Whole-exome sequencing revealed a likely pathogenic variant in NF1 causing neurofibromatosis type I and Arrhythmogenic Cardiomyopathy

BACKGROUND

Neurofibromatosis type I (NF1) is a genetic disorder characterized by the tumor's development in nerve tissue. Complications of NF1 can include pigmented lesions, skin neurofibromas, and heart problems such as cardiomyopathy. In this study, we performed whole-exome sequencing (WES) on an Iranian patient with NF1 to identify the genetic cause of the disease.

METHODS

Following clinical assessment, WES was used to identify genetic variants in a family with a son suffering from NF1. No symptomatic manifestations were observed in other family members. In the studied family, in silico and segregation analysis were applied to survey candidate variants.

RESULTS

Clinical manifestations were consistent with arrhythmogenic cardiomyopathy (ACM). WES detected a likely pathogenic heterozygous missense variant, c.3277G > A:p.Val1093Met, in the NF1 gene, confirmed by PCR and Sanger sequencing. The patient's parents and brother had a normal sequence at this locus.

CONCLUSIONS

Although there is no cure for NF1, genetic tests, such as WES, can detect at-risk asymptomatic family members. Furthermore, cardiac evaluation could also help these patients before heart disease development.

IgG4-Related disease with diffuse myopericardial involvement- value of CMR: a case report and literature review of cardiac involvement

BACKGROUND

IgG4-related disease is a fibro-inflammatory disorder with an unknown etiology, which can affect multiple organ systems, including the cardiovascular system. While most reported cases of cardiovascular involvement are primarily associated with the aorta, there have been sporadic reports of isolated cardiac involvement.

CASE PRESENTATION

This paper presents a documented case of IgG4-related systemic disease with symptoms indicative of restrictive cardiomyopathy. Subsequent Cardiac Magnetic Resonance imaging revealed diffuse myopericardial involvement, characterized by pericardial thickening and enhancement, accompanied by subepicardial and myocardial infiltration. Considering the rarity of cardiac involvement in our case, we conducted a thorough review of the existing literature pertaining to various patterns of cardiac involvement in IgG4-related disease, as well as the diagnostic modalities that can be employed for accurate identification and assessment.

CONCLUSIONS

This case report sheds light on the importance of recognizing and evaluating cardiac manifestations in IgG4-related systemic disease to facilitate timely diagnosis and appropriate management.

European Association of Cardiovascular Imaging (EACVI) survey on Cardiovascular Multimodality Imaging in Acute Myocarditis

AIMS

To assess the current role of cardiac imaging in the diagnosis, management, and follow-up of patients with acute myocarditis (AM) through an European Association of Cardiovascular Imaging survey.

METHODS AND RESULTS

A total of 412 volunteers from 74 countries responded to the survey. Most participants worked in tertiary centres(56%). All participants had access to echocardiography, while 79% and 75% had access to cardiac computed tomography (CCTA) and cardiac magnetic resonance (CMR), respectively. Less than half(47%) had access to myocardial biopsy and only 5% used this test routinely. CMR was performed within 7 days of presentation in 73% of cases. Non-ischemic late gadolinium enhancement (LGE,88%) and high-signal intensity in T2-weighted images(74%) were the most used diagnostic criteria for AM. CCTA was preferred to coronary angiography by 47% of participants to exclude coronary artery disease. Systematic prescription of beta-blockers and ACEi was reported by 38% and 32% of participants. Around a quarter of participants declared considering LGE burden as a reason to treat. Most participants (90%) reported performing a follow-up echocardiogram, while 63% scheduled a follow-up CMR. The main reason for treatment discontinuation was improvement of left ventricular ejection fraction(89%), followed by LGE regression(60%). In two-thirds of participants the decision to resume high-intensity sport was influenced by residual LGE.

CONCLUSION

This survey confirms the high utilization of cardiac imaging in AM, but reveals major differences in how cardiac imaging is used and how the condition is managed between centres, underlining the need for recommendation statements in this topic.

A novel homozygous variant (c.5876T > C: p. Leu1959Pro) in DYSF segregates with limb-girdle muscular dystrophy: a case report

BACKGROUND

Limb girdle muscular dystrophies (LGMDs) constitute a heterogeneous group of neuromuscular disorders with a very variable clinical presentation and overlapping traits. The clinical symptoms of LGMD typically appear in adolescence or early adulthood. Genetic variation in the dysferlin gene (DYSF) has been associated with LGMD.

METHODS

We characterized a recessive LGMD in a young adult from consanguineous Irani families using whole-exome sequencing (WES) technology. Sanger sequencing was performed to verify the identified variant. Computational modeling and protein-protein docking were used to investigate the impact of the variant on the structure and function of the DYSF protein.

RESULTS

By WES, we identified a novel homozygous missense variant in DYSF (NM_003494.4: c.5876T > C: p. Leu1959Pro) previously been associated with LGMD phenotypes.

CONCLUSIONS

The identification and validation of new pathogenic DYSF variant in the present study further highlight the importance of this gene in LGMD.

A novel likely pathogenic homozygous RBCK1 variant in dilated cardiomyopathy with muscle weakness

AIMS

Polyglucosan body myopathy 1 (PGBM1) is a type of glycogen storage disease where polyglucosan accumulation leads to cardiomyopathy and skeletal muscle myopathy. Variants of RBCK1 is related with PGBM1. We present a newly discovered pathogenic RBCK1 variant resulting in dilated cardiomyopathy (DCM) and a comprehensive literature review.

METHODS AND RESULTS

Whole-exome sequencing (WES) was utilized to detect genetic variations in a 7-year-old girl considered the proband. Sanger sequencing was performed to validate the variant in the patient and all the available family members, whether affected or unaffected. The variant's pathogenicity was assessed by conducting a cosegregation analysis within the family with in silico predictive software. WES showed that the proband's RBCK1 gene contained a missense likely pathogenic homozygous nucleotide variant, c.598_599insT: p.His200LeufsTer14 (NM_001323956.1), in exon 8. The computational analysis supported the variant's pathogenicity. The variant was identified in a heterozygous form among all the healthy members of the family. Variants with changes in N-terminal part of the protein were more likely to manifest immunodeficiency and auto-inflammation than those with C-terminal protein modifications according to prior variations of RBCK1 reported in the literature.

CONCLUSIONS

Our study offers novel findings indicating an RBCK1 variant in individuals of Iranian ancestry presenting with DCM leading to heart transplantation and myopathy without immunodeficiency or auto-inflammation.

Whole-exome sequencing reveals a likely pathogenic LMNA variant causing hypertrophic cardiomyopathy

OBJECTIVE

We studied the clinical and molecular features of a family with hypertrophic cardiomyopathy (HCM).

BACKGROUND

A very heterogeneous disease affecting the heart muscle, HCM is mostly caused by variants in the proteins of sarcomeres. The detection of HCM pathogenic variants can affect the handling of patients and their families.

METHODS

Whole-exome sequencing (WES) was performed to assess the genetic cause(s) of HCM in a consanguineous Iranian family.

RESULTS

Missense likely pathogenic variant c.1279C>T (p.Arg427Cys) within exon 7 of the LMNA gene (NM_170707) was found. The segregations were confirmed by polymerase chain reaction-based Sanger sequencing.

CONCLUSIONS

Variant c.1279C>T (p.Arg427Cys) in the LMNA gene seemed to have been the cause of HCM in the family. A few LMNA gene variants related to HCM phenotypes have been recognized so far. Identifying HCM genetic basis confers significant opportunities to understand how the disease can develop and, by extension, how this progression can be arrested. Our study supports WES effectiveness for first-tier variant screening of HCM in a clinical setting.

Role of feature tracking cardiac magnetic resonance imaging in early detection of cardiac dysfunction in β-thalassemia patients recovered from COVID-19: A cross-sectional study

Background and Aims

β-Thalassemia patients may have cardiac complications due to iron overload, which puts them at higher risk of cardiac complications induced by coronavirus disease 2019 (COVID-19) compared with the normal population. The present study aims to evaluate early cardiovascular complications following iron overload in β-thalassemia patients who had early recovery from COVID-19 by cardiac magnetic resonance imaging (MRI) and feature-tracking technique.

Methods

Thirty-two confirmed COVID-19-recovered β-thalassemia cases were evaluated within 3 weeks to 3 months after a positive reverse-transcriptase polymerase chain reaction COVID-19 test. Both the heart and liver of all patients were examined using cardiac MRI.

Results

We analyzed 32 patients with mean age of 32.84 ± 6.45 years at baseline. Left ventricular global strain values were significantly associated with myocardial T2*. A cut-off value of -15.08% for global longitudinal strain (GLS) with sensitivity and specificity of 90% and 61.1% (p = 0.017), 32.33% for global radial strain (GRS) with sensitivity and specificity of 80% and 94.4% (p = 0.001) and -16.21 for global circumferential strain (GCS), with sensitivity and specificity of 80% and 89.9% (p = 0.013) may indicate cardiac iron overload.

Conclusion

GLS, GRS, and GCS were significantly decreased in patients with myocardial T2* <20 ms (iron overload), while no significant change was observed in the right and left ventricular ejection fraction (RV- and LVEF). Cardiac MRI feature-tracking may be helpful in the early detection of cardiac complications resulting from iron overload in β-thalassemia patients who had early recovery from COVID-19.

Left Ventricular Myocardial Dysfunction Evaluation in Thalassemia Patients Using Echocardiographic Radiomic Features and Machine Learning Algorithms

Heart failure caused by iron deposits in the myocardium is the primary cause of mortality in beta-thalassemia major patients. Cardiac magnetic resonance imaging (CMRI) T2* is the primary screening technique used to detect myocardial iron overload, but inherently bears some limitations. In this study, we aimed to differentiate beta-thalassemia major patients with myocardial iron overload from those without myocardial iron overload (detected by T2*CMRI) based on radiomic features extracted from echocardiography images and machine learning (ML) in patients with normal left ventricular ejection fraction (LVEF > 55%) in echocardiography. Out of 91 cases, 44 patients with thalassemia major with normal LVEF (> 55%) and T2* ≤ 20 ms and 47 people with LVEF > 55% and T2* > 20 ms as the control group were included in the study. Radiomic features were extracted for each end-systolic (ES) and end-diastolic (ED) image. Then, three feature selection (FS) methods and six different classifiers were used. The models were evaluated using various metrics, including the area under the ROC curve (AUC), accuracy (ACC), sensitivity (SEN), and specificity (SPE). Maximum relevance-minimum redundancy-eXtreme gradient boosting (MRMR-XGB) (AUC = 0.73, ACC = 0.73, SPE = 0.73, SEN = 0.73), ANOVA-MLP (AUC = 0.69, ACC = 0.69, SPE = 0.56, SEN = 0.83), and recursive feature elimination-K-nearest neighbors (RFE-KNN) (AUC = 0.65, ACC = 0.65, SPE = 0.64, SEN = 0.65) were the best models in ED, ES, and ED&ES datasets. Using radiomic features extracted from echocardiographic images and ML, it is feasible to predict cardiac problems caused by iron overload.

Arrhythmogenic left ventricular cardiomyopathy caused by a novel likely pathogenic DSP mutation, p.K1165Rfs*8, in a family with sudden cardiac death

OBJECTIVE

We conducted an investigation into the clinical and molecular characteristics of Arrhythmogenic left ventricular cardiomyopathy (ALVC) caused by a novel likely pathogenic mutation in an Iranian pedigree with sudden cardiac death (SCD).

BACKGROUND

ALVC is a genetically inherited myocardial disease characterized by the substitution of fibro-fatty tissue in the left ventricular myocardium, predominantly inherited in an autosomal dominant pattern and is commonly associated with genes involved in encoding desmosomal proteins, specifically Desmoplakin (DSP).

METHODS

The patient and available family members underwent a comprehensive clinical assessment, including Cardiac magnetic resonance (CMR) imaging, along with Whole-exome sequencing (WES). The identified variant was confirmed and segregated by Polymerase chain reaction (PCR) and Sanger sequencing in the family members.

RESULTS

A novel likely pathogenic heterozygous variant, DSP (NM_004415.4), c.3492_3498del, p.K1165Rfs*8 was discovered in the proband. This variant is likely to be the primary reason for ALVC in this specific family. This variant was confirmed by Sanger sequencing and segregated in other affected members of the family.

CONCLUSION

We identified a novel likely pathogenic variant in the DSP gene, which has been identified as the cause of ALVC in an Iranian family. Our investigation underscores the importance of genetic testing, specifically WES, for individuals suspected of ALVC and have a family history of SCD.

Coronary artery involvement in a patient with IgG4-related disease

Immunoglobulin G4-related disease (IgG4-RD) is a chronic fibro-inflammatory disorder of obscure etiology characterized by significant infiltration of IgG4-positive plasma cells toward several organs. Coronary artery involvement is rarely seen in IgG4-RD patients; thereby, we aim to outline the noninvasive imaging findings of this rare case. Cardiac magnetic resonance (CMR) and coronary computed tomography angiography (CCTA) from a 15-year-old female diagnosed with IgG4-RD via histopathological assessment of orbital biopsy, were analyzed. CMR showed a severely reduced left ventricular ejection fraction and akinesia of the basal to mid-lateral, anterior, and septal walls. Inflammation of the basal to apical lateral wall and subendocardial infarction of the basal to apical lateral and mid inferoseptal walls were also evident. CCTA findings showed stenosis in branches of the left main artery (LM), left anterior descending artery (LAD), and right coronary artery (RCA), aortitis, and aortic wall thickening. After courses of proper treatment with prednisolone, Cellcept, and adalimumab, follow-up CMR showed significant improvement in LV systolic function and resolution of inflammation. Although IgG4-RD is an uncommon cause of coronary artery disease, it can cause lethal complications such as myocardial infarction. Hence, clinicians should be aware of cardiac complications in these patients.

Polymorphism of rs599839 in the PSRC1 gene is associated with coronary artery disease in an Iranian population

Introduction

Coronary artery disease (CAD) is the leading health complication worldwide because of its high prevalence and mortality. The association between CAD susceptibility and the rs599839 (C/T) polymorphism in the human proline and serine-rich coiled-coil (PSRC1) was reported in a genome-wide association study. To validate this association, we performed this case-control study to genotype the 1p13.3 (rs599839) locus in a sample of the Iranian population with CAD (stenosis≥70% in≥1 coronary artery).

Methods

We performed an association analysis with PCR and Sanger sequencing of rs599839 (C/T) polymorphism and CAD risk in 280 CAD patients and 287 healthy controls defined as a coronary calcium score of zero and no noncalcified plaques in coronary computed tomography angiography. SPSS, version 16.0, was applied for statistical analysis.

Results

The rs599839 (C/T) locus showed a significant association with CAD (P value<0.001). TT and CT genotypes were associated with CAD (P value<0.001). Furthermore, the dominant status (TT+CT vs. CC) was associated with an increased risk of CAD (OR, 9.14; 95% CI, 3.77 to 22.15; and P value<0.001).

Conclusion

The study findings indicate strong evidence for rs599839 (C/T) association with CAD risk.

Paediatric heart transplantation during the COVID-19 pandemic in Iran: single-centre experience

AIMS

Transplant services were imposed to the multiple challenges of insufficient facilities and resources during the COVID-19 pandemic. Thus, each centre modified and altered its routine practice to maintain the service. We report our experience in Iran's single-centre paediatric heart transplantation unit during the 2 year pandemic in transplant rate and early transplant outcomes.

METHODS AND RESULTS

We retrospectively reviewed all paediatric heart transplants performed at our centre between 19 February 2020 and February 2022. We studied the number and percentage of paediatric transplanted patients who developed COVID-19, in-hospital outcome, 30 day survival and left ventricular function during the first month of the follow-up visit. From February 2020 to February 2022, 59 transplants were performed compared with 62 patients from February 2018 to 2020. Compared with the year before the pandemic, the heart transplant rate was reduced by 34% in the first year of the pandemic; however, it bounced back in the second year with a 19% increase. The in-hospital mortality rate during the 2 year pandemic was (11.8%). One death occurred related to COVID-19 acute respiratory distress syndrome. The in-hospital COVID-19 infection rate was 11 patients (18%). In the 30 day follow-up, the overall 30 day survival rate was 88%, and the 30 day rejection rate was 10%. The mean left ventricular ejection fraction was (53.6 ± 4.9), the mean left ventricular global longitudinal strain was -16.9 ± 3.3, and the mean right ventricular global longitudinal strain was -17.0 ± 3.8 with no significant difference between patients with in-hospital COVID and other recipients (P = 0.1, P = 0.2 and P = 0.2).

CONCLUSIONS

Throughout the pandemic, although we experienced a reduction in the transplant rate in the first year, with the increasing vaccination rate in health care and later in the general population, we continued to maintain our transplant rate by incorporating safety protocols and more resources.

Feature tracking cardiac magnetic resonance imaging to assess cardiac manifestations of systemic diseases

Feature-tracking cardiac magnetic resonance (FT-CMR), with the ability to quantify myocardial deformation, has a unique role in the evaluation of subclinical myocardial abnormalities. This review aimed to evaluate the clinical use of cardiac FT-CMR-based myocardial strain in patients with various systemic diseases with cardiac involvement, such as hypertension, diabetes, cancer-therapy-related toxicities, amyloidosis, systemic scleroderma, myopathies, rheumatoid arthritis, thalassemia major, and coronavirus disease 2019 (COVID-19). We concluded that FT-CMR-derived strain can improve the accuracy of risk stratification and predict cardiac outcomes in patients with systemic diseases prior to symptomatic cardiac dysfunction. Furthermore, FT-CMR is particularly useful for patients with diseases or conditions which are associated with subtle myocardial dysfunction that may not be accurately detected with traditional methods. Compared to patients with cardiovascular diseases, patients with systemic diseases are less likely to undergo regular cardiovascular imaging to detect cardiac defects, whereas cardiac involvement in these patients can lead to major adverse outcomes; hence, the importance of cardiac imaging modalities might be underestimated in this group of patients. In this review, we gathered currently available data on the newly introduced role of FT-CMR in the diagnosis and prognosis of various systemic conditions. Further research is needed to define reference values and establish the role of this sensitive imaging modality, as a robust marker in predicting outcomes across a wide spectrum of patients.

Spontaneous coronary artery dissection in a patient with recent COVID-19 infection: A case report

We report a spontaneous coronary artery dissection (SCAD) case in a lady with a history of recent COVID-19 and without any known predisposing factors. We also highlight the value of CMR as a noninvasive tool for tissue characterization, which can also be more applicable during the COVID-19 pandemic.

Novel homozygous stop-gain pathogenic variant of PPP1R13L gene leads to arrhythmogenic cardiomyopathy

Background

Arrhythmogenic cardiomyopathy (ACM) is a heritable cardiac disease with two main features: electric instability and myocardial fibro-fatty replacement. There is no defined treatment except for preventing arrhythmias and sudden death. Detecting causative mutations helps identify the disease pathogenesis and family members at risk. We used whole-exome sequencing to determine a genetic explanation for an ACM-positive patient from a consanguineous family.

Methods

After clinical analysis, cardiac magnetic resonance, and pathology, WES was performed on a two-year-old ACM proband. Variant confirmation and segregation of available pedigree members were performed by PCR and Sanger sequencing. The PPP1R13L gene was also analyzed for possible causative variants and their hitherto reported conditions.

Results

We found a novel homozygous stop-gain pathogenic variant, c.580C > T: p.Gln194Ter, in the PPP1R13L gene, which was confirmed and segregated by PCR and Sanger sequencing. This variant was not reported in any databases.

Conclusions

WES is valuable for the identification of novel candidate genes. To our knowledge, this research is the first report of the PPP1R13L c.580C > T variant. The PPP1R13L variant was associated with ACM as confirmed by cardiac magnetic resonance and pathology. Our findings indicate that PPP1R13L should be included in ACM genetic testing to improve the identification of at-risk family members and the diagnostic yield.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02802-7.

Giant cell myocarditis following COVID ‐19 successfully treated by immunosuppressive therapy

It has been shown that severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), by coronavirus disease 2019 (COVID‐19), can lead to multi‐organ impairment including cardiac involvement and immunological problems. Acute myocarditis is one of serious and fatal complications of COVID‐19. In this case report, we present a 46‐year‐old lady with a history of lichen planus dermatitis who has developed a rapidly progressive heart failure after an episode of COVID‐19. The pathologic examination of her endomyocardial biopsy specimens was compatible with GCM, and she was successfully treated with a combined immunosuppressive therapy regimen.

Multimodality imaging in the diagnostic approach to a patient with carcinoid heart disease involving four heart valves

Carcinoid heart disease is a rare condition that occurs in less than half of patients with carcinoid syndrome. The disease mainly affects right‐sided heart valves; however, in 5%–10%, it can also involve left‐sided valves. This case illustrates the most complicated form of the disease involving four heart valves.

The Use of Feature Tracking Technique for the Quantification of Ventricular Strain Pattern in Patients with Ebstein's Anomaly: A Case-Control Study

Background

Ebstein's anomaly (EA) is a congenital heart disorder characterized by abnormal function of the tricuspid valve. There are several ways to study tissue composition using magnetic resonance imaging (MRI). One of the most accurate methods is strain calculation using the feature tracking (FT) technique. Due to the novelty of the FT technique in cardiac magnetic resonance (CMR) imaging, there is a lack of comprehensive guidelines to conduct FT-MRI and to present a quantitative report. The current study is aimed to evaluate the FT technique in EA patients and to compare the obtained numerical values with those of healthy individuals.

Methods

A total of 33 individuals were enrolled in a study conducted in 2018-2019 at Shahid Rajaei Hospital, Tehran, Iran. Radial, longitudinal, and circumferential strain patterns of the left and right ventricles were determined in both the patients and the controls using the FT technique. Data were analyzed using SPSS software, version 22.0.

Results

The results showed a significantly lower left ventricular (LV) radial strain in EA patients compared to the control group (P=0.002). In addition, the right ventricular (RV) global longitudinal strain (GLS) in EA patients was significantly lower than in the controls (P=0.001). Other parameters (LV global longitudinal strain, RV radial strain, LV circumferential strain, and RV circumferential strain) did not differ significantly between the two groups.

Conclusion

Determination of strain patterns using cardiac MRI is a promising method for the diagnosis of EA. Markers such as LV longitudinal strain and RV-GLS are the most suitable parameters for the early diagnosis of heart dysfunction.

Myocardial infarction with non-obstructive coronary artery in a middle-aged woman with COVID-19

Cardiovascular involvement is commonly described in coronavirus disease 2019 (COVID-19), where myocardial injury can be caused by exacerbation of the underlying disease and de novo cardiovascular involvement, including myocarditis, stress cardiomyopathy and myocardial infarction. There was a drop in acute coronary syndrome admission rates worldwide as collateral damage of the COVID-19 pandemic as patients were reluctant to seek appropriate care. We presented a 47-year-old woman with acute heart failure and COVID-19 pneumonia. She had a history of typical prolonged chest pain 2 weeks before but no coronary risk factors. The electrocardiogram was consistent with late presentation myocardial infarction. Focused echocardiography showed severe left ventricle systolic dysfunction. She was medically treated for both pneumonia and heart failure. Coronary angiography showed no flow-limiting lesion. Cardiac magnetic resonance in the recovery phase revealed subendocardial late gadolinium enhancement in the left anterior descending territory compatible with myocardial infarction.

Intramyocardial echo-free space with a turbulent flow within, suggestive of an aneurysmal coronary artery

Coronary artery aneurysms are well known, and intramyocardial coronary artery aneurysms comprise a rare type of this condition. This case image presents an incidentally detected intramyocardial aneurysm in the left anterior descending artery of a 32-year-old man with atypical chest pain evaluated by multimodality imaging. The presence of an intramyocardial echo-free space may flag up this condition.

Acute heart failure as an atypical presentation of Takayasu arteritis: The value of multi-modality imaging

Takayasu arteritis (TA) is an inflammatory disease that affects the aorta and the major branch arteries. Here, we describe an atypical presentation of the disease with heart failure.

Cytokine storm after heart transplantation in COVID-19-related haemophagocytic lymphohistiocytosis (HLH)

While severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection primarily causes inflammation in the respiratory system, there is growing evidence of extrapulmonary tissue damage mediated by the host innate immune system in children and adults. A cytokine storm can manifest as a viral‐induced haemophagocytic lymphohistiocytosis (HLH). Here, we present a previously healthy 8‐year‐old boy with newly diagnosed cardiac injury and COVID‐19‐related HLH syndrome with haemophagocytosis in bone marrow biopsy. After remission of inflammation, the patient underwent a heart transplant due to persistent cardiac failure. The histology of the explanted heart showed only a focal subtle subendocardial inflammation. Three days after transplant, he developed progressive acute respiratory distress syndrome (ARDS) with the rise of inflammatory markers. He unfortunately died after 20 days because of disseminated intravascular coagulation (DIC). For the first time, we described a child with COVID‐19‐related HLH and severe cardiac failure, which had a poor prognosis despite a heart transplant.

Whole-exome sequencing identified compound heterozygous variants in the TTN gene causing Salih myopathy with dilated cardiomyopathy in an Iranian family

BACKGROUND

Salih myopathy, characterised by both congenital myopathy and fatal dilated cardiomyopathy, is an inherited muscle disorder that affects skeletal and cardiac muscles. TTN has been identified as the main cause of this myopathy, the enormous size of this gene poses a formidable challenge to molecular genetic diagnostics.

METHOD

In the present study, whole-exome sequencing, cardiac MRI, and metabolic parameter assessment were performed to investigate the genetic causes of Salih myopathy in a consanguineous Iranian family who presented with titinopathy involving both skeletal and heart muscles in an autosomal recessive inheritance pattern.

RESULTS

Two missense variants of TTN gene (NM_001267550.2), namely c.61280A>C (p. Gln20427Pro) and c.54970G>A (p. Gly18324Ser), were detected and segregations were confirmed by polymerase chain reaction-based Sanger sequencing.

CONCLUSIONS

The compound heterozygous variants, c.61280A>C, (p. Gln20427Pro) and c.54970G>A, (p. Gly18324Ser) in the TTN gene appear to be the cause of Salih myopathy and dilated cardiomyopathy in the family presented. Whole-exome sequencing is an effective molecular diagnostic tool to identify the causative genetic variants of large genes such as TTN.

Concomitant active inflammation of myocardium and thyroid, incidental finding in COVID-19 pandemic: A case report

SARS-CoV-2 could affect every organ either directly or indirectly. We describe a young, healthy man diagnosed with COVID-19 whose inaugural presentation was concurrent myocarditis and incidental thyroiditis in cardiac magnetic resonance imaging within two months post recovery. This case illustrates the ongoing pro-inflammatory process several months' post-COVID-19 recovery.

Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia

Background

The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives

This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods

The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results

Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions

The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Clinical Significance of Partial Anomalous Pulmonary Venous Connections (Isolated and Atrial Septal Defect Associated) Determined by Cardiovascular Magnetic Resonance

BACKGROUND

Partial anomalous venous connections (PAPVC) are associated with left to right shunting and right heart dilatation. Identification of PAPVC has increased with widespread use of cross-sectional imaging modalities. However, management strategies are mostly based on expert opinion given the scarcity of data from large series. We aimed to define types and significance of isolated and atrial septal defect (ASD) associated PAPVC detected by cardiovascular magnetic resonance.

METHODS

We retrospectively reviewed our cardiovascular magnetic resonance database from 2002 to 2018 to identify isolated or ASD-associated PAPVC cases.

RESULTS

A total of 215 patients (median age 46 years; range, 6-83) with isolated or ASD-associated PAPVC were identified among 102 135 clinical cardiovascular magnetic resonance studies. Of these, 104 were isolated and 111 were associated with an ASD. Anomalous connection of right upper pulmonary vein was the most common single venous anomaly (99/215), but in the isolated PAPVC group there were more anomalous left than right upper pulmonary veins (39 versus 34). The Qp/Qs was significantly higher for isolated anomalous single right upper pulmonary vein than left upper pulmonary vein (1.6 versus 1.4 respectively; P=0.01) as were right ventricular end-diastolic volumes (113.7±30.9 versus 90 [57-157] mL/m2, P=0.004). In the PAPVC with an ASD group, sinus venosus ASDs (82%) were associated with right-sided PAPVCs while both right and left-sided venous anomalies were seen in secundum ASDs (18%). In a substantial number of patients (30 out of 91) with sinus venosus ASDs, PAPVCs were more complex and involved more than a single anomalous right upper pulmonary vein; and in 5 patients with ASD, PAPVC was identified only after the ASD closure.

CONCLUSIONS

This large series provides descriptive and hemodynamic features for isolated and ASD-associated PAPVCs. Anomalous isolated right upper pulmonary vein may cause a significant shunt (Qp/Qs >1.5). PAPVC associated with sinus venosus and secundum ASDs might be more complex than a single anomalous pulmonary vein and missed before ASD correction.

Effects of metformin on autoimmune immunoglobins and interferon-γ in patients with early diagnosed pemphigus vulgaris: a prospective clinical trial

The management of pemphigus vulgaris (PV) is challenging. This study aimed to evaluate the immunomodulating effects of metformin on PV. The study was conducted in two phases: in the first phase, patients received routine first-line treatment (prednisolone plus azathioprine) for 2 months, then in the second phase, metformin was added to this regimen for another 2 months. After addition of metformin to the first-line medications, significant reductions were seen in serum IgG1 (reduced from 534.92 ± 134.83 mg/dL to 481.58 ± 130.46 mg/dL, P < 0.001), IgG4 (51.83 ± 27.26 mg/dL to 44.50 ± 26.05 mg/dL, P < 0.001) and interferon-γ (277.99 ± 108.71 pg/mL to 45.05 ± 17.080 pg/mL, P = 0.03) concentrations. The suppressant effect of metformin was greatest on IgG4 (coefficient of variation 1.28), the dominant subclass of IgG involved in PV. Metformin could have immunomodulating effects on PV with controlling effects on steroid complications.

Deep COVID DeteCT: an international experience on COVID-19 lung detection and prognosis using chest CT

The Coronavirus disease 2019 (COVID-19) presents open questions in how we clinically diagnose and assess disease course. Recently, chest computed tomography (CT) has shown utility for COVID-19 diagnosis. In this study, we developed Deep COVID DeteCT (DCD), a deep learning convolutional neural network (CNN) that uses the entire chest CT volume to automatically predict COVID-19 (COVID+) from non-COVID-19 (COVID-) pneumonia and normal controls. We discuss training strategies and differences in performance across 13 international institutions and 8 countries. The inclusion of non-China sites in training significantly improved classification performance with area under the curve (AUCs) and accuracies above 0.8 on most test sites. Furthermore, using available follow-up scans, we investigate methods to track patient disease course and predict prognosis.

Asymptomatic young man with an incidental murmur

CLINICAL INTRODUCTION

A 32-year old man was referred to our institution for transthoracic echocardiography (TTE) following detection of an incidental murmur on physical examination before blood donation. He was asymptomatic with no significant medical history. Physical examination revealed dual heart sounds with a grade II/VI systolic murmur heard in the left sternal border. An ECG was in normal sinus rhythm. TTE was performed (figure 1A-C, online supplementary videos 1-4) followed by cardiac CT angiography (CTA) (figure 1D,E).heartjnl;104/15/1307/F1F1F1Figure 1(A) Transthoracic echocardiography, parasternal left ventricular long axis view. (B) Colour Doppler of modified short axis in the mid-left ventricular level. (C) Doppler flow velocity profile. (D) Cardiac CT angiography (CTA) sagittal reconstruction. (E) Three-dimensional CTA reconstruction of the heart.

QUESTION

What is the diagnosis?Pericardial cyst.Ventricular septal defect.Kawasaki.Anomalous left coronary artery from pulmonary artery (ALCAPA).

Endomyocardial Biopsy via the Femoral Vein Using a Long, Curved Sheath

BACKGROUND

Endomyocardial biopsy (EMB) has been defined as the gold standard method for surveillance of rejection after heart transplantation, and it has also been used in the diagnosis of myocarditis and the unknown causes of cardiomyopathies. The procedure, however, is not free from complications. Access through the jugular vein or the femoral vein is the standard approach. In this study, we performed biopsies by using a long, curved sheath and evaluated the rate of complications with this technique.

METHODS

In this descriptive case series study, 97 EMBs were performed in 72 patients who were referred to a cardiovascular and medical research center in Tehran, Iran, between October 2011 and May 2013. The procedures were performed via the femoral approach by using a long bioptome with a long, curved sheath.

RESULTS

Adequate specimens were obtained in 97.9% of the total EMBs, with an average of 5 fragments per procedure. No deaths occurred, and there were no cases of pericardial effusion, myocardial rupture, papillary muscle rupture, increase in the severity of tricuspid regurgitation, atrioventricular block, sustained and nonsustained ventricular tachycardia, or atrial fibrillation. There was one case of persistent right bundle branch block.

CONCLUSIONS

Using a long, curved sheath can facilitate access to the interventricular septum compared with common sheaths and can be used safely in EMB via the femoral approach.