. [PMID: 33347677 PMCID: PMC8048650 DOI: 10.1002/ejhf.2082] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/16/2020] [Accepted: 12/17/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS Previous uncontrolled studies suggested a possible benefit of intravenous immunoglobulin (IVIg) in parvovirus B19 (B19V)-related dilated cardiomyopathy (DCM). This randomized, double-blind, placebo-controlled, single-centre trial investigated the benefits of IVIg beyond conventional therapy in idiopathic chronic DCM patients with B19V persistence. METHODS AND RESULTS Fifty patients (39 men; mean age 54 ± 11 years) with idiopathic chronic (>6 months) DCM on optimal medical therapy, left ventricular ejection fraction (LVEF) <45%, and endomyocardial biopsy (EMB) B19V load of >200 copies/µg DNA were blindly randomized to either IVIg (n = 26, 2 g/kg over 4 days) or placebo (n = 24). The primary outcome was change in LVEF at 6 months after randomization. Secondary outcomes were change in functional capacity assessed by 6-min walk test (6MWT), quality of life [Minnesota Living with Heart Failure Questionnaire (MLHFQ)], left ventricular end-diastolic volume (LVEDV), and EMB B19V load at 6 months after randomization. LVEF significantly improved in both IVIg and placebo groups (absolute mean increase 5 ± 9%, P = 0.011 and 6 ± 10%, P = 0.008, respectively), without a significant difference between groups (P = 0.609). Additionally, change in 6MWT [median (interquartile range) IVIg 36 (13;82) vs. placebo 32 (5;80) m; P = 0.573], MLHFQ [IVIg 0 (-7;5) vs. placebo -2 (-6;6), P = 0.904] and LVEDV (IVIg -16 ± 49 mL/m2 vs. placebo -29 ± 40 mL/m2 ; P = 0.334) did not significantly differ between groups. Moreover, despite increased circulating B19V antibodies upon IVIg administration, reduction in cardiac B19V did not significantly differ between groups. CONCLUSION Intravenous immunoglobulin therapy does not significantly improve cardiac systolic function or functional capacity beyond standard medical therapy in patients with idiopathic chronic DCM and cardiac B19V persistence. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov ID NCT00892112.
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Affiliation(s)
- Mark R Hazebroek
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Michiel T H M Henkens
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Anne G Raafs
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Job A J Verdonschot
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Clinical Genetics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jort J Merken
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert M Dennert
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Casper Eurlings
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Myrurgia A Abdul Hamid
- Department of Pathology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Petra F G Wolffs
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bjorn Winkens
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christian Knackstedt
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vanessa P M van Empel
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stephane R B Heymans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiovascular Research, University of Leuven, Leuven, Belgium.,Netherlands Heart Institute (Nl-HI), Utrecht, The Netherlands
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16
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Abstract
Inflammatory cardiomyopathy, characterized by inflammatory cell infiltration into the myocardium and a high risk of deteriorating cardiac function, has a heterogeneous aetiology. Inflammatory cardiomyopathy is predominantly mediated by viral infection, but can also be induced by bacterial, protozoal or fungal infections as well as a wide variety of toxic substances and drugs and systemic immune-mediated diseases. Despite extensive research, inflammatory cardiomyopathy complicated by left ventricular dysfunction, heart failure or arrhythmia is associated with a poor prognosis. At present, the reason why some patients recover without residual myocardial injury whereas others develop dilated cardiomyopathy is unclear. The relative roles of the pathogen, host genomics and environmental factors in disease progression and healing are still under discussion, including which viruses are active inducers and which are only bystanders. As a consequence, treatment strategies are not well established. In this Review, we summarize and evaluate the available evidence on the pathogenesis, diagnosis and treatment of myocarditis and inflammatory cardiomyopathy, with a special focus on virus-induced and virus-associated myocarditis. Furthermore, we identify knowledge gaps, appraise the available experimental models and propose future directions for the field. The current knowledge and open questions regarding the cardiovascular effects associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are also discussed. This Review is the result of scientific cooperation of members of the Heart Failure Association of the ESC, the Heart Failure Society of America and the Japanese Heart Failure Society.
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17
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Abstract
Inflammatory dilated cardiomyopathy (DCMi) is a syndrome, not an etiological disease entity. The infective etiology and the immunopathology can be best determined through endomyocardial biopsy with a complete work-up by light microscopy, immunohistology, and polymerase chain reaction for microbial agents. This review focuses on the methodological advances in diagnosis in the past few years and exemplifies the importance of an etiology-orientated treatment in different case scenarios. In fulminant nonviral myocarditis, immunosuppressive treatment together with hemodynamic stabilization of the patient via mechanical circulatory support (e.g., microaxial pumps, extracorporeal membrane oxygenation, left ventricular assist device) can be life-saving. For viral inflammatory cardiomyopathy, intravenous immunoglobulin treatment can resolve inflammation and often eradicate the virus.
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Affiliation(s)
- Bernhard Maisch
- Medical Faculty, Philipps University, Marburg, Germany.
- Heart and Vessel Centre, Marburg, Germany.
| | - Sabine Pankuweit
- Department of Internal Medicine and Cardiology, Philipps University and UKGM, Marburg, Germany
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18
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Abstract
Myocarditis is generally a mild and self-limited consequence of systemic infection of cardiotropic viruses. However, patients can develop a temporary or permanent impairment of cardiac function including acute cardiomyopathy with hemodynamic compromise or severe arrhythmias. In this setting, specific causes of inflammation are associated with variable risks of death and transplantation. Recent translational studies suggest that treatments tailored to specific causes of myocarditis may impact clinical outcomes when added to guideline-directed medical care. This review summarizes recent advances in translational research that influence the utility of endomyocardial biopsy for the management of inflammatory cardiomyopathies. Emerging therapies for myocarditis based on these mechanistic hypotheses are entering clinical trials and may add to the benefits of established heart failure treatment.
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Affiliation(s)
- Carsten Tschöpe
- From the Charité, University Medicine Berlin, Campus Virchow Klinikum (CVK), Department of Cardiology, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin Institute of Health Center for Regenerative Therapies, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin-Brandenburg Centrum für Regenerative Therapien, Germany (C.T., S.V.L.).,Deutsches Zentrum für Herz Kreislauf Forschung (DZHK)-Standort Berlin/Charité, Germany (C.T., S.V.L.)
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL (L.T.C.)
| | - Guillermo Torre-Amione
- Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, Houston, TX (G.T.-A.).,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Cátedra de Cardiología y Medicina Vascular, Monterrey, Nuevo León, Mexico (G.T.-A.)
| | - Sophie Van Linthout
- From the Charité, University Medicine Berlin, Campus Virchow Klinikum (CVK), Department of Cardiology, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin Institute of Health Center for Regenerative Therapies, Germany (C.T., S.V.L.).,Charité-Universitätsmedizin Berlin, BCRT-Berlin-Brandenburg Centrum für Regenerative Therapien, Germany (C.T., S.V.L.).,Deutsches Zentrum für Herz Kreislauf Forschung (DZHK)-Standort Berlin/Charité, Germany (C.T., S.V.L.)
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19
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Abstract
Infectious myocarditis is the result of an immune response to a microbial infection of the heart. The blood vessels of the heart, both the intramyocardial microvasculature and the large epicardial coronary arteries, play an important role in the pathogenesis of infectious myocarditis. First of all, in addition to cardiomyocytes, endothelial cells of the cardiac (micro)vasculature are direct targets for infection. Moreover, through the expression of adhesion molecules and antigen presenting Major Histocompatibility Complex molecules, the blood vessels assist in shaping the cellular immune response in infectious myocarditis. In addition, damage and dysfunction of the cardiac (micro)vasculature are associated with thrombus formation as well as aberrant regulation of vascular tone including coronary vasospasm. These in turn can cause cardiac perfusion abnormalities and even myocardial infarction. In this review, we will discuss the role of the cardiac (micro)vasculature in the pathogenesis of infectious myocarditis.
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20
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Słomka A, Urban SK, Lukacs-Kornek V, Żekanowska E, Kornek M. Large Extracellular Vesicles: Have We Found the Holy Grail of Inflammation? Front Immunol 2018; 9:2723. [PMID: 30619239 PMCID: PMC6300519 DOI: 10.3389/fimmu.2018.02723] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 11/05/2018] [Indexed: 12/17/2022] Open
Abstract
The terms microparticles (MPs) and microvesicles (MVs) refer to large extracellular vesicles (EVs) generated from a broad spectrum of cells upon its activation or death by apoptosis. The unique surface antigens of MPs/MVs allow for the identification of their cellular origin as well as its functional characterization. Two basic aspects of MP/MV functions in physiology and pathological conditions are widely considered. Firstly, it has become evident that large EVs have strong procoagulant properties. Secondly, experimental and clinical studies have shown that MPs/MVs play a crucial role in the pathophysiology of inflammation-associated disorders. A cardinal feature of these disorders is an enhanced generation of platelets-, endothelial-, and leukocyte-derived EVs. Nevertheless, anti-inflammatory effects of miscellaneous EV types have also been described, which provided important new insights into the large EV-inflammation axis. Advances in understanding the biology of MPs/MVs have led to the preparation of this review article aimed at discussing the association between large EVs and inflammation, depending on their cellular origin.
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Affiliation(s)
- Artur Słomka
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Sabine Katharina Urban
- Department of Medicine II, Saarland University Medical Center, Saarland University, Homburg, Germany
| | - Veronika Lukacs-Kornek
- Institute of Experimental Immunology, University Hospital of the Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Ewa Żekanowska
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum, Bydgoszcz, Poland
| | - Miroslaw Kornek
- Department of Oncology, Hematology and Rheumatology, University Hospital Bonn, Bonn, Germany
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Extracellular Vesicles and Matrix Remodeling Enzymes: The Emerging Roles in Extracellular Matrix Remodeling, Progression of Diseases and Tissue Repair. Cells 2018; 7:cells7100167. [PMID: 30322133 PMCID: PMC6210724 DOI: 10.3390/cells7100167] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 09/17/2018] [Accepted: 10/12/2018] [Indexed: 12/21/2022] Open
Abstract
Extracellular vesicles (EVs) are membrane enclosed micro- and nano-sized vesicles that are secreted from almost every species, ranging from prokaryotes to eukaryotes, and from almost every cell type studied so far. EVs contain repertoire of bioactive molecules such as proteins (including enzymes and transcriptional factors), lipids, carbohydrates and nucleic acids including DNA, coding and non-coding RNAs. The secreted EVs are taken up by neighboring cells where they release their content in recipient cells, or can sail through body fluids to reach distant organs. Since EVs transport bioactive cargo between cells, they have emerged as novel mediators of extra- and intercellular activities in local microenvironment and inter-organ communications distantly. Herein, we review the activities of EV-associated matrix-remodeling enzymes such as matrix metalloproteinases, heparanases, hyaluronidases, aggrecanases, and their regulators such as extracellular matrix metalloproteinase inducers and tissue inhibitors of metalloproteinases as novel means of matrix remodeling in physiological and pathological conditions. We discuss how such EVs act as novel mediators of extracellular matrix degradation to prepare a permissive environment for various pathological conditions such as cancer, cardiovascular diseases, arthritis and metabolic diseases. Additionally, the roles of EV-mediated matrix remodeling in tissue repair and their potential applications as organ therapies have been reviewed. Collectively, this knowledge could benefit the development of new approaches for tissue engineering.
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22
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Van Linthout S, Elsanhoury A, Klein O, Sosnowski M, Miteva K, Lassner D, Abou-El-Enein M, Pieske B, Kühl U, Tschöpe C. Telbivudine in chronic lymphocytic myocarditis and human parvovirus B19 transcriptional activity. ESC Heart Fail 2018; 5:818-829. [PMID: 30099854 PMCID: PMC6165949 DOI: 10.1002/ehf2.12341] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/18/2018] [Accepted: 06/22/2018] [Indexed: 12/31/2022] Open
Abstract
Aims Myocarditis is often associated with parvovirus B19 (B19V) persistence, which can induce vascular damage. Based on the antiviral and anti‐inflammatory properties of telbivudine, we aimed to evaluate its efficacy to protect B19V‐infected endothelial cells in vitro and to treat chronic lymphocytic myocarditis patients with B19V transcriptional activity. Methods and results We evaluated the endothelial‐protective potential of telbivudine in human microvascular endothelial cells‐1, which were infected with B19V. Treatment with 10 ng/mL of telbivudine decreased the B19V‐induced endothelial cell apoptosis and endothelial‐to‐mesenchymal transition. Along with this finding, telbivudine reduced the expression of transforming growth factor‐β1 and of tenascin‐C. The endothelial‐protective properties of telbivudine were also found in tumour necrosis factor‐α‐stressed human microvascular endothelial cells‐1. In addition, oxidative stress in angiotensin II‐stressed and transforming growth factor‐β1‐stressed HL‐1 cardiomyocytes and fibroblasts, respectively, was reduced upon telbivudine treatment, illustrating that telbivudine exerts multimodal protective effects. Based on these in vitro findings, four patients severely suffering from an endomyocardial biopsy‐proven myocarditis associated with B19V transcriptional activity (VP1/VP2‐mRNA positive) were treated with telbivudine (600 mg/dL) for 6 months in a single‐patient‐use approach. Follow‐up biopsies 6 months after treatment showed that VP1/VP2‐mRNA levels and CD3 cells decreased in all patients and were associated with an improvement in ejection fraction and New York Heart Association class. These findings were paralleled by a drop in tenascin‐C expression as shown via matrix‐assisted laser desorption ionization–imaging mass spectrometry. Conclusions Telbivudine exerts endothelial‐protective effects in B19V‐infected endothelial cells and improves chronic myocarditis associated with B19V transcriptional activity. These findings will be further evaluated in the clinical exploratory trial: the PreTopic study.
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Affiliation(s)
- Sophie Van Linthout
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Klinikum, Südstrasse 2, 13353, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Cardiology, Campus Virchow Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Ahmed Elsanhoury
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Klinikum, Südstrasse 2, 13353, Berlin, Germany
| | - Oliver Klein
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Klinikum, Südstrasse 2, 13353, Berlin, Germany
| | - Marzena Sosnowski
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Klinikum, Südstrasse 2, 13353, Berlin, Germany
| | - Kapka Miteva
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Klinikum, Südstrasse 2, 13353, Berlin, Germany
| | - Dirk Lassner
- Institut Kardiale Diagnostik und Therapie (IKDT), Berlin, Germany
| | - Mohamed Abou-El-Enein
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Klinikum, Südstrasse 2, 13353, Berlin, Germany
| | - Burkert Pieske
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Cardiology, Campus Virchow Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Uwe Kühl
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Cardiology, Campus Virchow Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Carsten Tschöpe
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin-Brandenburg Center for Regenerative Therapies, Campus Virchow Klinikum, Südstrasse 2, 13353, Berlin, Germany.,Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Cardiology, Campus Virchow Klinikum, Augustenburgerplatz 1, 13353, Berlin, Germany
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23
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Affiliation(s)
- Giorgio Gallinella
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
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24
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Vítková V, Živný J, Janota J. Endothelial cell-derived microvesicles: potential mediators and biomarkers of pathologic processes. Biomark Med 2018; 12:161-175. [PMID: 29327597 DOI: 10.2217/bmm-2017-0182] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This review focuses on the formation, composition and function of endothelial microvesicles (MV), often called microparticles (MP). MV release is a controlled event and is considered a hallmark of cellular activation or alteration. MV may affect the function of target cells through surface interaction and receptor activation, cellular fusion and the delivery of intravesicular cargo. Endothelial MV are released as a consequence of endothelial activation during inflammation and have been described to affect hemostasis, various aspects of inflammatory reaction, vessel formation, apoptosis and cell survival, endothelial cell differentiation and function. Recent data suggest the potential use of MV in diagnostics, assessment of severity and prediction of outcomes in inflammatory diseases and their utilization as targets, mediators and vectors in therapy.
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Affiliation(s)
- Veronika Vítková
- First Faculty of Medicine, Institute of Pathological Physiology, Charles University, Prague, Czech Republic.,Thomayer Department of Neonatology, Thomayer Hospital Prague, Czech Republic
| | - Jan Živný
- First Faculty of Medicine, Institute of Pathological Physiology, Charles University, Prague, Czech Republic
| | - Jan Janota
- First Faculty of Medicine, Institute of Pathological Physiology, Charles University, Prague, Czech Republic.,Thomayer Department of Neonatology, Thomayer Hospital Prague, Czech Republic
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25
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Schwarz V, Düsing P, Liman T, Werner C, Herm J, Bachelier K, Krüll M, Brechtel L, Jungehulsing GJ, Haverkamp W, Böhm M, Endres M, Haeusler KG, Laufs U. Marathon running increases circulating endothelial- and thrombocyte-derived microparticles. Eur J Prev Cardiol 2017; 25:317-324. [PMID: 29183152 DOI: 10.1177/2047487317744364] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Acute vascular effects of high intensity physical activity are incompletely characterized. Circulating microparticles are cellular markers for vascular activation and damage. Methods Microparticles were analysed in 99 marathon runners (49 ± 6 years, 22% female) of the prospective Berlin Beat of Running study. Blood samples were taken within three days before, immediately after and within two days after the marathon run. Endothelial-derived microparticles were labelled with CD144, CD31 and CD62E, platelet-derived microparticles with CD62P and CD42b, leukocyte-derived microparticles with CD45 and monocyte-derived microparticles with CD14. Results Marathon running induced leukocytosis (5.9 ± 0.1 to 14.8 ± 0.3 109/l, p < 0.0001) and increased platelet counts (239 ± 4.6 to 281 ± 5.9 109/l, p < 0.0001) immediately after the marathon. Blood monocytes increased and lymphocytes decreased after the run ( p < 0.0001). Endothelial-derived microparticles were acutely increased ( p = 0.008) due to a 23% increase of apoptotic endothelial-derived microparticles ( p = 0.007) and returned to baseline within two days after the marathon. Thrombocyte-derived microparticles acutely increased by 38% accompanied by an increase in activated and apoptotic thrombocyte-derived microparticles ( p ≤ 0.0001) each. Both monocyte- and leukocyte-derived microparticles were decreased immediately after marathon run ( p < 0.0001) and remained below baseline until day 2. Troponin T increased from 12 to 32 ng/l ( p < 0.0001) immediately after the run and returned to baseline after two days. Conclusion Circulating apoptotic endothelial- and thrombocyte-derived microparticles increased after marathon running consistent with an acute pro-thrombotic and pro-inflammatory state. Exercise-induced vascular damage reflected by microparticles could indicate potential mechanisms of post-exertional cardiovascular complications. Further studies are warranted to investigate microparticles as markers to identify individuals prone to such complications.
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Affiliation(s)
- Viktoria Schwarz
- 1 Department for Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Saarland University, Homburg/Saar, Germany
| | - Philip Düsing
- 1 Department for Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Saarland University, Homburg/Saar, Germany
| | - Thomas Liman
- 2 Department of Neurology, Charité - Universitätsmedizin Berlin, Germany
| | - Christian Werner
- 1 Department for Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Saarland University, Homburg/Saar, Germany
| | - Juliane Herm
- 2 Department of Neurology, Charité - Universitätsmedizin Berlin, Germany.,3 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Katrin Bachelier
- 1 Department for Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Saarland University, Homburg/Saar, Germany
| | - Matthias Krüll
- 4 SMS Sports Medicine Berlin, Medical Institute of the BMW BERLIN-MARATHON, Germany
| | | | | | - Wilhelm Haverkamp
- 7 Department of Cardiology, Charité - Universitätsmedizin Berlin Campus Virchow-Klinikum, Germany
| | - Michael Böhm
- 1 Department for Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, Saarland University, Homburg/Saar, Germany
| | - Matthias Endres
- 2 Department of Neurology, Charité - Universitätsmedizin Berlin, Germany.,3 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany.,8 German Center for Neurodegenerative Diseases (DZNE) & German Center for Cardiovascular Diseases (DZHK), Partner Site, Berlin, Germany
| | - Karl Georg Haeusler
- 2 Department of Neurology, Charité - Universitätsmedizin Berlin, Germany.,3 Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Germany
| | - Ulrich Laufs
- 9 Department of Cardiology, Universitätsklinikum Leipzig, Germany
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