Many hands make light work. Echocardiography and computed tomography results from the Tricuspid Regurgitation IMAging (TRIMA) study

Background

Anatomic knowledge of the tricuspid valve (TV) is the first step in the diagnostic algorithm of patients with tricuspid regurgitation (TR), who are candidates for transcatheter tricuspid valve intervention (TTVI). Currently, echocardiography and computed tomography (CT) are available instruments to study the TV anatomy, guide the decision-making process and support the development of novel transcatheter therapies.

Purpose

The Tricuspid Regurgitation IMAging (TRIMA) study aimed to correlate CT parameters to commonly used echocardiographic variables.

Methods

This prospective, single-center study enrolled 22 consecutive patients with TR equal to or greater than severe (≥3+). All patients underwent transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) and cardiac CT study, in order to obtain anatomical dimensions of the tricuspid annulus and quantification of right-chambers remodeling and function. Novel CT scan measurements were analyzed. Correlation between measurements on echocardiography and CT imaging was assessed.

Results

Severe TR (3+) was present in 27.4% patients, massive (4+) in 4.8% and torrential (5+) in 3.2%. The mean right ventricle (RV) length, RV mid diameter, and right atrium area were 60.81±9.11 mm, 41.27±7.67 mm and 31.72±9.66 cm2, respectively. Tricuspid annular plane excursion, fractional area change, longitudinal myocardial velocity (S') were 16.09±3.25 mm, 33.36±9.47% and 9.18±1.94 cm/sec, respectively. The annular dimensions obtained by CT scan were generally observed to reduce from diastole to systole, except for eccentricity, angles and distance between the postero-septal and antero-posterior commissure and distance between centroid and antero-posterior commissure. A Kruskal-Wallis test showed a stepwise increase in the tricuspid anatomical regurgitant orifice area (AROA) values by CT across the expanded TR grades by TEE, χ2(2)=6,466, p=0.039. Using the Pearson correlation coefficient, we found a relationship between the AROA and TR grade (r=0.593; p<0.004), as well as ARO-perimeter and TR grade (r=0.470; p<0.027). Additionally, a significant correlation was found between septal lateral annulus diameter obtained by TEE and CT (r=0.637; p=0.001). Anyway, no correlations were found between novel CT variables and TR grade or RV function assessed by echocardiogram, as well as between CT systo-diastolic annulus variability and RV function.

Conclusions

Standard echocardiographic study provide invaluable information about the anatomy and function of the right-chambers, as well as an accurate grade of TR. Conventional and novel variables derived by CT scan may step up the anatomical assessment of the complex morphology of the TV apparatus, thanks to the high spatial resolution of the technique. Therefore, an integrated multimodality assessment is the key point of the screening process of TR candidates for TTVI.

Funding Acknowledgement

Type of funding sources: None.

A novel treatment of cystic fibrosis acting on-target: cysteamine plus epigallocatechin gallate for the autophagy-dependent rescue of class II-mutated CFTR

This corrects the article DOI: 10.1038/cdd.2016.22.

A novel treatment of cystic fibrosis acting on-target: cysteamine plus epigallocatechin gallate for the autophagy-dependent rescue of class II-mutated CFTR

We previously reported that the combination of two safe proteostasis regulators, cysteamine and epigallocatechin gallate (EGCG), can be used to improve deficient expression of the cystic fibrosis transmembrane conductance regulator (CFTR) in patients homozygous for the CFTR Phe508del mutation. Here we provide the proof-of-concept that this combination treatment restored CFTR function and reduced lung inflammation (P<0.001) in Phe508del/Phe508del or Phe508del/null-Cftr (but not in Cftr-null mice), provided that such mice were autophagy-competent. Primary nasal cells from patients bearing different class II CFTR mutations, either in homozygous or compound heterozygous form, responded to the treatment in vitro. We assessed individual responses to cysteamine plus EGCG in a single-centre, open-label phase-2 trial. The combination treatment decreased sweat chloride from baseline, increased both CFTR protein and function in nasal cells, restored autophagy in such cells, decreased CXCL8 and TNF-α in the sputum, and tended to improve respiratory function. These positive effects were particularly strong in patients carrying Phe508del CFTR mutations in homozygosity or heterozygosity. However, a fraction of patients bearing other CFTR mutations failed to respond to therapy. Importantly, the same patients whose primary nasal brushed cells did not respond to cysteamine plus EGCG in vitro also exhibited deficient therapeutic responses in vivo. Altogether, these results suggest that the combination treatment of cysteamine plus EGCG acts 'on-target' because it can only rescue CFTR function when autophagy is functional (in mice) and improves CFTR function when a rescuable protein is expressed (in mice and men). These results should spur the further clinical development of the combination treatment.

Environmental surveillance of poliovirus in Italy: pilot study

A pilot study on environmental surveillance of poliovirus included one hundred ninety-six samples (drinking water, surface water, seawater and sewage), collected between 1996 and 1998 in different regions of Italy. Samples were screened for the presence of poliovirus and other enteric viruses. Twelve polioviruses, 35 non polio enteroviruses (NPE) and 51 enteric non entero (NE) viruses were isolated. All poliovirus isolates, namely four type 1, four type 2 and four type 3, were characterised as Sabin-like strains. Thirty-one Coxsackie B and 4 Echo viruses were also detected. The presence of Sabin-like polioviruses in the environment is not unexpected since immunization with only oral poliovirus vaccine was performed in Italy until May 1999, when a sequential schedule consisting of two doses of inactivated polio vaccine (IPV) and two of oral polio vaccine (OPV) was adopted; in July 2002 a schedule consisting of four doses of IPV was adopted. Although this is only a pilot study and the number of samples analysed is limited, so far data from this study so far supports once again evidence of lack of circulating wild poliovirus and is in line with results from AFP surveillance in Italy and stool survey on healthy children.

Enterovirus surveillance of Italian healthy children

Surveillance of acute flaccid paralysis (AFP) is the golden strategy recommended by the WHO to verify the condition of polio eradication in a country. Because of the difficulty to detect all of the expected AFP cases and to reach the target incidence of 1/100,000 requested by WHO, the surveillance of enteroviruses in the population has been adopted by several countries as an important additional method to verify the absence of wild-poliovirus circulation. To complete the results of AFP surveillance set up in Italy in 1996, we have conducted a wild poliovirus surveillance by examining stool samples from 1551 healthy children aged less than 5 years, collected during the period January 1997 to January 1998. The children were from three cities (Parma, Rome and Bari) located in northern, central and southern Italy. Thirty-nine polioviruses, 72 non-polio enteroviruses and 50 enteric, nonentero (NE), viruses were isolated from stool specimens. Polioviruses identified were nine type 1, seven type 2 and twenty-three type 3. Characterization of isolates by both antigenic and molecular methods showed that all polioviruses were of vaccine origin. As expected, most polioviruses, especially types 2 and 3, presented retromutations known to be associated with loss of the Sabin attenuated phenotype. The results of this study support the data obtained from the active AFP surveillance conducted in Italy in the same period--on the absence of paralytic disease due to wild poliovirus--and altogether demonstrate the effectiveness of the vaccination program.

Surveillance of acute flaccid paralysis in Italy: 1996-1997. AFP Study Group. Acute flaccid paralysis

The last case of poliomyelitis due to transmission of indigenous wild poliovirus occurred in Italy in 1982. To achieve the certification of the eradication of poliomyelitis in Italy, an active surveillance of acute flaccid paralysis (AFP) in the population aged less than 15 years was set up following the World Health Organization (WHO) guidelines. The survey started in 1996 with a pilot study involving 4 out of 21 regions, and was gradually extended to a national level in 1997. The two-year survey identified five patients with diagnosis of vaccine associated paralytic poliomyelitis (VAPP). Polioviruses type 2 and 3 Sabin-like were isolated and characterized in three of them. In the remaining two cases, samples were collected late after the onset of symptoms, and poliovirus could not be isolated. No wild polioviruses were detected during the survey. The rate of non-polio AFP found in Italy in 1997 was 0.61 cases per 100,000, which is lower than the level of 1.0 case per 100,000 considered as acceptable by the WHO. This was mainly due to the delay in organizing the hospital network and starting the active search of AFP cases in the largest and most densely populated regions. Therefore, the overall rate of AFP found in Italy underestimates the global effectiveness of the program, which however will be better evaluated in the next few years. This study is the first systematic attempt to determine the rate of AFP in Italy.

Supratentorial diffuse astrocytic tumours: proposal of an MRI classification

The aim of this study was to obtain an MRI severity-related classification of diffuse astrocytic tumours able to integrate the histological data in the grading of such tumours. We studied presurgical MR images of 91 patients with a histological diagnosis of astrocytoma, anaplastic astrocytoma and glioblastoma. A score ranging from 1 to 3 was assigned by two independent readers to each of the following MR features: oedema, mass effect, contrast enhancement, borders, signal homogeneity, necrosis, haemorrhage and flow void. Statistical analysis showed significant differences in the mean MRI scores between the three histological grades. Contrast enhancement was found to be the best predictor of the histological grade followed by necrosis, signal homogeneity and border scores. This classification represents a simple and reproducible means of carefully evaluating some macroscopic characteristics of these tumours. It could be used to integrate histological data especially in cases in which tissue sampling defects may affect the validity of this examination.