Prevalence and Clinical Significance of Intraventricular Conduction Disturbances in Hospitalized Children

Introduction: Data on the prevalence and clinical significance of interventricular conduction disturbances (IVCDs) in children are scarce. While incomplete right bundle branch blocks (IRBBBs) seem to be the most frequent and benign findings, complete bundle blocks and fascicular blocks are often seen in children with congenital/acquired cardiac conditions. This study aims to delineate the prevalence and the diagnostic accuracy of IVCD in children admitted to a paediatric cardiology unit. Methods: Children admitted to the paediatric cardiology unit between January 2010 and December 2020 who had an ECG were included in the study. IVCDs were diagnosed according to standard criteria adjusted for age. Results: Three thousand nine hundred and ninety-three patients were enrolled. The median age was 3.1 years (IQR: 0.0-9.2 years), and 52.7% were males. IVCDs were present in 22.5% of the population: 17.4% of the population presented with IRBBBs, 4.8% with a complete right bundle branch block (CRBBB), 0.1% with a complete left bundle branch block (CLBBB), 0.2% with a left anterior fascicular block (LAFB) and 0.2% with a combination of CRBBB and LAFB. Also, 26% of children with congenital heart disease had an IVCD, and 18% of children with an IVCD had previous cardiac surgery. The overall sensitivity of IVCD in detecting a cardiac abnormality was 22.2%, with a specificity of 75.5%, a PPV of 83.1% and an NPV of 15.1%, but the values were higher for CLBBB and LAFB. Conclusions: IVCDs were present in one-fifth of children admitted to the cardiology unit. IRBBB was the most frequent disturbance, while CRBBB, CLBBB and fascicular blocks were much rarer, though they had a higher predictive value for cardiac abnormalities.

Untargeted NMR-based metabolomics analysis of kidney allograft perfusates identifies a signature of delayed graft function

INTRODUCTION

Kidney transplantation (KTx) necessarily conveys an ischemia/reperfusion (I/R) process, which impacts on allograft outcomes. Delayed graft function (DGF) is defined as a non-decrease of serum creatinine by at least 10% daily on 3 consecutive days during the first 7 days post-KTx. DGF significantly conditions both short- and long-term graft outcomes. Still there is a lack of DGF predictive biomarkers.

OBJECTIVES

This study aimed to explore the potential of kidney graft perfusate metabolomics to predict DGF occurrence.

METHODS

49 human perfusates from grafts categorized upon donor type [donation after brain death (DBD)/donation after circulatory death (DCD)] and DGF occurrence and 19 perfusates from a murine model classified upon death type (DBD/DCD) were collected and analyzed by NMR-based metabolomics.

RESULTS

The multivariate analysis of the murine data highlighted significant differences between perfusate metabolomes of DBD versus DCD. These differences were similarly observed in the human perfusates. After correcting for the type of donor, multivariate analysis of human data demonstrated a metabolomics signature that could be correlated with DGF occurrence.

CONCLUSIONS

The metabolome of kidney grafts is influenced by the donor's type in both human and pre-clinical studies and could be correlated with DGF in the human DBD cohort. Thus, metabolomic analysis of perfusate applied prior to KTx may represent a new predictive tool for clinicians in a more personalized management of DGF. Moreover, our data paves the way to better understand the impact of donor's types on the biochemical events occurring between death and the hypothermic storage.

[Clinical and genetic manifestations of left ventricular non-compaction in children]

Left ventricular non-compaction (LVNC) is a myocardial disease characterized by a two-layered structure typically seen at the apical and lateral left portions of the ventricular myocardium, distal to the papillary muscles. While considered a rare disease, its prevalence in children is increasing due to the increased awareness of this condition and improved resolution of imaging techniques. The etiology is heterogeneous, ranging from inherited conditions to acquired diseases. Although many patients are asymptomatic, some patients may experience adverse events, including heart failure, arrhythmias, or thromboembolic events. Several echocardiographic or cardiac magnetic resonance imaging diagnostic criteria have been proposed for diagnosing LVNC. However, their application in children is significantly limited. This review aims to describe the clinical and genetic characteristics of children with LVNC and discuss the role of the proposed diagnostic criteria.

Prediction of incident atrial fibrillation in hypertrophic cardiomyopathy

BACKGROUND AND AIM

Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM) with significant effects on outcome. We aim to compare the left atrial (LA) diameter measurement with HCM-AF Score in predicting atrial fibrillation (AF) development in HCM.

METHODS

From the regional cohort of the Campania Region, Italy, 519 HCM patients (38% women, age45 ± 17 years) without history of AF, were enrolled in the study. The primary clinical endpoint was the development of AF, defined as at least 1 episode documented by ECG.

RESULTS

During the follow-up (mean 8 ± 6, IQ range 2.5-11.2 years), 99 patients (19%) developed AF. Patients who developed AF were more symptomatic, had higher prevalence of ICD implantation, had larger LA diameter, greater left ventricular (LV) maximal wall thickness and LV outflow tract obstruction (p < 0.01). Both LA diameter and HCM-AF score were higher in patients who developed AF versus those who did not (LA diameter 49 ± 7 versus 43 ± 6 mm; HCM-AF score 22 ± 4 versus 19 ± 4; p < 0.0001); however, ROC curve analysis demonstrated that LA diameter had a significant greater area under the curve than HCM-AF Score (p < 0.0001). At 5 years follow-up, a LA diameter > 46 mm, showed a similar accuracy in predicting AF development of HCM-AF score ≥ 22, which identifies patients at high risk to develop AF.

CONCLUSION

Our analysis shows that LA diameter, a worldwide and simple echocardiographic measure, is capable alone to predict AF development in HCM patients.

Left Ventricular Non-Compaction in Children: Aetiology and Diagnostic Criteria

Left ventricular non-compaction (LVNC) is a heterogeneous myocardial disorder characterized by prominent trabeculae protruding into the left ventricular lumen and deep intertrabecular recesses. LVNC can manifest in isolation or alongside other heart muscle diseases. Its occurrence among children is rising due to advancements in imaging techniques. The origins of LVNC are diverse, involving both genetic and acquired forms. The clinical manifestation varies greatly, with some cases presenting no symptoms, while others typically manifesting with heart failure, systemic embolism, and arrhythmias. Diagnosis mainly relies on assessing heart structure using imaging tools like echocardiography and cardiac magnetic resonance. However, the absence of a universally agreed-upon standard and limitations in diagnostic criteria have led to ongoing debates in the scientific community regarding the most reliable methods. Further research is crucial to enhance the diagnosis of LVNC, particularly in early life stages.

Prevalence and clinical significance of right ventricular pulmonary arterial uncoupling in cardiac amyloidosis

BACKGROUND

This study aims to evaluate the prevalence and the clinical significance of the right ventricular pulmonary arterial (RV-PA) uncoupling in patients with cardiac amyloidosis (CA).

METHODS

The study population consisted in 92 consecutive patients with CA (age 71.1 ± 12.2 years, 71% males; 47% with immunoglobulin light chain (AL), 53% with transthyretin [ATTR]). A pre-specified tricuspid anulus plane systolic excursion on pulmonary arterial systolic pressure (TAPSE/PASP) value <0.31 mm/mmHg was used to define RV-PA uncoupling and to dichotomize the study population.

RESULTS

Thirty-two patients (35%) showed RV-PA uncoupling at baseline evaluation (15/44 [34%] AL and 17/48 [35%] ATTR). Patients with RV-PA uncoupling, in both AL and ATTR, showed worse NYHA functional class, lower systemic blood pressure, and more pronounced left ventricular and RV systolic dysfunction than those with RV-PA coupling. During a median follow-up of 8 months (IQR 4-13), 26 patients (28%) experienced cardiovascular death. Patients with RV-PA uncoupling showed lower survival at 12 months follow-up than those with RV-PA coupling (42.7% [95%CI 21.7-63.7%] vs. 87.3% [95%CI 78.3-96.3%], p-value<0.001). Multivariate analysis identified high-sensitivity troponin I values (HR 1.01 [95%CI 1.00-1.02] per 1 pg/mL increase; p-value 0.013) and TAPSE/PASP (HR 1.07 [95%CI 1.03-1.11] per 0.01 mm/mmHg decrease; p-value 0.002) as independent predictors of cardiovascular death.

CONCLUSIONS

RV-PA uncoupling is common among patient with CA, and it is a marker of advanced disease and worse outcome. This study suggest that TAPSE/PASP ratio has the potential to improve risk stratification and guide management strategies in patients with CA of different etiology and advanced disease.

Cardiovascular Involvement in Fabry's Disease: New Advances in Diagnostic Strategies, Outcome Prediction and Management

Cardiovascular involvement is common in Fabry's disease and is the leading cause of morbidity and mortality. The research is focused on identifying diagnostic clues suggestive of cardiovascular involvement in the preclinical stage of the disease through clinical and imaging markers. Different pathophysiologically driven therapies are currently or will soon be available for the treatment of Fabry's disease, with the most significant benefit observed in the early stages of the disease. Thus, early diagnosis and risk stratification for adverse outcomes are crucial to determine when to start an aetiological treatment. This review describes the cardiovascular involvement in Fabry's disease, focusing on the advances in diagnostic strategies, outcome prediction and disease management.

Multimodality Imaging in Arrhythmogenic Left Ventricular Cardiomyopathy

The term arrhythmogenic cardiomyopathy (ACM) describes a large spectrum of myocardial diseases characterized by progressive fibrotic or fibrofatty replacement, which gives the substrate for the occurrence of ventricular tachyarrhythmias and the development of ventricular dysfunction. This condition may exclusively affect the left ventricle, leading to the introduction of the term arrhythmogenic left ventricular cardiomyopathy (ALVC). The clinical features of ALVC are progressive fibrotic replacement with the absence or mild dilation of the LV and the occurrence of ventricular arrhythmias within the left ventricle. In 2019, the diagnostic criteria for the diagnosis of ALVC, based on family history and clinical, electrocardiographic, and imaging features, have been proposed. However, since the significant clinical and imaging overlap with other cardiac diseases, genetic testing with the demonstration of a pathogenic variant in an ACM-related gene is required for diagnostic confirmation. In ALVC, the multimodality imaging approach comprises different imaging techniques, such as echocardiography, cardiac magnetic resonance, and cardiac nuclear imaging. It provides essential information for the diagnosis, differential diagnosis, sudden cardiac death risk stratification, and management purposes. This review aims to elucidate the current role of the different multimodality imaging techniques in patients with ALVC.

22q11.2 Deletion Syndrome: Impact of Genetics in the Treatment of Conotruncal Heart Defects

Congenital heart diseases represent one of the hallmarks of 22q11.2 deletion syndrome. In particular, conotruncal heart defects are the most frequent cardiac malformations and are often associated with other specific additional cardiovascular anomalies. These findings, together with extracardiac manifestations, may affect perioperative management and influence clinical and surgical outcome. Over the past decades, advances in genetic and clinical diagnosis and surgical treatment have led to increased survival of these patients and to progressive improvements in postoperative outcome. Several studies have investigated long-term follow-up and results of cardiac surgery in this syndrome. The aim of our review is to examine the current literature data regarding cardiac outcome and surgical prognosis of patients with 22q11.2 deletion syndrome. We thoroughly evaluate the most frequent conotruncal heart defects associated with this syndrome, such as tetralogy of Fallot, pulmonary atresia with major aortopulmonary collateral arteries, aortic arch interruption, and truncus arteriosus, highlighting the impact of genetic aspects, comorbidities, and anatomical features on cardiac surgical treatment.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Multimodality Imaging in Cardiomyopathies with Hypertrophic Phenotypes

Multimodality imaging is a comprehensive strategy to investigate left ventricular hypertrophy (LVH), providing morphologic, functional, and often clinical information to clinicians. Hypertrophic cardiomyopathy (HCM) is defined by an increased LV wall thickness not only explainable by abnormal loading conditions. In the context of HCM, multimodality imaging, by different imaging techniques, such as echocardiography, cardiac magnetic resonance, cardiac computer tomography, and cardiac nuclear imaging, provides essential information for diagnosis, sudden cardiac death stratification, and management. Furthermore, it is essential to uncover the specific cause of HCM, such as Fabry disease and cardiac amyloidosis, which can benefit of specific treatments. This review aims to elucidate the current role of multimodality imaging in adult patients with HCM.

Pathophysiological, haemodynamic and prognostic implications of left atrial dysfunction in cardiac amyloidosis and other cardiomyopathies with hypertrophic phenotype

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND & PURPOSE. Left atrial function (LAF) is a determinant of clinical status and outcome in many cardiac disorders, including cardiac amyloidosis (CA). Aim of this study is to explores the LAF in CA and other cardiomyopathies with hypertrophic phenotype, and its consequences on cardiovascular haemodynamics, right ventricular function and survival.

METHODS. We enrolled 50 patients with CA (26 AL and 24 wtATTR) and 75 with hypertrophic phenotype (LVH group) [25 hypertrophic cardiomyopathy (HCM) pts, 25 hypertensive pts (HypCM), and 25 pts with aortic stenosis (AS)]. LAF was analysed using the phasic method [LAEI as reservoir, LAPEF as conduit, LAAEF as active pump and TLAEF as total emptying function; see figure 1] by LA volumes determination.

RESULTS. ATTR patients showed higher LA dimensions and impaired reservoir and total LA emptying function (TLAEF) compared to AL without differences LAF. Compared to the LVH group, CA patients showed higher LA dimension with impaired LAF in all phasic parameters, higher LV filling pressures and reduced biventricular function. We further divided CA and LVH patients into four subgroups based on the presence or absence of LA dysfunction (LADys+ for TLAEF values below the median: &lt;50.2%; range 9.3-70.9%]. Among the groups, patients with CA/LADys+ showed worst clinical status, higher pulmonary pressures (sPAP) and lower TAPSE and TAPSE/sPAP ratio values. After a median follow-up of 24 months, 19 patients died from cardiovascular (CV) causes (15 in CA/LADys+ group and 4 in LVH/LADys+). The overall survival free of CV death was  64% in CA/LADys+ and 85% in LVH/LADys+ (4/26) group [log-rank χ2 29.6; p &lt; 0.0001]. A sequential multivariate model was employed to assess whether LAF could predict CV deaths: TLAEF was entered together with established clinical and echocardiographic parameters (NYHA functional class, LAVI, E/Em, sPAP, TAPSE and TAPSE/sPAP ratio). At the final backward analysis, LAVI, TAPSE/sPAP and TLAEF were independent prognosticators of CV death.

CONCLUSIONS. LAF is significantly more impaired in CA than LVH group and is associated with worst clinical status, RV dysfunction and higher LV filling and pulmonary pressure. Moreover, LADys is a frequent feature of CA and significantly associated with higher CV mortality. We suggests that LADys in LVH group could results from chronic pressure overload due to LA"s exposure to high LV diastolic pressure (impaired LV compliance). In CA, LADys could also be determined by direct LA infiltration. The pathophysiological result is a progressive LA remodelling with increased LA pressure, consequent backward transmission to the pulmonary venous system and, ultimately, RV dysfunction. TLAEF is parameter of LAF that correlates with increased pulmonary vascular resistance (measured elsewhere with cardiac catheterisation) and RV dysfunction. In CA, it  seems  promising as marker of the haemodynamic consequences of LADys and CV mortality. Abstract Figure 1  Abstract Figure 2

Diagnostic and prognostic implications of myocardial work in cardiac amyloidosis and in genetic and non-genetic cardiomyopathies with hypertrophic phenotype

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND & PURPOSE. Cardiac amyloidosis (CA) is an infiltrative disorder characterized by left ventricular (LV) thickening with early systolic and diastolic dysfunction. Due to it poor prognosis, and the beneficial impact of novel treatments when started in early stages of disease, its forward detection is crucial. Aim of this study is comparing the diagnostic accuracy of classical and novel echocardiographic parameters in detecting CA among other forms of genetic and non-genetic cardiomyopathies with hypertrophic phenotype.

METHODS. We enrolled 50 pts with CA (26 AL and 24 wtATTR) and 75 phenocopies (LVH group) [25 hypertrophic cardiomyopathy (HCM) pts, 25 hypertensive (HypCM) pts, and 25 pts with non-severe aortic stenosis (AS)]. Standard and novel LV morpho-functional echo parameters [LV ejection fraction (LVEF), myocardial contraction fraction (MCF), global longitudinal strain (GLS), relative regional strain ratio (RRSR), ejection fraction on strain ratio (EFSR)], and novel Myocardial Work (MW) parameters [Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW), Global Work Efficiency (GWE)] were analyzed.

RESULTS. LV standard, novel and MW-derived systolic parameters were more impaired in CA compared to LVH group. At ROC curve analysis, GCW showed the best performance in discriminating CA from other forms of LVH (AUC 0.886; 95% CI: 0.819-0.954; P &lt; 0.0001), with a cut-off value &lt; 1473 mmHg% showing 90% of sensitivity and 82% of specificity). At linear regression analysis, GCW correlated with many echocardiographic parameters (IVSD, PWD, RWT ratio, LVMi, MCF, LVESV, LVEF, EFSR and RRSR). At multivariate analysis, PWD (P &lt; 0,029) and RWT ratio (p &lt; 0,014) were the only parameters associated with GCW. At 24 months follow-up, there were 15 deaths in CA and 4 in LVH group. At Kaplan-Meier analysis the overall survival free of cardiovascular death was reduced in the lowest GCW interquartile ranges (log-rank χ2 21.5; p &lt; 0.0001). At Cox hazard ratio analysis, GCW was the only prognostic parameter associated with cardiovascular mortality (β 1.006; 95% CI: 1.003-1.009; P &lt; 0.0001).

CONCLUSIONS. Despite CA and LVH patients shows a similar phenotype, the systolic function differs greatly. In the present study, the GCW showed the best ability in detecting CA among other forms of LVH. Its reduction in CA seems reflect the infiltrative burden and its consequences on myocardial deformation properties, while its reduction in LVH group has been attributed elsewhere to fibrotic derangement. GCW showed to be a promising novel diagnostic and prognostic factor in this setting. Abstract Figure 1  Abstract Table 1

Diagnostic and prognostic implications of right ventricular-arterial coupling in cardiac amyloidosis and in genetic and non-genetic cardiomyopathies with hypertrophic phenotype

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND & PURPOSE. Right ventricular (RV) dysfunction in cardiomyopathies is a consequence of chronic overload (i.e. aortic stenosis, AS) or direct involvement of systemic disorders (i.e. cardiac amyloidosis, CA). The Tricuspid Annular Plane Systolic Excursion/Systolic Pulmonary Artery Pressure (TAPSE/sPAP) ratio has been recently proposed as a surrogate of RV-arterial coupling (RVAC). This study aims to compare RVAC between CA subgroups and between CA and other forms of genetic and non-genetic cardiomyopathies with hypertrophic phenotype.

METHODS. We enrolled 50 patients with CA (26 AL and 24 wtATTR) and 75 cardiomyopathies with hypertrophy phenotype (LVH group) [25 pts with hypertrophic cardiomyopathy (HCM), 25 hypertensive pts(HypCM), and 25 pts with AS]. Besides routine echocardiographic measurements, we analysed right chambers dimensions and classical and novel parameters of RV function [TAPSE, TAPSE/sPAP, St wave, global (RVGLS) and free-wall (RVFWS) strain].

RESULTS. Compared to AL, the ATTR group showed higher right chambers dimensions, without differences in all RV systolic parameters. Compared to the LVH group, CA patients showed no differences in RV dimensions while RV systolic parameters,  including the TAPSE/sPAP ratio, were significantly reduced in the presence of significantly higher LV filling pressures.  At ROC curve analysis, TAPSE (AUC 0.877; 95% CI: 0.811-0.943; p &lt; 0,0001) and TAPSE/sPAP ratio (AUC 0.859; 95% CI: 0.783-0.935; p &lt; 0,0001) showed the best ability in discriminating CA among other forms of LVH (cut-off 20.5 mm for TAPSE with sensibility of 80.5% and specificity of 78.8%, respectively; cut-off 0.62 for TAPSE/sPAP ratio with  sensibility of 85.4% and specificity 81.8%). At 24 months follow-up, there were 15 deaths in CA (30%) and 4 in LVH group (5%). At Kaplan-Meier estimation, the TAPSE/sPAP ratio showed progressively a significantly reduced survival in the lowest interquartile ranges. Moreover, at multivariate analysis, TAPSE/sPAP was the only independent prognostic factor (β -5,644; 95% IC: 0,000-0,522; p &lt; 0,027).

CONCLUSIONS. The RVAC is significantly impaired in CA compared to the LVH group but not between CA subgroups. Its reduction seems attributable to both increase LV filling pressure, due to the restrictive nature of the infiltrative cardiomyopathy, and reduced RV systolic function, due to either indirect RV chronic overload and direct myocardial infiltration. The TAPSE/sPAP ratio is a surrogate of RVAC and proved to be a novel echocardiographic parameter useful in both discriminating CA among genetic and non-genetic forms of LVH, and stratifying the prognosis. Abstract Table 1  Abstract Figure 1

Natural history of left ventricular hypertrophy in infants of diabetic mothers

BACKGROUND

This study sought to describe the characteristics and the natural course of left ventricular hypertrophy (LVH) in a well-characterized consecutive cohort of infants of diabetic mothers (IDMs).

METHODS

Sixty consecutive IDMs with LVH have been retrospectively identified and enrolled in the study. All IDMs were evaluated at baseline and every 6 months until LV wall thickness regression, defined as the decrease of wall thickness measurement into the normal reference range for cardiac parameters (z-score > -2 and < 2). A comprehensive assessment was performed in those patients with diagnostic markers suggestive of a different cause and/or without significant reduction of the LVH during follow-up.

RESULTS

At 1-year follow-up, all IDMs showed a significant reduction of maximal wall thickness MWT (6.00 mm [IQR 5.00-712] vs. 5.50 mm [IQR 5.00-6.00], p-value <0.001; MWT-z-score: 4.86 [IQR 3.93-7.61] vs. 1.72 [IQR 1.08-2.85], p-value <0.001) compared to baseline, and all patients showed LV wall thickness regression or residual mild or moderate LVH (57%, 28%, and 12%, respectively), except 2 patients with persistent severe LVH, that after a comprehensive clinical-genetic assessment were diagnosed as Noonan syndrome with multiple lentigines. At multivariate analysis, MWT was negatively associated with LV wall thickness regression at 1-year follow-up (MWT-mm: OR 0.48[0.29-0.79], p-value = 0.004; MWT-z-score: OR 0.71[0.56-0.90], p-value = 0.004).

CONCLUSIONS

LVH in IDMs represents a benign condition with complete regression during the first years of life. In those patients without LV wall thickness regression, combined with clinical markers suggesting a specific disease, a complete work-up is required for a definite diagnosis.

589 External validation of the increased wall thickness score for the diagnosis of cardiac amyloidosis

Aims

This study aimed to validate the increased wall thickness (IWT) score, a multiparametric echocardiographic score to facilitate diagnosis of cardiac amyloidosis (CA), in an independent population of patients with increased LV wall thickness suspicious for CA.

Methods and results

Between January 2019 and December 2020, 152 consecutive patients with increased LV wall thickness suspicious for CA were included. For all patient, the multiparametric echocardiographic score (IWT score) was calculated. To validate the diagnostic accuracy of an IWT score ≥8 to predict the diagnosis of CA, sensibility (Se), specificity (Sp), positive predictive value (PPV), negative predictive value (NPV), and predictive accuracy (PA) were calculated. Among the 152 patients included in the study, 50 (33%) were diagnosed as CA, 25 (16%) had severe aortic stenosis, 25 (16%) had hypertensive remodelling, and 52 (34%) had hypertrophic cardiomyopathy. Among the 50 and 102 patients with and without CA, 19 (38%) and 1 (1%) showed an IWT score ≥8, respectively. Overall, the diagnostic accuracy of an IWT score ≥8 for the diagnosis of CA in our population was the following: Se 38% (95% CI: 25–53%); Sp 99% (95% CI: 95–100%); PPV 95% (95% CI: 72–99%); NPV 77% (95% CI: 73–80%); PA 79% (95% CI: 72–85%).

Conclusions

This study reports the first external validation of the IWT score for the diagnosis of CA in patients with increased LV wall thickness. A score ≥8 showed a high Sp, PPV and PA, suggesting that the IWT score can be used to identify CA patients in those with increased LV wall thickness.

577 Bisoprolol for the treatment of symptomatic patients with obstructive hypertrophic cardiomyopathy

Aims

To evaluate to role of bisoprolol to control symptoms and left ventricular outflow tract obstruction (LVOTO) in a consecutive cohort of adults with hypertrophic cardiomyopathy (HCM).

Methods and results

In this retrospective study, patients with HCM with an LVOT gradient ≥50mmHg after Valsalva manoeuvre and New York Heart Association (NYHA) class II-III symptoms were assigned to receive bisoprolol (starting at 1.25 mg daily). The initial dose was increased every two weeks to achieve the target in LVOT gradient &lt;30 mmHg or the maximum tolerated dose. The primary endpoint was the achievement of a LVOT gradient &lt;30 mmHg and ≥1 NYHA class improvement. The secondary endpoints were proportion of patients with LVOT gradient &lt;30 mmHg or &lt; 50 mmHg, proportion of patients with ≥1 NYHA class improvement, and change from baseline in LVOT gradient. Between December 2001 and December 2020, 92 patients were enrolled into the study. Sixteen (17%) patients on bisoprolol met the primary endpoint. Bisoprolol reduced the LVOT gradient to less than 30 mmHg in 33 (36%) patients, to less than 50 mmHg in 57 (62%), and improved NYHA class in 30 (33%). The mean reduction of LVOT gradient on bisoprolol was 28 (±14) mmHg and the percentage reduction was 42 (±21)%. In 35 (39%) patients, bisoprolol did not reduce the gradient to less than 50 mmHg requiring disopyramide and/or myectomy to achieve this goal.

Conclusions

Treatment with bisoprolol was well-tolerated and effective in relieving obstruction and improving symptoms in a significant proportion of patients with symptomatic obstructive HCM.

Diagnosis and Management of Cardiovascular Involvement in Fabry Disease

Fabry disease (FD, OMIM 301500) is an X-linked lysosomal storage disease caused by pathogenic variants in the GLA gene. Cardiac involvement is common in FD and is responsible for impaired quality of life and premature death. The classic cardiac involvement is a nonobstructive form of hypertrophic cardiomyopathy, usually manifesting as concentric left ventricular hypertrophy, with subsequent arrhythmogenic intramural fibrosis. Treatment of patients with FD should be directed to prevent the disease progression to irreversible organ damage and organ failure. The aim of this review is to describe the current state of knowledge regarding cardiovascular involvement in FD, focusing on clinical and instrumental features, cardiovascular management, and targeted therapy.

Clinical Manifestations of 22q11.2 Deletion Syndrome

DiGeorge syndrome (DGS), also known as "22q11.2 deletion syndrome" (22q11DS) (MIM # 192430 # 188400), is a genetic disorder caused by hemizygous microdeletion of the long arm of chromosome 22. In the last decades, the introduction of fluorescence in situ hybridization assays, and in selected cases the use of multiplex ligation-dependent probe amplification, has allowed the detection of chromosomal microdeletions that could not be previously identified using standard karyotype analysis. The aim of this review is to address cardiovascular and systemic involvement in children with DGS, provide genotype-phenotype correlations, and discuss their medical management and therapeutic options.

The Risk of Sudden Unexpected Cardiac Death in Children: Epidemiology, Clinical Causes, and Prevention

"Sudden unexplained death (SUD) is a tragic event for both the family and community, particularly when it occurs in young individuals. Sudden cardiac death (SCD) represents the leading form of SUD and is defined as an unexpected event without an obvious extracardiac cause, occurring within 1 hour after the onset of symptoms. In children, the main causes of SCD are inherited cardiac disorders, whereas coronary artery diseases (congenital or acquired), congenital heart diseases, and myocarditis are rare. The present review examines the current state of knowledge regarding SCD in children, discussing the epidemiology, clinical causes, and prevention strategies."

Diagnosis and Management of Cardiovascular Involvement in Friedreich Ataxia

Friedreich ataxia (FRDA) is an autosomal recessive neurodegenerative disorder caused by a homozygous GAA triplet repeat expansion in the frataxin gene. Cardiac involvement, usually manifesting as hypertrophic cardiomyopathy, can range from asymptomatic cases to severe cardiomyopathy with progressive deterioration of the left ventricular ejection fraction and chronic heart failure. The management of cardiac involvement is directed to prevent disease progression and cardiovascular complications. However, direct-disease therapies are not currently available for FRDA. The present review aims to describe the current state of knowledge regarding cardiovascular involvement of FRDA, focusing on clinical-instrumental features and management of cardiac manifestation.

Natural history of left ventricular hypertrophy in infants of diabetic mothers

Background

Left ventricular hypertrophy (LVH) in infants of diabetic mothers (IDMs) has been generally considered a benign condition, which usually regresses as the stimulus for the insulin production disappears, resulting in normalized left ventricular wall thickness in the 6 months of life. However, these conclusions have been based on small, mostly outdated cohort studies. Indeed, it has been recently shown that increased left ventricular mass persists in late infancy (6 to 12 months), long after the intrauterine exposure has been removed, suggesting that other factors may potentially contribute.

Purpose

This study sought to describe the characteristics and the natural course of LVH in a well-characterized consecutive cohort of IDMs.

Methods

Sixty consecutive IDMs with LVH have been retrospectively identified and enrolled in the study. All IDMs were evaluated at baseline and every 6 months until LV wall thickness regression, defined as the decrease of wall thickness measurement into the normal reference range for cardiac parameters (z-score &gt;−2 and &lt;2). A comprehensive assessment was performed in those patients with diagnostic markers suggestive of a different cause and/or without significant reduction of the LVH during follow-up.

Results

At 1-year follow-up, all IDMs showed a significant reduction of maximal wall thickness (MWT) (MWT-mm: 6.67±2.37 vs. 5.83±1.70, p-value&lt;0.001; MWT-z-score: 6.67±4.71 vs. 2.39±2.55, p-value&lt;0.001) and left ventricular outflow tract (LVOT) gradient (15.35±15.58 vs. 11.22±8.14, p-value&lt;0.004), compared to baseline, and all patients showed LV wall thickness regression or residual mild or moderate LVH (57%, 28%, and 12%, respectively) (Figure 1), except 2 patients with persistent severe LVH, that after a comprehensive clinical-genetic assessment were diagnosed as Noonan syndrome with multiple lentigines.

At multivariate analysis, MWT was significantly associated with LV wall thickness regression at 1-year follow-up (MWT-mm: OR 0.48 [0.29–0.79], p-value=0.004; MWT-z-score: OR 0.71 [0.56–0.90], p-value=0.004) in an inversely proportional fashion.

Overall, 59%, 72% and 79% of IDMs with LVH showed a complete LV wall thickness regression at 1-year, 2-year and 3-year follow-up, respectively (Figure 2). Excluding the two patients with a different cause of LVH, all IDMs showed a LV wall thickness regression in the first 6 years of life.

Conclusions

LVH in IDMs represents a benign condition with complete regression during the first years of life. In those patients without LV wall thickness regression, combined with clinical markers suggesting a specific disease, a complete work-up is required for a definite diagnosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Advanced Heart Failure in Special Population-Pediatric Age

Heart failure (HF) is an important health care issue in children because of its considerable morbidity and mortality. Advanced HF encompasses patients who remained symptomatic despite optimal medical treatment and includes patients who require special management, such as continuous inotropic therapy, mechanical circulatory support, or heart transplantation (HT). HT is the gold standard for children with advanced HF; nonetheless, the number of suitable donors has not increased for decades, leading to prolonged waitlist times and increased mortality rates. Therefore, the role of pediatric mechanic circulatory support has been assessed as an alternative treatment in patients in whom heart transplant could not be performed. The authors discuss the epidemiology, causes, pathophysiology, clinical manifestation, medical treatment, device therapy, and HT in pediatric HF, and a particular emphasis was posed on patients with advanced HF.

Diagnostic issues faced by a rare disease healthcare network during Covid-19 outbreak: data from the Campania Rare Disease Registry

Background

The aims of this study were: to investigate the capacity of the rare disease healthcare network in Campania to diagnose patients with rare diseases during the outbreak of Covid-19; and to shed light on problematic diagnoses during this period.

Methods

To describe the impact of the Covid-19 pandemic on the diagnosis of patients with rare diseases, a retrospective analysis of the Campania Region Rare Disease Registry was performed. A tailored questionnaire was sent to rare disease experts to investigate major issues during the emergency period.

Results

Prevalence of new diagnoses of rare disease in March and April 2020 was significantly lower than in 2019 (117 versus 317, P < 0.001 and 37 versus 349, P < 0.001, respectively) and 2018 (117 versus 389, P < 0.001 and 37 versus 282, P < 0.001, respectively). Eighty-two among 98 rare disease experts completed the questionnaire. Diagnostic success (95%), access to diagnosis (80%) and follow-up (72%), lack of Personal Protective Equipment (60%), lack of Covid-19 guidelines (50%) and the need for home therapy (78%) were the most important issues raised during Covid-19 outbreak.

Conclusions

This study describes the effects of the Covid-19 outbreak on the diagnosis of rare disease in a single Italian region and investigates potential issues of diagnosis and management during this period.

Hypertrophic Cardiomyopathy in Children: Pathophysiology, Diagnosis, and Treatment of Non-sarcomeric Causes

Hypertrophic cardiomyopathy (HCM) is a myocardial disease characterized by left ventricular hypertrophy not solely explained by abnormal loading conditions. Despite its rare prevalence in pediatric age, HCM carries a relevant risk of mortality and morbidity in both infants and children. Pediatric HCM is a large heterogeneous group of disorders. Other than mutations in sarcomeric genes, which represent the most important cause of HCM in adults, childhood HCM includes a high prevalence of non-sarcomeric causes, including inherited errors of metabolism (i.e., glycogen storage diseases, lysosomal storage diseases, and fatty acid oxidation disorders), malformation syndromes, neuromuscular diseases, and mitochondrial disease, which globally represent up to 35% of children with HCM. The age of presentation and the underlying etiology significantly impact the prognosis of children with HCM. Moreover, in recent years, different targeted approaches for non-sarcomeric etiologies of HCM have emerged. Therefore, the etiological diagnosis is a fundamental step in designing specific management and therapy in these subjects. The present review aims to provide an overview of the non-sarcomeric causes of HCM in children, focusing on the pathophysiology, clinical features, diagnosis, and treatment of these rare disorders.

Impact of Regular Physical Activity on Aortic Diameter Progression in Paediatric Patients with Bicuspid Aortic Valve

Patients with bicuspid aortic valve (BAV) have an increased risk of aortic dilation and aortic dissection or rupture. The impact of physical training on the natural course of aortopathy in BAV patients remains unclear. The aim of this study was to evaluate the impact of regular physical activity on aortic diameters in a consecutive cohort of paediatric patients with BAV. Consecutive paediatric BAV patients were evaluated and categorized into two groups: physically active and sedentary subjects. Only the subjects with a complete 2-year follow-up were included in the study. To evaluate the potential impact of physical activity on aortic size, aortic diameters were measured at the sinus of Valsalva and mid-ascending aorta using echocardiography. We defined aortic diameter progression the increase of aortic diameter ≥ 10% from baseline. Among 90 BAV patients (11.5 ± 3.4 years of age, 77% males), 53 (59%) were physically active subjects. Compared to sedentary, physically active subjects were not significantly more likely to have > 10% increase in sinus of Valsalva (13% vs. 8%, p-value = 0.45) or mid-ascending aorta diameter (9% vs. 13%, p-value = 0.55) at 2 years follow-up, both in subjects with sinus of Valsalva diameter progression (3.7 ± 1.0 mm vs. 3.5 ± 0.8 mm, p-value = 0.67) and in those with ascending aorta diameter progression (3.0 ± 0.8 mm vs. 3.2 ± 1.3 mm, p-value = 0.83). In our paediatric cohort of BAV patients, the prevalence and the degree of aortic diameter progression was not significantly different between physically active and sedentary subjects, suggesting that aortic dilation is unrelated to regular physical activity over a 2-year period.

Potential role of imaging markers in predicting future disease expression of arrhythmogenic cardiomyopathy

Aim: To evaluate the predictive accuracy of trabecular hypertrophy/derangement and late gadolinium enhancement in predicting diagnosis of arrhythmogenic cardiomyopathy (AC). Materials & methods: Fifty-nine suspected AC patients were evaluated. To evaluate the ability of these markers to detect patients fulfilling definite diagnosis at 4-year follow-up, sensitivity (Se), specificity (Sp), positive and negative predictive value (PPV and NPV) and predictive accuracy (PA) were calculated. Results: Presence of trabecular hypertrophy/derangement showed high NPV, while late gadolinium enhancement at cardiac MRI high Sp, NPV and PA. Their combination with symptoms and/or revised Task Force Criteria showed a high Sp, NPV and PA for definitive diagnosis during follow-up. Conclusion: In suspected AC patients, the absence of these markers allows to identify those with lower risk of disease progression.

[Physiological and paraphysiological echocardiographic findings in neonatal and pediatric age]

Echocardiographic quantification is crucial for the diagnosis and management of patients with acquired and congenital heart disease (CHD). In neonatal and pediatric age, the echocardiogram begins with subxiphoid, or subcostal, imaging instead of left parasternal views. This allows for the determination of visceral situs (site or location) at the beginning of an examination. Regardless of where the examination starts, the segmental approach is used to describe all of the major cardiovascular structures in sequence. Patent foramen ovale is a normal interatrial communication during fetal life. Complete anatomic closure of the foramen ovale occurs in 70-75% of adults, which means that almost 25% of the population has a patent foramen ovale. Atrial septal defects are a common congenital disorder with a prevalence of approximately 2 per 1000 live births. The reported rate of spontaneous atrial septal defect closure in the first year of life ranges from 4% to 96%. The most important predictor for spontaneous closure is the size of the defect, with smaller defects more likely to close. Systemic-to-pulmonary collateral arteries can occur in premature infants without chronic lung disease and may represent a transient phenomenon. They may be present normally after birth and then gradually disappear. Physiological valvular regurgitation is most commonly observed in the tricuspid valve among children (32.8%), followed by pulmonary regurgitation (17.2%). The ductus arteriosus usually is functionally closed within 48 h of birth, although some authors consider the patent ductus to be abnormal only after 3 months of age. Prematurity clearly increases the incidence of patent ductus arteriosus.

Atrial Myxoma and Williams-Beuren Syndrome. An Incidental Association?

We report the case of a 15 years old girl with Williams-Beuren syndrome and atrial mixoma.

Response of Primary Breast Cancer to Tamoxifen Alone in Elderly Women

The authors report on a consecutive series of 62 evaluable, elderly (age > 69 years) women with primary operable breast cancer treated only with tamoxifen. The treatment schedule was 160 mg on day 1 followed by a daily maintenance dose of 20 mg. Compliance to treatment was excellent, and subjective side effects were minimal. The best response achieved after at least 6 months of treatment was complete in 7, partial in 22 and minor in 3, whereas stable disease or progression was observed in 28 and 2 patients, respectively. The response rate decreased and progressions increased with time. At 6, 12, 24, 36 and 48 months of treatment, the complete + partial response rates were 30.6 %, 45 %, 45.6 %, 38.7 % and 25% and the progressive disease rates 4.8%, 19.6%, 34.8%, 45.2 % and 66.6 %, respectively. These results do not confirm some previous reports of a high response to tamoxifen. This difference is only partially explained by the use of mammography, which is more sensitive than palpation, to assess tumor size and treatment response. The present study does not support primary hormone therapy as a current alternative to surgery, which should be the standard treatment in otherwise healthy elderly patients with operable breast cancer.

The Risk of Breast Cancer Subsequent to Histologic Diagnosis of Benign Intraductal Papilloma Follow-Up Study of 339 Cases

The risk of developing breast cancer was investigated in 339 patients in whom histologically confirmed intraductal papilloma had been surgically removed. Follow-up ranged from 2 to 14 years, (average, 6.62 years). Ten breast cancers were observed, whereas 3 were expected on the basis of age-specific incidence rates drawn from local cancer registries (relative risk = 3.33, 95% confidence interval = 1.60-6.13). No significant difference in the relative risk was observed as far as papilloma type (single or multiple) was concerned. All breast cancers observed occurred in the same breast as the papilloma. Women in whom a benign intraductal papilloma has been excised should be carefully followed since they at are higher risk for ipsilateral breast cancer.

Severe hypertrophic cardiomyopathy in a patient with atypical Anderson-Fabry disease

AIM

Anderson-Fabry disease (AFD) is a hereditary disorder caused by a deficiency in the lysosomal enzyme α-galactosidase A which causes dysfunctions in multiple organ systems. Cardiac manifestation includes left ventricular hypertrophy, thickening of the valves, conduction disturbances and in the late phase, extensive areas of myocardial fibrosis with increased risk of sudden cardiac death. Case example: A case of AFD with exclusive cardiac involvement is described. During follow-up, due to the high risk of life-threatening arrhythmic events, implantation of an implantable cardioverter defibrillator is performed.

CONCLUSION

AFD patients with advanced cardiac disease might represent a subgroup of patients who may require an implantable cardioverter defibrillator for primary prevention of sudden cardiac death.

Genetics of Takotsubo Syndrome

Takotsubo syndrome (TTS) is an enigmatic disease with a multifactorial and still unresolved pathogenesis. A genetic predisposition has been suggested based on the few familial TTS cases. Conflicting results have been published regarding the role of functional polymorphisms in relevant candidate genes, such as α1-, β1-, and β2-adrenergic receptors; G protein-coupled receptor kinase 5; and estrogen receptors. Further research is required to help clarify the role of genetic susceptibility in TTS.

Pathogenesis of Takotsubo Syndrome

Takotsubo syndrome (TTS) is an enigmatic disease with a multifactorial and still unresolved pathogenesis. Postulated mechanisms include catecholamine excess, coronary artery spasm, and microvascular dysfunction, however catecholamines seem to play a central role in the pathophysiology of TTS. In facts catecholamines have relevant effects on the vasculature and myocardium. Toxic direct effects of catecholamine on myocardium are mediated by multiple pathway including functional hypoxia, metabolic changes and changes in membrane permeability leading to various electrolytic imbalances. Recently report of familial cases has suggested a genetic component. Further research is required to help clarify the proposed hypotheses and to increase our understanding of the cardiovascular responses to acute stress and the pathophysiology underpinning TTS.

Management of pregnancy in cardiomyopathies and heart failure

Pregnancy exposes women with inherited cardiomyopathies to increased risk for arrhythmias and heart failure. In asymptomatic patients with inherited cardiomyopathies, pregnancy is generally well tolerated. Preconception evaluation, risk assessment and proper counseling by a team of experienced physicians are mandatory in managing women with inherited cardiomyopathies planning pregnancy. In this paper, we reviewed the clinical course, risk assessment and management during pregnancy of women with cardiomyopathies.

[New perspectives in cardiovascular risk reduction: focus on HDL]

Cardiovascular diseases represent the leading cause of morbidity and mortality worldwide, mostly contributing to hospitalizations and health care costs. Dyslipidemias represent one of the major cardiovascular risk factor and its management, throughout life-style modifications and pharmacological interventions, has shown to reduce cardiac events. The risk of adverse cardiovascular events is related not only to elevated LDL blood levels, but also to decreased HDL concentrations, that exhibit protective effects in the development of atherosclerotic process. Aim of this review is to summarize current evidences about defensing effects of such lipoproteins and to show the most recent pharmacological strategies to reduce cardiovascular risk through the increase of their circulating levels.

[Cardiovascular risk in systemic inflammatory diseases]

Systemic inflammatory diseases are associated with increased cardiovascular morbidity and mortality. The link between inflammatory and cardiovascular diseases can be attributed to the coexistence of classical risk factors and inflammatory mechanisms activated during systemic inflammatory diseases involving the immune system. Unfavorable metabolic effects of anti-inflammatory drugs can also contribute to increase cardiovascular risk. Yet, clinical implications of these findings are not entirely clear, and deeper knowledge and awareness of cardiac involvement in inflammatory diseases are necessary. The aim of this review is to summarize cardiac involvement in systemic inflammatory diseases and to identify aspects where evidence is currently lacking that would deserve further investigation in the future.

Frenulectomy: proposal of a new surgical approach and case report

The frenula of the oral cavity represent the insertion of perioral muscles in jaws, consisting of a fold of the triangular fibro-connective tissue covered with mucous membrane and usually inserted at the mucogingival line. The purpose of this work, after a review of literature, was to provide the clinical signs above the median frenum removal order for the orthodontic closure of a interincisor diastema and to present a new surgical technique.

A preamplification approach to GMO detection in processed foods

DNA is widely used as a target for GMO analysis because of its stability and high detectability. Real-time PCR is the method routinely used in most analytical laboratories due to its quantitative performance and great sensitivity. Accurate DNA detection and quantification is dependent on the specificity and sensitivity of the amplification protocol as well as on the quality and quantity of the DNA used in the PCR reaction. In order to enhance the sensitivity of real-time PCR and consequently expand the number of analyzable target genes, we applied a preamplification technique to processed foods where DNA can be present in low amounts and/or in degraded forms thereby affecting the reliability of qualitative and quantitative results. The preamplification procedure utilizes a pool of primers targeting genes of interest and is followed by real-time PCR reactions specific for each gene. An improvement of Ct values was found comparing preamplified vs. non-preamplified DNA. The strategy reported in the present study will be also applicable to other fields requiring quantitative DNA testing by real-time PCR.

Efficient immunization of rhesus macaques with an HCV candidate vaccine by heterologous priming-boosting with novel adenoviral vectors based on different serotypes

Efficient vaccination against viral agents requires a strong T-cell-mediated immune response to clear viral-infected cells. Optimal vaccination can be achieved by administration of recombinant viral vectors encoding phatogen antigens. Adenoviral vectors have attracted considerable attention as potential viral vectors for genetic vaccination owing to their favorable safety profile and potent transduction efficiency following intramuscular injection. However, the neutralizing antibody response against adenoviral capsid proteins following adenoviral vectors injection limits the success of vaccination protocols based on multiple administrations of the same adenoviral serotype. In this work, we describe efficient immunization of rhesus macaques, the preferred model for preclinical assessment, with an HCV candidate vaccine by heterologous priming-boosting with adenoviral vectors based on different serotypes. The induced responses are broad and show significant cross-strain reactivity. Boosting can be delayed for over 2 years after priming, indicating that there is long-term maintenance of resting memory cells.