Predictors and prognostic value of left ventricle branch block in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Conduction abnormalities as left bundle branch block (LBBB) are common in myocardial disease and contribute to LV dyssynchrony and adverse LV remodeling. The relevance of LBBB in the context of hypertrophic cardiomyopathy (HCM) is unclear. The aim of this study is to find factors that are associated to LBBB in HCM and its impact in prognosis.  

Methods

Retrospective single-center study of 36 consecutive patients (pts) with HCM defined by wall thickness≥15 mm in≥1 myocardial segments in CMR; pts with history of uncontrolled hypertension (HTN) and significant valvular disease were excluded. 

Demographic, clinical, ECG and CMR data (including ventricular volumes, late gadolinium enhancement (LGE) and ventricular strain using feature tracking analysis (Circle CVi 42) were analyzed. For statistical analysis X2 test, Mann-Whitney and logistic regression model were used.  

Results

 Patient’s median age was 63 years (IQR: 49,5-74,8), 64% men. 69% had controlled hypertension, 46% dyslipidemia and 23% diabetes; family history of sudden death and HCM occurred in 16% and 46% respectively. 42% had genetic study and mutations were identified in 25% (TNNT2: 8%; MYBPC3: 6%). 

During a mean follow-up (FUP) of 17 ± 11 months, 24% had HF, 3% thromboembolic events, 26% new onset atrial fibrillation, 20% ventricular tachycardia (VT), 29% received an ICD and 3% died.

On ECG evaluation, 33% had intraventricular disturbance conduction with 12% having LBBB, 49% had LVH criteria.  

On CMR, 81% had septal hypertrophy, 11% apical, 3% anterior-wall LVH and 6% lateral-wall hypertrophy. LVOTO was present in 33%. 69% of the patients had LGE (midwall: 61%, subendocardial: 11%, subepicardial: 3%; at segments with LVH: 47%, RV/LV insertion points: 25%, other:19.4%); the median LGE was 13.6g (IQR 6.7-22.4) corresponding to 7.4% of the LV mass (IQR 3.7-10.9). The median of the maximal wall thickness was 19mm (IQR 16.9-20.9), median LVEF was 70% (IQR 35-87); median LV indexed mass of 105 g/m2 (IQR 54.9-160.7). The median longitudinal strain in 4 and 2 chambers was -9.1 (IQR 15.6-4.6) and -9.1mm (IQR -16-2.6), respectively and the median radial strain in 4 and 2 chambers was 15.6 (IQR 6.5-28.2) and 13.7 (3.5-30.1), respectively. 

Patients with LBBB had more VT and ICD implantation in follow-up (p = 0.038). 

The presence of LGE in RV/LV insertion points (p = 0.019) and in the area of higher LVH (p = 0.033) were the only variables associated with LBBB. The area of LGE involving the RV/LV insertion points was an independent predictor of LBBB (p = 0.02, OR 36.0, IC:1.710-757.79). 

Conclusion

  In our sample, fibrosis in the RV/LV insertion points in CMR was an independent predictor of LBBB, which was associated with ventricular arrhythmias in follow-up. Further prospective studies with larger number of patients are needed to confirm our findings.

Hypertrophic cardiomyopathy: CMR to predict dysrhythmic events

Funding Acknowledgements

Type of funding sources: None.

Introduction

In hypertrophic cardiomyopathy (HCM), there is a significant contribute of dysrhythmic events (DE) for the burden of morbidity and mortality of the disease. The aim of this study is to assess the arrhythmic profile of HCM patients (pts) and predictors of DE.

Methods

Retrospective single-center study of consecutive pts with HCM defined by wall thickness ≥15 mm in ≥1 LV myocardial segments in CMR; pts with history of uncontrolled hypertension (HTN) and significant valvular disease were excluded. Demographic, clinical, CMR data and outcomes were analyzed. For statistical analysis, chi-square and Mann-Whitney tests were used, with prediction of DE (atrial fibrillation (AF); ventricular tachycardia (VT)) and implantation of cardioverter defibrillator (ICD)) with binary logistic regression model.

Results

We included 36 pts, aged 62.5 year-old (IQR: 49,5-74,8), 64% male. 69% had controlled HTN, 46% dyslipidemia and 23% diabetes; family history (FH) of sudden cardiac death and HCM occurred in 16% and 46%, respectively. 9% presented with syncope, 21% with palpitations and 12% with angina. Previous history of AF was present in 12% pts. 42% pts had genetic study and mutations were identified in 25% (TNNT2: 8,3%; MYBPC3:5.6%). All were in sinus rhythm at baseline. On ECG, intraventricular disturbance conduction was found in 33% and T wave inversion in 39%.

On CMR, most pts had septal wall hypertrophy(81%), while 11% had apical, 3% anterior-wall and 6% lateral-wall. SAM was present in 28% and LVOTO in 33%. 69% of the pts had LGE (midwall: 61%, subendocardial: 11%, subepicardial: 3%, at hypertrophic segments: 47%, RV/LV insertion points: 25%, other: 19.4%).

During a mean follow-up of 496 ± 338 days, new onset of AF was found in 26%, VT episodes in 20%, ICD implantation in 29% and 3% died.

There were no associations of clinical data and AF. In univariate analysis,  SAM  (OR 5.25, CI95% 1.02-26.9, p = 0.047), LVOTO (OR 6.7, CI95% 1.27-35.0, p = 0.025), distribution of LGE on other segments than RV/LV insertion points (OR 9.6, CI95% 1.36-67.6, p = 0.023) and absence of T-wave inversion (OR 0.17, CI95% 0.033-0.937, p = 0.042), predicted AF. The absence of T-wave inversion was the only independent predictor of AF in our population (OR 0.073, CI95% 0.006-0.949, p = 0.045).There were no independent predictors of ventricular arrythmias.

Also, we found that AF predicted VT (OR 6.13, CI95% 1.032-36.45, p = 0.046) in univariate analysis and was an independent predictor for ICD (OR 9.6, CI95% 1.26-67.59, p = 0.023). AF was a predictor of composite outcome (death, heart failure and thromboembolic events) in our population (OR 6.3 CI95% 1.3-31.1, p = 0.024).

Conclusion

 In our population, T-wave changes, SAM, LVOTO and LGE distribution were predictors of AF, which was an independent predictor for ICD implantation. No predictors for ventricular arrhythmias were found. Larger studies taking into account echo and CMR data should be conducted to confirm these findings.

Long term left ventricular impairment after SARS-COV2 infection

Funding Acknowledgements

Type of funding sources: None.

Introduction

The impact of acute infection by SARS-COV2 on the cardiovascular system has been previously reported in the literature, with a higher propensity in patients with more serious pattern of disease and pro-inflammatory status. Nevertheless, the long-term burden and sequels of COVID-19 on the cardiovascular system is still unknown.

Purpose

To evaluate the long-term impact of COVID-19 on left ventricular function in patients with severe clinical presentation requiring intensive care hospitalization.

Methods

 

This was a single-center observational, prospective study which included patients requiring admission to the Intensive Care Unit (ICU) due to COVID-19 infection from January to November 2020. All discharged patients were contacted to perform a clinical, electrocardiographic and echocardiographic evaluation and those who accepted were included on the protocol. Baseline and clinical characteristics were collected from clinical reports. For the global longitudinal strain (GLS) analysis all patients with significant wall motion abnormalities and valvular cardiopathy were excluded. Statistical analysis was performed with Mann-Whitney and a safety cut-off was established with ROC curve analysis.

Results

 

A total of 43 patients were included (mean age 64 ± 12, 67.4% males). During SARS-COV2 infection 49% presented with severe ARDS and 51% with moderate, 35% required invasive mechanical ventilation, 14% noninvasive mechanical ventilation and 52% with high nasal flow cannula. On the follow-up analysis, fatigue was the most reported in symptom (52% patients) and the majority did not present other signs or symptoms suggestive of heart failure, with the mean NT-proBNP of 49 ± 389 pg/dL. The standard ECG and echocardiogram did not show significant changes with a mean LVEF of 58 ± 7.8 and mean TAPSE of 21 ± 4. The strain analysis showed low value of GLS (mean GLS of -17.14 ± 2.36) for a reference cut-off of -18%, suggesting subclinical left ventricular dysfunction in this subset of patients with preserved ejection fraction. Maximum CPR values during ICU did not correlate either with the extent of disease evolvement in CT (p= NS) or ARDS severity (p= NS). Nevertheless, maximum CPR correlated significantly with GLS reduction (R = 0.44, p = 0.019). A CPR value higher than iger30mg/dL had 100% specificity for GLS reduction and a cut-off of 14gm/dL reported a sensitivity of 65% and specificity pf 75% for reduction in GLS.

Conclusion

In our study, we reported subclinical impairment in left ventricular function detected with global longitudinal strain after serious infection with SARS-COV2. The detected myocardial dysfunction was related with higher inflammatory as expressed by CPR values. Long-term monitoring of these patients should be undertaken in order to timely detect late complications. Abstract Figure.

Mitral valve prolapse: impact of mitral valve disjunction in a large single-center

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite being known for more than a century, mitral valve prolapse (MVP) is an

entity not fully understood with controversial data regarding the prognosis.

Aim

To characterize a sample of patients with MVP and to access the frequency of

complications associated with MVP (arrhythmias, hospital admissions and death).

Methods

Single-center retrospective study of consecutive patients with MVP documented in

transthoracic echocardiogram between January 2014 and October 2019. MVP was defined as

systolic displacement of the mitral leaflet into the left atrium≥ 2 mm from the mitral annular

plane. Demographic, clinical, echo, EKG data were collected as well as major adverse events at follow-up. Categorical variables were reported in absolute number and/or % and continuous variables were reported as mean and SD or median and IQR. The results were obtained using Chi-square and ANOVA tests.

Results

247 patients were included (mean age 62.9 ± 18 years, 61% male). The mean

distance of the MVP was 6mm (IQR 5-9). The posterior mitral valve leaflet (PL) was the most

frequently involved (49%), followed by involvement of both leaflets (BL) (27%) and the anterior

leaflet (AL) (25%). Patients with MVP of PL were older compared to patients with BL and AL

involvement (68 ±15 vs 58 ± 17 vs 59 ± 22 years, respectively, p < 0.001) and had longer QT

interval (419 ± 35 vs 403 ± 25 vs 410 ± 34ms, respectively, p = 0.013). 70.4% (174) had

significant MR. Mitral annulus disjunction (MAD) was present in 9.3% (n = 23). The mean LVEF was 63% ± 6.3% and LV mass was 124,7 ± 41g/m2. Most of the patients were in sinus rhythm (SR) (78%). 13.3% had hospital admission for cardiovascular cause and 8.5% (n = 21) died.

During a mean follow-up of 30 ± 19 months, 25.1% of the patients had de novo atrial fibrillation (AF), 8 patients (3%) were submitted to supraventricular dysrhythmia ablation. 16.2% had premature ectopic ventricular complexes, 2.4% non-sustained VT, 0.4% sustained VT, 0.8% needed ICD, 8.5% had a pacemaker. 25% of the patients underwent mitral valve intervention (23.9% to surgical intervention and 3 to percutaneous). 12% of the patients had a hospital admission for CV cause and 8.5% of the patients died.

In multivariate analysis, hospitalization for CV cause (OR 7.27, p = 0.011, CI 95% 1.59- 33.3), higher NYHA class (III-IV) (p = 0.036 OR 5.7 CI95% 1.125-28.84) and the presence of LBBB (p = 0.021 OR = 6.78 CI95% 1.13-28.85) were independent predictors of mortality.

MAD was not associated with the outcomes. SR (OR 0.3, p = 0.014, CI95% 0.119-0.786) and prolapse (OR 0.37, p = 0.035, CI95%0.148-0.935) according to the ESC classification (comparing to flail and billowing) predicted survival.

Conclusion

MVP was traditionally described as a benign entity. However, in our population it was associated with significant mitral regurgitation, some requiring intervention. Besides that, 44% had arrhythmias, with AF occurring in about 25%, hospitalization in 13.3% and cardiovascular death in 8.5%.

Modified CHA2DS2-VASc can predict mortality in COVID-19 patients admitted to the emergency department

Introduction

CHA2DS2-VASc score is used to determine the thromboembolic risk, but its prognostic value has been demonstrated in several cardiovascular (CV) diseases. Except for female gender, many CV risk factors comprising this score are recognized as risk factors for mortality in COVID-19. Cetinak G. et al demonstrated the ability of modified CHA2DS2-VASc (M-CHA2DS2-VASc) to predict mortality in COVID-19, which is based on changing gender criteria from female to male.

Purpose

To evaluate the prognostic value of a M-CHA2DS2-VASc score to predict pulmonary embolism (PE) and mortality in pts with COVID-19 admitted at the emergency department (ED).

Methods

Retrospective study of pts admitted to the ED between June 2020-January 2021, who underwent computed tomography pulmonary angiography (CTPA) due to PE suspicion. Pts were stratified into 3 M-CHA2DS2-VASc risk groups: lower (0–1), intermediate (2–3) and high risk (≥4). Kruskal-Wallis and X-square test were used to compare score risk groups. Logistic regression was used to determine predictors of PE and mortality. ROC curve was performed to evaluate the discriminative power of the score.

Results

We included 300 pts: median age 71 years, 59% male. Hypertension (59%) chronic kidney disease (CKD, 33%), dyslipidemia (32%) and diabetes (28%) were the most common comorbidities. PE was diagnosed in 46 pts (15%). We found no difference in PE incidence according to M-CHA2DS2-VASc groups (p=0.531) and it showed no predictive value for PE (OR: 1.050, p=0.596). The AUC of M-CHA2DS2-VASc was 0.52, suggesting no discriminative power to predict PE.

Regarding mortality, M-CHA2DS2-VASc score was higher in non-survivors COVID-19 pts than in survivors [4 (IQR 3–5) vs 2 (1–4), respectively, p<0.001]. A multivariate logistic regression analysis was performed for mortality based on M-CHA2DS2-VASC, troponin, CKD and smoking history, and only M-CHA2DS2-VASc was identified as an independent predictor of mortality (OR: 1.406, p=0.007). Kaplan-Meier showed that M-CHA2DS2-VASc score was associated with mortality: the survival rate was 92%, 80% and 63% in the lower, intermediate and higher M-CHA2DS2VASc score risk group (logrank test p<0.001; Fig. A).

Most of the pts in the cohort were hospitalized (83%), but 21 pts (17%) discharged from the ED. Among these pts, 33% (n=17) had low risk, 37% (n=19) intermediate risk and 29% (n=15) high risk for mortality according to the M-CHA2DS2VASc score. The Kaplan-Meier individual survival analysis for hospitalized patients (Fig. B) and for those discharged from the ED (Fig. C) showed that M-CHA2DS2-VASc score had a good discriminative ability to predict short-term mortality for both groups (logrank test p<0.001 and p=0.007, respectively).

Conclusion

Considering the lack of validated scores to predict mortality in COVID-19 pts, the M-CHA2DS2-VASc might be a simple tool to predict short-term mortality in these pts, irrespectively of the need for hospitalization or not.

Funding Acknowledgement

Type of funding sources: None.

Wells and Geneva decision rules to predict pulmonary embolism: can we use them in Covid-19 patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Pulmonary embolism (PE) is a recognized complication of SARS-COV2 infection due to hypercoagulability. Before the COVID era, the need for computed tomography pulmonary angiography (CTPA) to rule out PE was determined by clinical probability, based on Wells and Geneva scores, in association with D-dimer measurements. However, patients with SARS-COV2 infection have a pro-thrombotic and pro-inflammatory state which may compromise the usefulness of these algorithms to select patients for CTPA. 

Purpose

 To evaluate the accuracy of the Wells and Geneva scores to predict PE in patients with SARS-COV2 infection.

Methods

 Retrospective study of consecutive outpatients with SARS-COV2 infection proved by positive PCR who underwent CTPA due to suspected PE. The Wells and Geneva scores were calculated and the area under the curve (AUC) of the receiver operating characteristic curve was measured.

Results

 We enrolled 235 patients (61% males, mean age 69.10 ± 16.69 years) and the incidence of pulmonary embolism was 15% (35 patients). In patients with PE, emboli were located mainly in segmental arteries (60%) and bilaterally (46%). Patients with PE were older (mean age 75.06 ± 2.23 vs. 68.06 ± 1.21 years, p = 0.022), and did not differ in sex or risk factors for thromboembolic diseases from the non-PE group. Patients with PE had higher D-dimer levels (median 15.41 mg/dl, IQR 1.17 – 20.00) compared to patients without PE (median 5.99 mg/dl, IQR 0.47 – 2.82, p &lt; 0.001).

 There was no statically significant difference between the average Wells score in patients with PE and without PE (1.04 and 0.89 respectively, p = 0.733) and the AUC demonstrated that the Wells score had no discriminatory power (AUC = 0.52). Within patients with PE, 19 patients had a Wells score of zero. Regarding the Geneva score, there was also no difference between the average score in patients with and without PE (4.20 vs 3.93 respectively, p = 0.420). AUC for Geneva score was 0.54.

Clinical probability combined with D-dimer measurement had a 100% sensitivity for both Wells and Geneva scores, but a specificity of 10% and 11%, respectively. 

Conclusion

 PE diagnosis may be challenging in patients with SARS-COV2 infection since both conditions may have similar signs and symptoms and may be associated with increased D-dimers. According to our results, traditional clinical prediction scores have little discriminatory power in these patients and a higher D-dimer cut-off should be considered to better select patients for CTPA to minimize radiation exposure and contrast-related complications in COVID-19 patients.

Best approach in d-dimer algorithm to exclude pulmonary thromboembolism: a comparative study

Funding Acknowledgements

Type of funding sources: None.

Background

 Ruling out pulmonary embolism (PE) through a combination of clinical assessment and Ddimer is crucial to avoid excessive computed tomography pulmonary angiography (CTPA), and different algorithms should be considered as an alternative to the fixed cutoff to achieve that goal.

Purpose

 To compare sensitivity, specificity, and reduction in CTPA requests of 4 algorithms to rule out PE: fixed Ddimer cutoff, age-adjusted, YEARS and PEGeD.

Methods

 Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to February 2020. The clinical-decision algorithms were retrospectively applied. 

In fixed and age-adjusted cutoffs, high probability patients are directly selected for CTPA and the others perform CTPA if Ddimer ≥500µg/L or age x10 µg/L within patients over 50 years, respectively. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimers &gt;500µg/L or low probability and Ddimer &gt;1000 µg/L are selected for CTPA.

Results

We enrolled 409 patients and PE was confirmed by CTPA in 125 patients. Compared with a fixed Ddimer cutoff, age-adjusted was associated with a significant increased of specificity (p &lt; 0.001), correctly avoiding 29 CTPAs, without losing sensitivity. YEARS resulted in a marked increase in specificity, compared to the fixed cutoff, but with an impairment of sensitivity(p = 0.002). PEGeD had the worst sensitivity, associated with 11 more false negatives (FN) than the fixed cutoff. Despite the lack of difference between PEGed and YEARS strategies regarding sensitivity, YEARS had a significantly higher specificity (p &lt; 0.001) and allowed to correctly avoid a higher number of CTPA(55 vs 63), compared to the fixed cutoff. Results are summarized in table 1.

Conclusion

 Compared to fixed d-dimer cutoff, all algorithms were associated with an increased specificity. Age-adjusted cutoff was the only that is not associated with a significant decrease in sensitivity when compared to fixed cutoff, allowing to safely reduce the need to perform CTPA.

Sens(%) Spec(%) Correctly avoid CTPAs(n) FN(n) Fixed cutoff 95 29 85 6 Age-adjusted 93 40 114 9 YEARS 87 52 148 16 PEGeD 86 49 140 17

Mitral valve prolapse - it"s possible to stratify prognosis in these patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Mitral valve prolapse (MVP) is one of the most frequent causes of mitral valve disease in developed countries, traditionally with a benign prognosis, however some patients develop arrythmias and significant mitral regurgitation (MR) with need of intervention. Herein our purpose was to establish clinical, electrocardiographic and echocardiographic predictors of arrythmias, mitral valve intervention (MVI) and hospitalization in MVP patients to better characterize the prognosis in these patients.

Methods

 Single-center retrospective study of consecutive patients with MVP documented in transthoracic echocardiogram between January 2014 and October 2019. MVP was defined as systolic displacement of the mitral leaflet into the left atrium ≥ 2 mm from the mitral annular plane. Demographic, clinical, echocardiographic, electrocardiographic data were collected as well as adverse events at follow-up. The results were obtained using Chi-square and Student-t tests; predictors were found with logistic regression.

Results

 247 patients were included (mean age 62.9 ± 18 years, 61% males), most with MVP involving the posterior leaflet (48.6%). 40% were symptomatic, 47.4% had more than moderate MR, and 25% had interventricular conduction delay in the ECG. During a mean follow-up of 30 ± 19 months, 38% had arrythmias, 27.1% needed mitral valve intervention (95% surgery and 5% percutaneous), 27.1% had atrial fibrillation (AF), 3.4% had ventricular arrythmias, 19.2% had ventricular premature beats, 13.3% had hospital admission for cardiovascular cause and 8.5% (n = 21) died. 9.3% of the patients had mitral annulus disjunction (MAD).

Palpitations (p = 0.018), AF (p &lt; 0.001), significant MR (p &lt; 0.001), higher NYHA class (p = 0.016), systolic pulmonary artery pressure (SPAP) (p &lt; 0.001), LV mass (p &lt; 0.001), QTc (p = 0.01) and MAD maximum distance (p = 0.02) associated with MVI.

MAD maximum distance value presented an excellent capacity to predict the MVI (AUC 0.85 p = 0.019); the best cut-off was 11,5 mm (Sens = 80%; Spec = 83%).

AF was a predictor of hospitalization in univariate analysis (OR = 2.57, CI95% 1.15-5.75, p = 0.022).

Regarding arrhythmic events, we found association with aortic root dilatation (p = 0.032), NYHA III-IV (p = 0.013), age and LV mass (both with p &lt; 0.001).

In multivariate analysis, LV mass (OR = 1.02, CI95% 1.005-1.027, p = 0.005) and age (OR = 1.038, CI95% 1.004-1.053, p = 0.021) were independent predictors of arrythmias.

In this sample, MAD was not associated with arrythmias.

Conclusion

 Opposing to previous studies in our population, MAD was not associated with arrythmias but had an excellent capacity to predict MVI. Age and LV hypertrophy were independent predictors of arrythmias in our patients. Larger studies are needed to better stratify patients with MVP, as its association with arrhythmias, hospitalization and the need for intervention is not negligible.

Mitral annulus disjunction: is it a marker of ominous prognosis?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Mitral annulus disjunction (MAD) has been proposed as a contributing factor for arrythmias and mitral regurgitation in patients with mitral valve prolapse (MVP), however its clinical relevance is still under investigation.

Objective

To evaluate the frequency of MAD in MVP patients, to characterize clinically patients with MAD and assess potential markers for events.

Methods

Single-center retrospective study of consecutive patients with MVP documented in transthoracic echocardiogram between January 2014 and October 2019. MVP was defined according to the 2017 AHA recommendations; MAD was defined as a separation between mitral valve annulus and the left ventricle free wall. Demographic, clinical, echocardiographic, electrocardiographic data were collected. The results were obtained using Chi-square and Mann-Whitney tests; logistic regression was used to find predictors of events.

Results

247 patients were included (mean age 62.9 ± 18 years, 61% males), of these 23 (9.3%) had MAD (mean age 56 ± 20 years, 56.5% males). The maximum diameter of MAD was 10 ± 3mm (range 5-18). 21 patients (92.3%) had mitral regurgitation, and it was at least of moderate severity in 65.2% of patients. Most of the patients (91.3, n = 21) were in sinus rhythm (SR).

During follow-up (FUP) of 29 ± 19 months, 39% (n = 9) of the patients developed symptoms, 22% (n = 5) had atrial fibrillation (AF), 4.3% (n = 1) had acute aortic syndrome (AAS), 4.3% (n = 1) needed ICD, 22% (n = 5) were submitted to mitral valve intervention, 8.7% (n = 2) were admitted to hospital and 8.7% (n = 2) died. None of the patients presented sustained ventricular arrhythmias (SVA) as assessed in regular Holter monitoring.

These patients had more AAS and needed more ICD in FUP compared to patients without MAD (p = 0.007 and p = 0.006, respectively)

Mitral cord rupture (p = 0.04), age (p = 0.044), maximum velocity of tricuspid regurgitation (p = 0.04) and IVS thickness (p = 0.017) were associated with AF in MAD patients. in univariate analysis, interventricular septum thickness was a predictor of AF in this subgroup (OR 4.0, 95%CI 1.1-14.3, p = 0-032) The presence of SR was associated with survival (p = 0.03). There were no predictors of hospital admission or mitral intervention.

Conclusion

Patients with MAD had a relatively benign prognosis with few events during follow-up, although with more AAS and ICD in FUP. In our sample, AF was more common than SVA. Left ventricle hypertrophy was a predictor of AF and sinus rhythm was associated with survival. Larger studies with more patients and other methods of imaging are needed to confirm our results.

P1246 The Eustachian valve: a structure not so innocent

Background

The eustachian valve is an embryological remnant of the inferior vena cava (IVC) valve. It is usually absent or inconspicuous and has no known function in the normal adult. However, there are reports suggesting that the EV is not as innocent as we thought. The EV can be a site of infective vegetations or be mistaken for a thrombus or tumor. The EV can also make interventional procedures (closure of ASD (atrial septal defect) or ablation for atrial flutter) more laborious.

Clinical Case

A 80 year-old female patient was referred to the emergency department after an episode of acute palpitations, right chest pain, followed by syncope. She had a previous medical history of type 2 diabetes and epilepsy. On admission she was normotensive (104/67mmHg). The ECG showed atrial fibrillation with heart rate of 180 beats per minute. The echocardiogram show slight dilation of the right ventricle and bilateral atrial dilatation. The blood tests documented an elevated D-dimers 2,73 μg/mL, troponin (hs-TNT 27ng/L) and NT-proBNP 4339pg/ml, with a normal renal function.

Computed tomographic (CT) pulmonary angiography revealed filling defects on the segmentar and subsegmentar inferior lobes, compatible with the diagnosis of pulmonary embolism and also revealed a dilatation of the main pulmonary trunk (35mm).

Based on this result the patient start anticoagulation with low molecular weight heparin and heart rate control with bisoprolol. However besides of this strategy the patient remain in atrial fibrillation without a controlled hear rate and an transesophageal echocardiography (TOE) was performed.

The TOE shown a small freely mobile mass – thombi - at the inferior vena cava-right atrium (IVC-RA) junction tethered at the eustachian valve; a small atrial septal defect (4mm) – ostium secundum type – with a left to right shunt; and a preserved biventricular function (figure 1).

Based on this exams we optimize the therapy with digoxin and amiodarone with a good control of the heart rate and patient was discharge on warfarine, bisoprolol and digoxin asymptomatic and to be reevaluated on cardiology clinic.

Discussion/Conclusion: The eustachian valve in adult is an embryological remainder of the fetal venous sinus valve. This structure is located in the right atrium and is a common, not pathological, echocardiographic finding. It is known that a small percentage of the pulmonary embolisms, thrombi are discovered in the right side of the heart; however, their presence on the Eustachian valve is very unusual. Besides this in our particular case in the present we will have also to ensure that the anticoagulation is effective to avoid that the trombi migrates into the systemic circulation by the atrial septal defect.

Abstract P1246 Figure.

Characterization of the immune response of human cord-blood derived gamma/delta T cells to stimulation with aminobisphosphonate compounds

Vγ9Vδ2 T lymphocytes have been shown to respond to a variety of non-peptide antigens including alkylamines and phosphoantigens. Recently, aminobisphosphonates have also been shown to stimulate this subset of γδ+ T cells. In this study we analyzed the proliferative responses of freshly isolated γδ T lymphocytes obtained from human cord blood when challenged with pyrophosphomonoesters or aminobisphosphonates. Nitrogen-containing aminobisphopsphonates, in contrast to phoshoantigens, readily stimulated expansion of Vδ2Vγ9 cells in human cord blood. Expanded cells displayed an activated mature phenotype, and were capable of producing TNFalpha and IFNgamma but not perforin following secondary stimulation, consistent with the development of a regulatory, as opposed to cytotoxic, phenotype. This approach may provide a useful strategy for a new approach to the treatment of neonatal pathologies.

Role of chest radiography in the diagnosis of allergic bronchopulmonary aspergillosis in adult patients with cystic fibrosis

PURPOSE

This study aimed to verify the usefulness of chest radiography in the diagnosis of allergic bronchopulmonary aspergillosis (ABPA) in adult patients with cystic fibrosis.

MATERIALS AND METHODS

Eleven patients (with a total of 14 episodes) affected by ABPA were selected from among subjects attending a Regional Cystic Fibrosis Centre. For each episode, we retrospectively reviewed the baseline chest radiographs obtained before the diagnosis of ABPA, those obtained during the course of ABPA and those obtained during follow-up. Radiographs were assessed for the presence of bronchial wall thickening, bronchiectasis, infiltrates, atelectasis, mucoid impaction, lymphadenopathy, pleural effusion and fluid levels. Radiographic findings that had appeared at the time of ABPA diagnosis and disappeared after treatment were considered related to ABPA and thus useful for a correct diagnosis of the disease. Chest radiograph abnormalities were compared with changes on the respiratory function tests [forced expiratory volume in 1 s (FEV1)] during the different stages of the disease.

RESULTS

Radiographic findings at the time of ABPA diagnosis appeared to have deteriorated in 8/14 cases when compared with the baseline films; after treatment, the radiographic findings deteriorated in 6/14 cases and improved in 6/14. The most significant among the radiographic signs considered (infiltrates and mucoid impaction) appeared at the time of ABPA diagnosis in 7/14 and 4/14 cases, respectively, and in some patients, they were also present at baseline and persisted during follow-up. FEV1 values were significantly decreased (>10%) in 9/14 cases at the time of ABPA diagnosis.

CONCLUSIONS

Our results demonstrate the limited usefulness of chest radiography in the diagnosis of ABPA in patients with cystic fibrosis. The most significant abnormalities are nonspecific and commonly seen on baseline films in cystic fibrosis without ABPA and persist after treatment in most cases.

P2X7 receptors and apoptosis in tuberculosis infection

Immune cells express P2 purinoceptors of the P2Y and P2X subtypes. Evidence accumulated has shown that many different cell types are killed by sustained exposure to high concentrations of extracellular ATP. Depending on the ATP dose, length of stimulation and receptor subtype, P2X receptor stimulation may cause necrosis or apoptosis. Triggering of apoptosis, in response to intracellular infection, has been identified for a wide range of pathogens and host organisms, and there is now emerging interest about mechanism mediating host cell death and its role in pulmonary tuberculosis. The physiological meaning of P2X receptor-dependent cell death is not completely understood, but and involvement in immune-mediated reactions is postulated.

Evidence for a role of gammadelta T cells in demyelinating diseases as determined by activation states and responses to lipid antigens

In this report we review current information on the phenotypic and functional properties of gammadelta T cells in demyelinating disorders. The results support the conclusion that although gammadelta T cells show evidence of activation in patients with either multiple sclerosis (MS) or Guillain Barrè syndrome (GBS), differences exist in the phenotypic and functional properties of these cells between the two diseases. In particular, our data indicate that in patients with MS the Vdelta2 subset is activated and that these cells can be induced to secrete high levels of proinflammatory cytokines. In contrast, in patients with GBS, the Vdelta1 subset is expanded and can be induced to secrete cytokines more associated with a humoral response.

Phenotypic and functional properties of gamma delta T cells from patients with Guillain Barré syndrome

In this study we have examined the phenotypic and functional properties of circulating gamma delta T cells in patients with Guillain Barre syndrome (GBS), in normal healthy controls, and in patients with active multiple sclerosis (MS). Cells expressing the Vdelta2 T cell receptor showed elevated expression of the C-lectin receptor NKRP1A in both GBS and MS, suggestive of an activated state. However, in patients with GBS these cells failed to respond to pyrenil-pyrophosphate derivatives and Vdelta2 + T cell clones derived from these patients released lower levels of IFNgamma than Vdelta2 + clones derived from controls and MS patients. In contrast, in patients with GBS the Vdelta1 + subset was expanded, showed elevated expression of NKRPIA and Vdelta1 + clones derived from these patients secreted high levels of IL-4. Our findings of expanded NKRP-1A +, IL-4-producing Vdelta1 T cells in the GBS patients suggests the possibility that these cells are activated by the recognition of non-protein antigens in an MHC-unrestricted manner and contribute to the humoral response to glycolipids that is a hallmark of this disease.

Activation of C-C beta-chemokines in human peripheral blood gammadelta T cells by isopentenyl pyrophosphate and regulation by cytokines

Human gammadelta T lymphocytes respond to viral, bacterial, protozoal, and tumoral antigens, but their precise function remains unknown. In adults the major circulating gammadelta T-cell subset expresses the Vgamma9Vdelta2 T-cell receptor and responds to protease-resistant phosphorylated derivatives found in many pathogens. In this study we show that activation of Vdelta2(+) cells with the nonpeptidic antigen isopentenyl pyrophosphate (IPP) rapidly induces (within 4-12 hours) the C-C chemokines MIP-1alpha, MIP-1beta, and lymphotactin but not MCP-1. The most robust response was obtained for MIP-1beta. IPP induction of MIP-1alpha and MIP-1beta was not affected by costimulation with interleukin-4 (IL-4), IL-10, TGF-beta, or interferon-gamma (INF-gamma). However, IL-12 significantly enhanced IPP-induced expression and release of MIP-1alpha that was down-regulated by TGF-beta whereas the induction of MIP-1beta by IPP+IL-12 was refractory to cotreatment with TGFbeta indicating that these chemokines are differentially regulated by these cytokines. Vdelta2(+) T cells also expressed a wide range of C-C chemokine receptors including CCR1, CCR5, and CCR8, all of which were down-regulated following activation. We conclude that Vdelta2(+) cells can be rapidly induced by components of bacterial cell walls to express high levels of proinflammatory chemokines, supporting an important role for these cells in the early stages of the inflammatory responses to many common pathogens. (Blood. 2000, 95:39-47)

Enhanced production of tumor necrosis factor-alpha and interleukin-6 due to prolonged response to lipopolysaccharide in human macrophages infected in vitro with human immunodeficiency virus type 1

Elevated levels of circulating tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 have been detected in human immunodeficiency virus (HIV) type 1 infection. The overproduction of these cytokines could contribute to AIDS pathogenesis. Thus, the expression of TNF-alpha and IL-6 in human macrophages infected with HIV-1 was investigated. HIV-1 infection, per se, did not induce any TNF-alpha or IL-6 production or cytokine-specific mRNA expression. In contrast, HIV-1 primed macrophages to a prolonged TNF-alpha and IL-6 response to lipopolysaccharide (LPS) stimulation with respect to uninfected cells. Time-course analysis and flow cytometry demonstrated that cytokine production stopped at 6 h in uninfected macrophages but continued up to 24 h in HIV-1-infected cells. RNA studies suggested that HIV-1 interfered with late steps of cytokine synthesis. No modulation of membrane CD14 was found to account for the enhanced response to LPS. Finally, the effect of HIV-1 on cytokine response could not be abolished by the antiviral compound U75875.

IL-12-mediated NKRP1A up-regulation and consequent enhancement of endothelial transmigration of V delta 2+ TCR gamma delta+ T lymphocytes from healthy donors and multiple sclerosis patients

Gamma delta T lymphocytes are thought to play a role in the pathogenesis of multiple sclerosis (MS) contributing to demyelinization and fibrosis in the central nervous system. In this study, we show that, in MS patients with active disease, the percentage of circulating V delta 2+ gamma delta T cells coexpressing NKRP1A is significantly increased compared with healthy donors. V delta 2+ and V delta 1+ T cells were sorted from MS patients and healthy volunteers and cloned. At variance with V delta 1+ clones, all V delta 2+ clones expressed NKRP1A, which was strongly up-regulated upon culture with IL-12; this effect was neutralized by specific anti-IL-12 Abs. No up-regulation of NKRP1A by IL-12 was noted on V delta 1+ clones. RNase protection assay showed that IL-12R beta 2 subunit transcript was significantly less represented in V delta 1+ than V delta 2+ clones. This finding may explain the different effect exerted by IL-12 on these clones. In transendothelial migration assays, V delta 2+ NKRP1A+ clones migrated more effectively than V delta 1+ clones, and this migratory potential was enhanced following culture with IL-12. Migration was strongly inhibited by the F(ab')2 of an anti-NKRP1A Ab, suggesting that this lectin is involved in the migration process. We also show that, in freshly isolated PBMC from MS patients, the migrated population was enriched for V delta 2+ NKRP1A+ cells. We conclude that the expression of NKRP1A on V delta 2+ cells is associated with increased ability to migrate across the vascular endothelium and that this phenomenon may be regulated by IL-12 present in the microenvironment.

HIV-1 does not alter in vitro and in vivo IL-10 production by human monocytes and macrophages

The present study analyses the ability of HIV-1 to modulate IL-10 production in cells of monocyte-macrophage lineage cultured in the presence of macrophage colony-stimulating factor (M-CSF). Both monocytes and macrophages spontaneously produced low amount of IL-10. Lipopolysaccharide (LPS) induced a strong IL-10 response in fresh monocytes and in M-CSF-treated macrophages. In contrast, macrophages cultured in the absence of M-CSF exhibited a marked decrease in their susceptibility to LPS stimulation. M-CSF increased the IL-10 response of macrophages to LPS by enhancing both the expression of membrane-bound CD14, the protein that serves as LPS receptor, and the sensibility of CD14-expressing cells to LPS stimulation. Neither spontaneous nor LPS-induced expression of IL-10 was modulated in monocytes and macrophages by infection with eight monocytotropic strains, as demonstrated by ELISA and cytofluorimetric analysis. In contrast, all the HIV-1 strains primed macrophages for an increased IL-6 response to LPS stimulation. To determine whether IL-10 production was associated with in vivo infection, monocytes from AIDS individuals were analysed for IL-10 production. We found that neither spontaneous nor LPS-induced IL-10 production were different between healthy controls and HIV-infected patients. Taken together, these data strongly suggest that HIV-1 infection of monocytes-macrophages does not play a significant role in the regulation of IL-10 in infected patients. This study also emphasizes the role of M-CSF activation in the regulation of the cytokine response in macrophages.

Infection of human monocytes with Mycobacterium tuberculosis enhances human immunodeficiency virus type 1 replication and transmission to T cells

Mycobacterium tuberculosis and human immunodeficiency virus type 1 (HIV-1) are virulent intracellular pathogens that invade and multiply within macrophages. The effect of M. tuberculosis on HIV-1 infection and replication was analyzed in vitro using human monocyte-derived macrophages (MDM) isolated from peripheral blood mononuclear cells by countercurrent centrifugal elutriation. Preinfection of MDM with M. tuberculosis followed by HIV-1 infection resulted in an increase in p24 release, reverse transcriptase activity, and infective virus production. In contrast, no increase in HIV-1 production was observed when MDM were infected with Mycobacterium avium complex or heat-killed M. tuberculosis. Coinfected MDM were potent stimulators of T cell proliferation, while HIV-1-infected MDM failed to present exogenous tuberculin to T cells. Furthermore, coinfected MDM showed an increased capacity to transmit HIV-1 to activated T cells. These results suggest that M. tuberculosis infection can both up-regulate HIV-1 infection and replication within MDM and increase the efficiency of virus transmission from infected MDM to T cells.

Apoptosis of human monocytes/macrophages in Mycobacterium tuberculosis infection

Tuberculosis (TB) is still a major health problem, both as a single disease entity and as a cofactor in AIDS. The interaction between macrophage and Mycobacterium tuberculosis (MTB) is a critical step in the establishment of an early chronic infection. This study analyses the capacity of MTB to induce apoptosis in cells obtained by broncho-alveolar lavage (BAL) from patients with reactive pulmonary tuberculosis and from AIDS patients with disseminated pulmonary tuberculosis. Apoptosis was increased three-fold in BAL cells obtained from patients with pulmonary tuberculosis and even more markedly in alveolar macrophages of MTB-infected AIDS patients, compared with controls. Apoptosis was analysed and characterized by propidium iodide (PI) incorporation, terminal deoxy transferase (TDT)-mediated dUTP-biotin nick end labelling (TUNEL), and tissue transglutaminase (tTG) expression. The MTB-macrophage interaction was also investigated in vitro by infecting monocyte-derived macrophages (MDM) with MTB (virulent strain H37Rv). The induction of apoptosis by MTB required viable bacteria, was dose-dependent, and was restricted to H37Rv. Infection with either Mycobacterium avium complex (MAC) or HIV-1 and treatment with heat-killed MTB failed to induce apoptosis.

In vitro inhibition of the replication of human immunodeficiency virus type 1 by beta-mercaptoethylamine (cysteamine)

This study investigates the effects of cysteamine alone and in association with zidovudine or didanosine on the replication of human immunodeficiency virus type 1 (HIV-1). More than 90% viral inhibition was obtained by 200 microM cysteamine in lymphocytes and 100 microM cysteamine in macrophages against 4 primary isolates and 2 laboratory strains of HIV-1. Polymerase chain reaction analysis demonstrated that cysteamine interferes with early steps of HIV-1 replication, before proviral DNA formation. The use of cysteamine in conjunction with zidovudine or didanosine brought about an additive antiviral effect without concomitant increases in toxicity. The concentrations of cysteamine that are effective against HIV-1 in vitro have been well tolerated over long periods by patients under treatment for cystinosis, an inherited disorder. These observations suggest that cysteamine alone or in combination with zidovudine or didanosine could be a new potential treatment of HIV-1 infection.

Human immunodeficiency virus-induced cell death in cytokine-treated macrophages can be prevented by compounds that inhibit late stages of viral replication

The basis of the cytopathic effect induced by a laboratory strain and several clinical isolates of human immunodeficiency virus (HIV) in human macrophages cultured in the presence of macrophage colony-stimulating factor was studied. Infected macrophages die of necrosis, the consequence of the production of mature virions in infected cells. Cell death can be prevented by antiviral compounds that interfere with the assembly and budding of virions. Programmed cell death (apoptosis), a potential mechanism of HIV-mediated cell death in CD4 T lymphocytes, does not occur in infected macrophages as shown by electron microscopy, cytofluorometric and gel electrophoretic DNA analysis, and nuclear fluorescent staining by Hoechst and terminal dUTP-nick-end-labeling (TUNEL) assay. The data suggest that macrophage killing by HIV may occur in vivo. Thus, combination therapies that include compounds that inhibit the cytopathic effect of HIV in macrophages should be considered for AIDS patients.

Heat-shock protein expression on the membrane of T cells undergoing apoptosis

Heat-shock proteins (hsp) represent a highly conserved family of proteins, normally localized in the cytoplasm and nucleus, whose expression is induced in situations involving cell stress. This paper reports the unusual translocation of hsp to the cell membrane of T cells undergoing apoptosis. We observed that glucocorticosteroid-induced thymocyte death is associated to the surface expression of hsp 60 and hsp 70 in a discrete fraction of apoptotic cells. hsp surface expression is closely related to a thymic subset of immature CD3low/- T cells. The expression of surface hsp 60 appears early after treatment with dexamethasone (3 hr) whereas the membrane expression of hsp 70 follows different kinetics and peaks later. Morphological analysis of the hsp+ apoptotic cells suggest that this subset represents late-stage apoptotic cells at their minimal volume before fragmentation into apoptotic bodies. Membrane expression of hsp is also associated with apoptosis in peripheral blood mononuclear cells from AIDS patients cultured in vitro. Altogether, we show that a discrete fraction of cells undergoing apoptosis expresses membrane hsp 60 and hsp 70, supporting the hypothesis that apoptosis causes a radical alteration in the expression of cell surface molecules. Surface hsp expressed during apoptosis may constitute a novel immune-context able to generate packages of self- and exogenous antigens, originating from degradation of altered cells.

CD4-8- T-cells increase in MRI/lpr mice treated with thymic factors

The in vivo effect of thymic factors on immature lymphocytes was analysed in MRL/lpr mice. This strain carries a genetic defect that causes during their life cycle a block of T-cell differentiation and abnormal proliferation of CD4-8- (double-negative, DN) T-lymphocytes. In vivo administration of four preparations of thymic factors, thymopentin (TP-1), thymopoietin (TP-5), thymolymphotropin (TLT), and thymomodulin (TMD) into young (2-month-old) MRL/lpr mice induced a significant increase of DN T-cells both in the thymus and in the peripheral lymph nodes, with a concomitant decrease of double-positive (DP) T-cells in the thymus and of single-positive (SP) T-cells in the lymph nodes. The level of DNA fragmentation measured as propidium iodide fluorescence was increased in the thymus population of young mice and in the lymph node population of old mice treated with TLT. SCID mice transplanted with lymph node cells from MRL/lpr donors (MRL-->SCID) developed graft versus host (GvH) reaction due to the activation of MRL CD8+ alloreactive T-cells. This model was used to analyse the effect of TMD/TLT in vivo on MRL cell proliferation and expansion; in fact, spleen cells from MRL-->SCID mice after treatment with TMD/TLT showed an increased cell proliferation, and an expansion of DN T-cells with a concomitant decrease of SP cells (both CD4+ and CD8+ cells). Decreased SP cell numbers in this context could explain why TMD/TLT treatment of SCID mice engrafted with MRL cells increased their survival compared to untreated MRL-->SCID mice.

Epitope specificity, antibody-dependent cellular cytotoxicity, and neutralizing activity of antibodies to human immunodeficiency virus type 1 in autoimmune MRL/lpr mice

The specificity and functional activity of antibodies to human immunodeficiency virus (HIV) in the sera of MRL/lpr mice were analyzed by peptide-ELISA, antibody-dependent cellular cytotoxicity, and virus neutralization. The specificity of the antibodies in the sera of autoimmune MRL/lpr mice was similar to that of HIV-infected persons; the mouse sera specifically recognized the V3 loop of gp120 and immunodominant regions of gp41 and p24. Moreover, such binding was inhibited both by human HIV-positive sera and by soluble peptides in competition experiments. MRL/lpr sera displayed anti-HIV antibody-dependent cellular cytotoxicity using human peripheral blood lymphocytes as effector cells and HIV-infected H9 cells. Furthermore, the fact that MRL/lpr sera neutralized in vitro infectious HIV (both strains IIIB and MN) suggests these antibodies recognize viral epitopes on the membrane of infected T cells.